Reducing Variation in the Use of Inhaled Nitric Oxide

Abstract

BACKGROUND AND OBJECTIVE: Decreasing practice variation and following clinical guidelines improve patient outcomes and reduce costs. Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension and right heart failure in patients with congenital or acquired heart disease. Our objective was to implement standardized initiation and weaning guidelines for iNO usage in the cardiothoracic ICU (CTICU) to reduce variation in use while maintaining quality patient care. METHODS: All CTICU patients who received iNO from January 2011 to December 2012 were retrospectively reviewed. Standardized iNO initiation and weaning guidelines were implemented in January 2012. Variables before and after guideline implementation were compared. RESULTS: From January to December 2011, there were 36 separate iNO events (6% of CTICU admissions; n = 547). Mean ± SD iNO usage per event was 159 ± 177 hours (median: 63 hours; range: 27–661 hours). From January to December 2012, there were 47 separate iNO events (8% of CTICU admissions; n = 554). Mean iNO usage per event was 125 ± 134 hours (median: 72 hours; range: 2–557 hours). Initiation guideline compliance improved from 83% to 86% (P = .9); weaning guideline compliance improved from 17% to 79% (P < .001). Although mean iNO usage per event decreased, there was no significant reduction in utilization of iNO (P = .09). CONCLUSIONS: Implementation of standardized iNO initiation and weaning guidelines in the CTICU was successful in reducing practice variation supported by increasing guideline compliance. However, decreasing practice variation did not significantly reduce iNO utilization and does not necessarily reduce cost.

Impact of Stewardship on Inhaled Nitric Oxide Utilization in a Neonatal ICU

“…Clinical practice guidelines are widely regarded as key to reducing practice variation and improving the quality of care. 29,33 However, to be effective, guidelines must be updated regularly to reflect current evidence or expert opinion, must be minimally controversial to ensure maximum buy-in, and must be implemented in an environment characterized by sustained communication and vigilance. The stewardship model has been used successfully in the pediatric setting to promote safe and evidence-based use of antimicrobial agents.…”

“…[25][26][27][28] At best, such practices have major economic consequences; at worst, have the potential to cause harm. Lack of adherence to guidelines relating to commencement and weaning of iNO therapy represents another practice with major economic and patient safety implications 29 ; however, compliance with guidelines relating to iNO use has not been previously examined in the NICU setting.…”

A Quality Improvement Initiative to Standardize Use of Inhaled Nitric Oxide in the PICU

“… Nationwide Children’s Hospital PICU iNO treatment guidelines, including criteria for starting, response, and weaning. *Cardiac patients identified with pulmonary hypertension were managed according to a separate protocol described by Simsic et al 14 P/F ratio is the arterial partial pressure of oxygen to the fraction of inspired oxygen. When arterial blood gases were not available, the S/F ratio or oxygen saturation to fraction of inspired oxygen was used.…”

Implementation of an Inhaled Nitric Oxide Protocol: A Paradox or the Perfect Pair?

“…12,13 INO is often SEE THE ORIGINAL STUDY ON PAGE 644 prescribed to treat pulmonary hypertension in the cardiac ICU setting; however, its overall effectiveness in improving outcomes and in comparison with other available pulmonary vasodilators has yet to be determined. In addition, Simsic et al 14 reported that the use of an INO protocol in this subject population reduced variation, but not utilization or cost. This is in contrast to a study in this issue of RESPIRATORY CARE.…”