Karsies Todd J, Evans Laura, Frost Randall, Ayad Onsy, McClead Richard
Department of Pediatrics, Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Respiratory Therapy, Nationwide Children's Hospital, Columbus, Ohio; Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Office of the Chief Medical Officer, Nationwide Children's Hospital, Columbus, Ohio.
Pediatr Qual Saf. 2017 Feb 27;2(2):e011. doi: 10.1097/pq9.0000000000000011. eCollection 2017 Mar-Apr.
Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator used off-label to treat refractory hypoxemia in the pediatric intensive care unit (PICU). However, clinical practice varies widely, and there is limited evidence to support this expensive therapy. Our objective was to test whether implementation of a clinical guideline for iNO therapy would decrease practice variability, reduce ineffective iNO utilization, and control iNO-related costs.
We used quality improvement (QI) methodology to standardize the use of iNO in a single quaternary care PICU (noncardiac). All PICU patients receiving iNO therapy between January 1, 2010, and December 31, 2013, were included. The QI intervention was the development and implementation of a clinical guideline for iNO initiation, continuation, and weaning. iNO use was monitored using statistical process control charts.
We derived baseline data from 30 preguideline patients (35 separate iNO courses) compared with 33 postguideline patients (36 separate iNO courses). Despite similar baseline characteristics, disease severity, and degree of hypoxemia, postguideline patients had a shorter median [interquartile range (IQR)] duration of iNO therapy than preguideline patients [76 (48-124) hours versus 162 (87-290) hours; < 0.0001]. We have sustained the reduced iNO usage throughout the postguideline period. Postguideline patients also had improved provider documentation and a median iNO cost savings of $4,600.
Implementation of iNO usage guidelines was associated with decreased iNO usage and cost of iNO therapy in the PICU.
吸入一氧化氮（iNO）是一种强效肺血管扩张剂，在儿科重症监护病房（PICU）中被用于治疗难治性低氧血症，但属于超说明书用药。然而，临床实践差异很大，且支持这种昂贵治疗方法的证据有限。我们的目的是测试实施iNO治疗临床指南是否会减少实践差异、降低iNO的无效使用并控制iNO相关成本。
我们采用质量改进（QI）方法对一家单一的四级医疗PICU（非心脏）中iNO的使用进行标准化。纳入了2010年1月1日至2013年12月31日期间接受iNO治疗的所有PICU患者。QI干预措施是制定并实施iNO起始、持续和撤机的临床指南。使用统计过程控制图监测iNO的使用情况。
我们将30例指南前患者（35个独立的iNO疗程）的基线数据与33例指南后患者（36个独立的iNO疗程）进行了比较。尽管基线特征、疾病严重程度和低氧血症程度相似，但指南后患者的iNO治疗中位[四分位间距（IQR）]持续时间比指南前患者短[76（48 - 124）小时对162（87 - 290）小时；<0.0001]。在整个指南后期间，我们一直维持着iNO使用量的减少。指南后患者的医疗记录也有所改善，iNO成本中位数节省了4600美元。
iNO使用指南的实施与PICU中iNO使用量的减少及iNO治疗成本的降低相关。
