Simsic Janet M, Dolan Kevin, Miller Julie, Yates Andrew R, Fernandez Richard, Phelps Christina, Fitch Jill, Lee Anthony, Lloyd Eric, Gauntt Jennifer, Gajarski Robert
Heart Center, Nationwide Children's Hospital, Columbus, Ohio.
Pediatr Qual Saf. 2019 Nov 25;4(6):e237. doi: 10.1097/pq9.0000000000000237. eCollection 2019 Nov-Dec.
Decreasing practice variation and following evidence-based clinical guidelines improve patient outcomes and often reduce cost. Essentially all postsurgical cardiac patients require diuretics. The approach to diuresis in the pediatric cardiothoracic intensive care unit (CTICU) is not standardized. Our objective was to develop and implement guidelines for diuretic utilization in the CTICU to reduce high charge medication utilization while maintaining the delivery of high-quality care.
Two of the top 10 medications by charge in the CTICU during 2016 were diuretics [fenoldopam and intravenous (IV) chlorothiazide]. Standardized diuretic utilization guidelines were developed to reduce the utilization of fenoldopam and IV chlorothiazide. We implemented guidelines in April 2017. The utilization of fenoldopam and IV chlorothiazide, as well as overall diuretic charges, before and after guideline implementation were compared.
We normalized all comparisons to 100 CTICU patient-days. Fenoldopam starts were reduced from 1.1 in 2016 to 0.03 in 2019 (through February); days of fenoldopam use were reduced from 4 in 2016 to 0.15 days in 2019 (through February); IV chlorothiazide doses decreased from 20 in 2016 to 8 in 2019 (through February). These changes reduced the mean charges for diuretics from $25,762 in 2016 to $8,855 in 2019 (through February). CTICU average daily census did not change significantly during the study period (12.8 in 2016 vs 11.8 in 2018).
Value-added implementation of standardized diuretic utilization guidelines in the CTICU successfully reduced the use of high-charge diuretics without unfavorably impacting the quality of care delivery.
减少实践差异并遵循循证临床指南可改善患者预后，且通常能降低成本。基本上所有心脏手术后的患者都需要使用利尿剂。小儿心胸重症监护病房（CTICU）的利尿方法并不规范。我们的目标是制定并实施CTICU利尿剂使用指南，以减少高费用药物的使用，同时维持高质量护理的提供。
2016年CTICU中费用最高的10种药物中有两种是利尿剂[非诺多泮和静脉注射（IV）氯噻嗪]。制定了标准化的利尿剂使用指南，以减少非诺多泮和IV氯噻嗪的使用。我们于2017年4月实施了这些指南。比较了指南实施前后非诺多泮和IV氯噻嗪的使用情况以及利尿剂的总费用。
我们将所有比较结果标准化为100个CTICU患者日。非诺多泮的起始使用量从2016年的1.1次降至2019年（截至2月）的0.03次；非诺多泮的使用天数从2016年的4天降至2019年（截至2月）的0.15天；IV氯噻嗪的剂量从2016年的20剂降至2019年（截至2月）的8剂。这些变化使利尿剂的平均费用从2016年的25,762美元降至2019年（截至2月）的8,855美元。在研究期间，CTICU的平均每日普查人数没有显著变化（2016年为12.8人，2018年为11.8人）。
在CTICU中增值实施标准化利尿剂使用指南成功减少了高费用利尿剂的使用，且未对护理质量产生不利影响。
