Reinhart Richelle M, McClary Jacquelyn D, Zhang Mengqi, Marasch Jaime L, Hibbs Anna Maria, Nock Mary L
Division of Neonatology at University Hospitals Rainbow Babies.
Department of Pharmacy at University Hospitals Rainbow Babies and Children's, Cleveland, Ohio, USA.
Pediatr Qual Saf. 2020 May 12;5(3):e303. doi: 10.1097/pq9.0000000000000303. eCollection 2020 May-Jun.
Gastroesophageal reflux is a physiologic occurrence in infants. Clinicians caring for neonates use histamine-2 receptor antagonists (H2As) or proton pump inhibitors (PPIs) for symptomatic reflux, apnea/bradycardia/desaturations, or irritability. Recent studies have shown that there is an increased incidence of infection, fracture, and mortality in neonates who receive antacids.
A multidisciplinary team aimed to decrease nonindicated antacid use in the NICU by 50% by April 2019. Outcome measures include the median number of inappropriate antacid prescriptions and patient-days on acid-suppressants. Interventions include education regarding use and risks of antacids, development of a list of indications deemed "appropriate" for starting an H2A or PPI, mandatory discussion on rounds when considering antacids, documentation of treatment goal, and indication, and an automatic drop-off in the electronic medical record.
Baseline data (June-December 2017) showed 19 prescriptions of H2As or PPIs. Of those, 10 orders were deemed "inappropriate," according to our indicated uses. There were 407 total patient-days of medication-use (median: 51 patient-days). After the implementation of the interventions (October 2018-May 2019), there were 11 prescriptions of antacid medications, 3 of which were deemed "inappropriate." There were 206 total days of medication-use (median: 18.5 patient-days).
A multidisciplinary agreement on indications for antacid use in neonates stimulates discussion and creates more purposeful use. Overall, we successfully decreased nonindicated antacid prescriptions in the NICU. For the next steps, we hope to educate physicians on the risks of antacid use and reduce prescriptions in other areas of the hospital and the outpatient setting.
胃食管反流在婴儿中是一种生理现象。照顾新生儿的临床医生使用组胺-2受体拮抗剂（H2A）或质子泵抑制剂（PPI）来治疗有症状的反流、呼吸暂停/心动过缓/血氧饱和度下降或烦躁不安。最近的研究表明，接受抗酸剂治疗的新生儿感染、骨折和死亡率有所增加。
一个多学科团队旨在到2019年4月将新生儿重症监护病房（NICU）中无指征的抗酸剂使用减少50%。结果指标包括不适当抗酸剂处方的中位数以及使用抑酸剂的患者天数。干预措施包括关于抗酸剂使用和风险的教育、制定一份被认为“适当”启动H2A或PPI的指征清单、在考虑使用抗酸剂时在查房时进行强制性讨论、记录治疗目标和指征，以及在电子病历中自动减少使用。
基线数据（2017年6月至12月）显示有19份H2A或PPI处方。根据我们规定的用途，其中10份医嘱被认为是“不适当的”。药物使用的总患者天数为407天（中位数：51个患者天数）。在实施干预措施后（2018年10月至2019年5月），有11份抗酸剂药物处方，其中3份被认为是“不适当的”。药物使用的总天数为206天（中位数：18.5个患者天数）。
关于新生儿抗酸剂使用指征的多学科共识促进了讨论并实现了更有针对性的使用。总体而言，我们成功减少了NICU中无指征的抗酸剂处方。对于下一步，我们希望教育医生了解抗酸剂使用的风险，并减少医院其他区域和门诊环境中的处方。
