Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, USA.
J Perinatol. 2022 Aug;42(8):1118-1125. doi: 10.1038/s41372-021-01262-9. Epub 2021 Nov 2.
Acid-suppressing medications (ASMs) are commonly prescribed in the neonatal intensive care unit (NICU), in particular among preterm infants, despite well-established adverse effects and little evidence to support efficacy.
We sought to develop an initiative to reduce ASM exposure in our predominantly inborn level III NICU. Our specific aim was to reduce the number of nonindicated ASM prescriptions by 50% within a 12-month period.
Our multidisciplinary team developed an evidence-based guideline defining indications for ASM prescription in a level III NICU. Plan-do-study-act cycles included staff education, formal clinical practice guideline implementation, and implementation of standardized documentation tools in the electronic health record (EHR). Outcome measures were the number of nonindicated and total inpatient prescriptions started per month, duration of ASM prescription, and number of prescriptions continued after NICU discharge. Balancing measures were the number of patients started on thickened feeds and number of patients discharged home on nasogastric tube feeds. We used statistical process control and Pareto charts to assess these measures over a 12-month baseline period, 9-month implementation period, and 19-month post-implementation period spanning September 2017-December 2020.
Nonindicated ASM prescriptions decreased from median 3 to 0 per month from the baseline to post-implementation period. Simultaneously, the median number of ASM prescriptions at discharge declined from 2 to 0 per month. The median duration of inpatient prescriptions declined from 23 to 7 days. Rates of patients started on thickened feeds and patients discharged home on nasogastric tube feeds remained stable throughout the study.
Enactment of an evidence-based guideline was associated with a substantial decline in nonindicated ASM use in our NICU and a decline in duration of exposure to ASM's when prescribed. Our interventions proved effective in altering clinical practice and could be applied to other NICUs with similar patient populations aiming to reduce ASM use.
尽管酸抑制药物（ASM）具有明确的不良反应，且几乎没有疗效证据支持，但在新生儿重症监护病房（NICU）中，尤其是在早产儿中，此类药物仍被广泛应用。
我们试图在我们以收治经产儿为主的三级 NICU 中开展一项减少 ASM 暴露的活动。我们的具体目标是在 12 个月内将非指征性 ASM 处方数量减少 50%。
我们的多学科团队制定了一项基于循证的指南，该指南确定了三级 NICU 中 ASM 处方的适应证。计划-实施-研究-行动循环包括员工教育、正式临床实践指南的实施以及电子健康记录（EHR）中标准化文档工具的实施。结果衡量指标为每月非指征性和总住院处方数量、ASM 处方持续时间以及 NICU 出院后继续处方的数量。平衡衡量指标为开始使用增稠喂养的患者数量和通过鼻胃管喂养出院的患者数量。我们使用统计过程控制和 Pareto 图来评估这些措施在 12 个月的基线期、9 个月的实施期和 19 个月的实施后期（2017 年 9 月至 2020 年 12 月）内的情况。
从基线期到实施后期，非指征性 ASM 处方数量从每月中位数 3 次减少至 0 次。同时，出院时 ASM 处方的中位数数量从每月 2 次减少至 0 次。住院期间处方的中位数持续时间从 23 天减少至 7 天。开始使用增稠喂养的患者和通过鼻胃管喂养出院的患者比例在整个研究期间保持稳定。
实施基于证据的指南与我们 NICU 中非指征性 ASM 使用量的大幅下降以及处方时 ASM 暴露时间的缩短有关。我们的干预措施在改变临床实践方面是有效的，并且可以应用于其他具有类似患者群体的 NICU，以减少 ASM 的使用。
