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Published on: May 4, 2021
Impact of Stewardship on Inhaled Nitric Oxide Utilization in a Neonatal ICU
Amir Elmekkawi1, Kiran More2, Jennifer Shea1
1Division of Neonatology and.
Insights
Implementing an inhaled nitric oxide (iNO) stewardship program reduced iNO use in newborns with respiratory failure. This quality improvement initiative improved adherence to guidelines and decreased treatment duration.
Area of Science:
- Neonatal Medicine
- Pulmonary Medicine
- Quality Improvement Science
Background:
- Inhaled nitric oxide (iNO) is a standard therapy for neonatal hypoxemic respiratory failure.
- Significant practice variations exist in iNO timing and weaning protocols.
- An iNO stewardship program was implemented to promote evidence-based use.
Purpose of the Study:
- To evaluate the impact of an iNO stewardship program on iNO utilization and weaning practices.
- To assess changes in adherence to established iNO guidelines.
Main Methods:
- A quality improvement project was conducted in a quaternary NICU.
- Two cohorts were compared: prestewardship (retrospective) and poststewardship (prospective).
- Data on iNO utilization and patient outcomes were collected and analyzed.
Main Results:
- A significant reduction in the number of neonates receiving iNO was observed post-stewardship (64 vs 87).
- Median total hours on iNO per patient decreased significantly (47 to 20 hours).
- Hours from maximum dose to initial wean and from initial wean to discontinuation were also significantly reduced.
Conclusions:
- The introduction of an iNO stewardship program improved adherence to evidence-based guidelines.
- The program led to a significant overall reduction in iNO use per patient.
Objectives:
Inhaled nitric oxide (iNO) remains the "gold standard" therapy for hypoxemic respiratory failure in newborns. Despite good quality evidence to guide iNO use in this population, we observed considerable practice variation, particularly in timing and rate of weaning. To promote evidence-based practice, we launched an iNO stewardship program in April 2013. Our objective was to determine whether iNO stewardship led to changes in iNO utilization and weaning.
Methods:
We conducted a quality improvement project in an outborn quaternary NICU, targeting improved iNO guideline compliance. We compared patterns of iNO utilization between 2 cohorts: prestewardship (April 2011-March 2013; retrospective data collection) and poststewardship (April 2013-March 2015; prospective data collection).
Results:
Eighty-seven neonates received 88 courses of iNO in the 2 years prestewardship, and 64 neonates received 64 courses of iNO in the 2 years poststewardship. There were no significant differences (P > .05) in patient demographics, in the proportion of patients receiving iNO "off-label," in proportion initiated at the referring hospital, or in outcomes (death or extracorporeal membrane oxygenation). There were significant (P < .05) reductions in median total hours on iNO per patient (47 vs 20; P < .001), in iNO hours per patient from maximum dose to initial wean (28 vs 9; P < .01), and in hours from initial wean to discontinuation (14 vs 8; P < .05).
Conclusions:
The introduction of iNO stewardship was associated with improved adherence to evidence-based guidelines and an overall reduction in total and per-patient iNO use.
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