A Quality Improvement Project to Improve Evidence-Based Inhaled Nitric Oxide Use

Inhaled nitric oxide (INO) reduces extracorporeal membrane oxygenation (ECMO) use in term and near-term neonates with persistent pulmonary hypertension of the newborn; however, its overutilization is increasing. We hypothesized that implementing a shared baseline protocol would safely improve evidence-based INO use in a Level IV neonatal ICU.

Through several plan-do-study-act cycles, a shared baseline protocol for initiation and weaning of INO was developed and implemented starting in August 2014. Based on user feedback, the shared baseline protocol was amended and re-evaluated at regular intervals. Significant changes for process and outcome measures related to utilization of INO were detected using statistical process control, bivariate analyses using t test or nonparametric Wilcoxon rank-sum test as appropriate, and chi-square and Fisher exact testing as appropriate. Comparisons between the pre-plan-do-study-act group (January 2012 to July 2014) and post-plan-do-study-act group (August 2014 to October 2015) were made.

One hundred sixteen INO courses in 95 subjects were administered during the pre-plan-do-study-act period, and 44 episodes were initiated in 39 subjects during the post-plan-do-study-act period. Process control charts demonstrate significant reductions in the percentage of INO doses > 20 ppm and the percentage of prolonged (>4-d) INO courses. Prolonged INO courses decreased from 67.9 to 40% (P = .032), whereas the median duration of INO per course decreased from 8 to 4 d (P < .001). The percentage of INO courses that exceeded the dose of 20 ppm decreased from 18.1 to 2.3% (P = .009). Very delayed INO weaning (weaning at F_IO ≤ 0.40) decreased from 41.9 to 21.2% (P = .038). There were no differences in the percentage of INO courses administered to non-sedated subjects or the percentage of INO courses administered to preterm infants. There was no difference for death or ECMO between groups.

Implementation of a shared baseline protocol to encourage appropriate INO initiation and weaning safely decreased INO exposures. Focused efforts on reducing unapproved INO use in preterm infants are warranted.