Abstract
Background:
Inhaled nitric oxide (INO) is a costly but effective pulmonary vasodilator that can improve oxygenation in a few disorders. The off and on-label use of INO has rapidly expanded throughout our ICUs since the FDA cleared INO for clinical use in 2001. Our respiratory care department did not have a process in place to manage the use of INO. In 2016, an institution-wide Clinical Practice Guideline (CPG) was implemented with Medical Leadership support. Initial findings showed a 22% decrease in INO utilization for the first year of CPG managed practice. The purpose of this study is to examine continued INO utilization related to compliance with the CPG.
Methods:
Department utilization of INO for August 2015-July 2016 prior to CPG launch was examined and compared to utilization and compliance post implementation spanning August 2016-April 2018. Monthly utilization data from August 2015 through July 2016 was obtained from department billing to determine baseline aggregate utilization. We gathered monthly data for aggregate utilization from August 2016 (CPG launch) through April 2018 for comparison. We then gathered personnel compliance with the CPG from August 2016 to the present across all ICUs.
Results:
Our institution utilized 25,120 hours of INO in the 12 months prior to the CPG launch. After initiation of the CPG, the next 12 months' utilization hours dropped to 17,341.9, a 31.12% decrease in utilization from FY16 to FY17. Nine months of FY18 data show 12,706.4 hours of INO utilization with projected use of 18,015.4 hours at the end of this year. INO utilization will have decreased compared to initial FY16 data by 7,194.6 hours, or 28.54%. As part of our analysis, we found that INO use was inversely associated with protocol compliance. In April and May 2017, INO utilization increased with a corresponding drop in CPG compliance. This is repeated in October and November. Although RTs query attending physicians daily to trial wean the INO dose therefore testing the INO effectiveness, there is still reluctance to comply.
Conclusions:
Establishing an institution-wide INO CPG has significantly decreased overall utilization. CPG compliance has an average of 82.67%; increases in compliance have shown to be beneficial in decreasing INO utilization over time. We have neither observed nor reported adverse events related to the implementation or adherence to this CPG. Ongoing vigilance for protocol compliance across all providers and units is important to our goals.
Figure 1 demonstrates the relationship of the increase and decrease of ION utilization compared to CPG compliance.
Get full access to this article
View all access options for this article.