Decreasing INO Waste: A Quality Improvement Project to Reduce Non-Indicated Use of Inhaled Nitric Oxide in the Neonatal Intensive Care Unit Through Practice Guidelines

Background: Inhaled nitric oxide (INO) is a selective pulmonary vasodilator designed to treat pulmonary hypertension (PHTN) in the neonate. In 2017 the NICU consumed 7,858 INO hours. The aim of this quality improvement project was to reduce non-indicated use of INO in the NICU by 20% within 1 fiscal year (FY) through implementation of practice guidelines. Methods: A multidisciplinary team formed and determined characteristics of infants and variation in practice for INO use in the NICU. Case reviews determined the NICU lacked a standardized approach to the initiation, management or weaning of INO. Pre-intervention data from chart reviews showed that 52% of all INO hours were used by 3 infants with birth weights 500-1000 g. In FY17, 26% of the INO hours were used for non-indicated therapy and there were 9 infants prescribed INO without clinical documentation of PHTN. This totaled in 2,057 potentially avoidable hours. Clinical practice guidelines were developed to define parameters for the initiation and weaning of INO. Respiratory therapists (RTs) championed this guideline with the following interventions: 1. Were granted autonomy to wean INO per the guideline, 2. Developed a rounding tool to address weaning during patient care rounds and 3. Created an INO note template to document indication for and response to therapy. Patients who have received INO are reviewed monthly by a multidisciplinary group. The process measure is compliance with the clinical guidelines for INO. The outcome measure is non-indicated hours. Plan-Do-Study-Act (PDSA) cycles were used to test and learn from changes implemented. Results: The clinical guidelines were implemented in July 2017 (FY18). There was no change in the number of INO users. In FY18, 8% of the INO hours were used for non-indicated therapy. An annotated XmR chart of total non-indicated INO hours shows we improved our mean non-indicated hours from 163 in FY17 to 26 for FY18 to date. We anticipate a sustained improvement through FY18, ending June 30th. We continue to audit the INO note and educate on the clinical guidelines in an effort to improve percent compliance. Conclusions: Implementation of clinical practice guidelines in the NICU can significantly reduce non-indicated use of INO. Additional studies are required to evaluate compliance with clinical practice guidelines over time.