title: Reducing variation in the use of inhaled nitric oxide.
abstract: OBJECTIVE
  Decreasing practice variation and following clinical guidelines improve patient outcomes and reduce costs. Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension and right heart failure in patients with congenital or acquired heart disease. Our objective was to implement standardized initiation and weaning guidelines for iNO usage in the cardiothoracic ICU (CTICU) to reduce variation in use while maintaining quality patient care.
  
  
  METHODS
  All CTICU patients who received iNO from January 2011 to December 2012 were retrospectively reviewed. Standardized iNO initiation and weaning guidelines were implemented in January 2012. Variables before and after guideline implementation were compared.
  
  
  RESULTS
  From January to December 2011, there were 36 separate iNO events (6% of CTICU admissions; n = 547). Mean ± SD iNO usage per event was 159 ± 177 hours (median: 63 hours; range: 27-661 hours). From January to December 2012, there were 47 separate iNO events (8% of CTICU admissions; n = 554). Mean iNO usage per event was 125 ± 134 hours (median: 72 hours; range: 2-557 hours). Initiation guideline compliance improved from 83% to 86% (P = .9); weaning guideline compliance improved from 17% to 79% (P < .001). Although mean iNO usage per event decreased, there was no significant reduction in utilization of iNO (P = .09).
  
  
  CONCLUSIONS
  Implementation of standardized iNO initiation and weaning guidelines in the CTICU was successful in reducing practice variation supported by increasing guideline compliance. However, decreasing practice variation did not significantly reduce iNO utilization and does not necessarily reduce cost.
authors.affiliation: The Heart Center, janet.simsic@nationwidechildrens.org.
authors.forename: Janet M
authors.initials: JM
authors.lastname: Simsic
authors.affiliation: Department of Quality Improvement Services, and.
authors.forename: Sheilah
authors.initials: S
authors.lastname: Harrison
authors.affiliation: Department of Respiratory Therapy, Nationwide Children's Hospital, Columbus, Ohio.
authors.forename: Laura
authors.initials: L
authors.lastname: Evans
authors.affiliation: Department of Quality Improvement Services, and.
authors.forename: Richard
authors.initials: R
authors.lastname: McClead
authors.affiliation: The Heart Center.
authors.forename: Douglas
authors.initials: D
authors.lastname: Teske
mesh_terms: D000280:Administration, Inhalation; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D017046:Cost Savings; D004334:Drug Administration Schedule; D005260:Female; D019983:Guideline Adherence / Q000191:economics / Q000592:standards; D006330:Heart Defects, Congenital / Q000188:drug therapy* / Q000191:economics; D006333:Heart Failure / Q000188:drug therapy* / Q000191:economics; D006776:Hospitals, Pediatric; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy* / Q000191:economics; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric / Q000191:economics / Q000592:standards; D008297:Male; D009569:Nitric Oxide / Q000008:administration & dosage* / Q000191:economics; D009820:Ohio; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000592:standards*; D058996:Quality Improvement / Q000191:economics / Q000592:standards*; D012189:Retrospective Studies; D014600:Utilization Review
chemical_list: D009569:Nitric Oxide
keywords: congenital heart disease; guidelines; inhaled nitric oxide; outcomes; pulmonary hypertension; quality improvement