title: Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures.
abstract: OBJECTIVE
  The implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit (ICU) is described.
  
  
  METHODS
  This retrospective study compared the use of i.v. chlorothiazide and i.v. ethacrynic acid in pediatric cardiovascular surgery patients before and after implementation of a diuretic stewardship program. All pediatric patients admitted to the pediatric cardiovascular service were included. The cardiovascular surgery service was educated on formal indications for specific diuretic agents, and the diuretic stewardship program was implemented on January 1, 2013. Under the stewardship program, i.v. ethacrynic acid was indicated in patients with a sulfonamide allergy, and i.v. chlorothiazide was considered appropriate in patients receiving maximized i.v. loop diuretic doses. A detailed review of the pharmacy database and medical records was performed for each patient to determine i.v. chlorothiazide and i.v. ethacrynic acid use and expenditures, appropriateness of use, days using a ventilator, and cardiovascular ICU length of stay.
  
  
  RESULTS
  After implementation of diuretic stewardship, the use of i.v. chlorothiazide decreased by 74% (531 fewer doses) while i.v. ethacrynic acid use decreased by 92% (47 fewer doses), resulting in a total reduction of $91,398 in expenditures on these diuretics over the six-month study period and an estimated annual saving of over $182,000. The median number of days using a ventilator and the length of ICU stay did not differ significantly during the study period.
  
  
  CONCLUSIONS
  Implementation of a diuretic stewardship program reduced the use of i.v. chlorothiazide and i.v. ethacrynic acid without adversely affecting clinical outcomes such as ventilator days and length of stay in a pediatric cardiovascular ICU.
authors.affiliation: Christopher A. Thomas, Pharm.D., is Clinical Pharmacy Specialist-Pediatric Cardiovascular Intensive Care Unit (ICU), Department of Pharmacy, Riley Hospital for Children at Indiana University Health (IUH), Indianapolis; at the time of writing he was Clinical Pharmacy Specialist-Pediatric Cardiovascular ICU, Department of Pharmacy Services, Phoenix Children's Hospital, Phoenix, AZ. Jennifer L. Morris, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston; at the time of writing she was Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Riley Hospital for Children at IUH. Elizabeth A. Sinclair, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston. Richard H. Speicher, M.D., is Medical Director, Pediatric ICU, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH, and Assistant Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland. Sheikh S. Ahmed, M.D., is Assistant Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy, Riley Hospital for Children at IUH. Alexandre T. Rotta, M.D., is Chief, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, and Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University. cthomas15@iuhealth.org.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Thomas
authors.affiliation: Christopher A. Thomas, Pharm.D., is Clinical Pharmacy Specialist-Pediatric Cardiovascular Intensive Care Unit (ICU), Department of Pharmacy, Riley Hospital for Children at Indiana University Health (IUH), Indianapolis; at the time of writing he was Clinical Pharmacy Specialist-Pediatric Cardiovascular ICU, Department of Pharmacy Services, Phoenix Children's Hospital, Phoenix, AZ. Jennifer L. Morris, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston; at the time of writing she was Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Riley Hospital for Children at IUH. Elizabeth A. Sinclair, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston. Richard H. Speicher, M.D., is Medical Director, Pediatric ICU, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH, and Assistant Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland. Sheikh S. Ahmed, M.D., is Assistant Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy, Riley Hospital for Children at IUH. Alexandre T. Rotta, M.D., is Chief, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, and Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Morris
authors.affiliation: Christopher A. Thomas, Pharm.D., is Clinical Pharmacy Specialist-Pediatric Cardiovascular Intensive Care Unit (ICU), Department of Pharmacy, Riley Hospital for Children at Indiana University Health (IUH), Indianapolis; at the time of writing he was Clinical Pharmacy Specialist-Pediatric Cardiovascular ICU, Department of Pharmacy Services, Phoenix Children's Hospital, Phoenix, AZ. Jennifer L. Morris, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston; at the time of writing she was Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Riley Hospital for Children at IUH. Elizabeth A. Sinclair, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston. Richard H. Speicher, M.D., is Medical Director, Pediatric ICU, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH, and Assistant Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland. Sheikh S. Ahmed, M.D., is Assistant Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy, Riley Hospital for Children at IUH. Alexandre T. Rotta, M.D., is Chief, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, and Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Sinclair
authors.affiliation: Christopher A. Thomas, Pharm.D., is Clinical Pharmacy Specialist-Pediatric Cardiovascular Intensive Care Unit (ICU), Department of Pharmacy, Riley Hospital for Children at Indiana University Health (IUH), Indianapolis; at the time of writing he was Clinical Pharmacy Specialist-Pediatric Cardiovascular ICU, Department of Pharmacy Services, Phoenix Children's Hospital, Phoenix, AZ. Jennifer L. Morris, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston; at the time of writing she was Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Riley Hospital for Children at IUH. Elizabeth A. Sinclair, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston. Richard H. Speicher, M.D., is Medical Director, Pediatric ICU, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH, and Assistant Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland. Sheikh S. Ahmed, M.D., is Assistant Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy, Riley Hospital for Children at IUH. Alexandre T. Rotta, M.D., is Chief, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, and Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Speicher
authors.affiliation: Christopher A. Thomas, Pharm.D., is Clinical Pharmacy Specialist-Pediatric Cardiovascular Intensive Care Unit (ICU), Department of Pharmacy, Riley Hospital for Children at Indiana University Health (IUH), Indianapolis; at the time of writing he was Clinical Pharmacy Specialist-Pediatric Cardiovascular ICU, Department of Pharmacy Services, Phoenix Children's Hospital, Phoenix, AZ. Jennifer L. Morris, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston; at the time of writing she was Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Riley Hospital for Children at IUH. Elizabeth A. Sinclair, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston. Richard H. Speicher, M.D., is Medical Director, Pediatric ICU, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH, and Assistant Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland. Sheikh S. Ahmed, M.D., is Assistant Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy, Riley Hospital for Children at IUH. Alexandre T. Rotta, M.D., is Chief, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, and Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University.
authors.forename: Sheikh S
authors.initials: SS
authors.lastname: Ahmed
authors.affiliation: Christopher A. Thomas, Pharm.D., is Clinical Pharmacy Specialist-Pediatric Cardiovascular Intensive Care Unit (ICU), Department of Pharmacy, Riley Hospital for Children at Indiana University Health (IUH), Indianapolis; at the time of writing he was Clinical Pharmacy Specialist-Pediatric Cardiovascular ICU, Department of Pharmacy Services, Phoenix Children's Hospital, Phoenix, AZ. Jennifer L. Morris, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston; at the time of writing she was Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Riley Hospital for Children at IUH. Elizabeth A. Sinclair, Pharm.D., is Clinical Pharmacy Specialist-Pediatric ICU, Department of Pharmacy Services, Texas Children's Hospital, Houston. Richard H. Speicher, M.D., is Medical Director, Pediatric ICU, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH, and Assistant Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland. Sheikh S. Ahmed, M.D., is Assistant Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy, Riley Hospital for Children at IUH. Alexandre T. Rotta, M.D., is Chief, Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, and Professor, Department of Pediatrics, School of Medicine, Case Western Reserve University.
authors.forename: Alexandre T
authors.initials: AT
authors.lastname: Rotta
mesh_terms: D061605:Administration, Intravenous; D006348:Cardiac Surgical Procedures / Q000191:economics / Q000379:methods; D002648:Child; D002740:Chlorothiazide / Q000008:administration & dosage* / Q000191:economics; D017046:Cost Savings; D004232:Diuretics / Q000008:administration & dosage* / Q000191:economics; D004976:Ethacrynic Acid / Q000008:administration & dosage* / Q000191:economics; D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000191:economics; D007902:Length of Stay; D016730:Program Development; D015397:Program Evaluation; D012189:Retrospective Studies; D012122:Ventilators, Mechanical / Q000706:statistics & numerical data
chemical_list: D004232:Diuretics; D002740:Chlorothiazide; D004976:Ethacrynic Acid