Impact of Stewardship on Inhaled Nitric Oxide Utilization in a Neonatal ICU.
Inhaled nitric oxide (iNO) remains the "gold standard" therapy for hypoxemic respiratory failure in newborns. Despite good quality evidence to guide iNO use in this population, we observed considerable practice variation, particularly in timing and rate of weaning. To promote evidence-based practice, we launched an iNO stewardship program in April 2013. Our objective was to determine whether iNO stewardship led to changes in iNO utilization and weaning.



We conducted a quality improvement project in an outborn quaternary NICU, targeting improved iNO guideline compliance. We compared patterns of iNO utilization between 2 cohorts: prestewardship (April 2011-March 2013; retrospective data collection) and poststewardship (April 2013-March 2015; prospective data collection).



Eighty-seven neonates received 88 courses of iNO in the 2 years prestewardship, and 64 neonates received 64 courses of iNO in the 2 years poststewardship. There were no significant differences (P > .05) in patient demographics, in the proportion of patients receiving iNO "off-label," in proportion initiated at the referring hospital, or in outcomes (death or extracorporeal membrane oxygenation). There were significant (P < .05) reductions in median total hours on iNO per patient (47 vs 20; P < .001), in iNO hours per patient from maximum dose to initial wean (28 vs 9; P < .01), and in hours from initial wean to discontinuation (14 vs 8; P < .05).



The introduction of iNO stewardship was associated with improved adherence to evidence-based guidelines and an overall reduction in total and per-patient iNO use.
Division of Neonatology and.
Amir
A
Elmekkawi
Department of Neonatology, Christchurch Women's Hospital, Christchurch, New Zealand; and.
Kiran
K
More
Division of Neonatology and.
Jennifer
J
Shea
Department of Critical Care, The Hospital for Sick Children, Toronto, Canada.
Christina
C
Sperling
Division of Neonatology and.
Zelia
Z
Da Silva
Division of Neonatology and.
Michael
M
Finelli
Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada.
Asaph
A
Rolnitsky
Division of Neonatology and robert.jankov@sickkids.ca.
Robert P
RP
Jankov
D002170:Canada / Q000453:epidemiology; D019091:Critical Pathways / Q000458:organization & administration / Q000592:standards; D055317:Evidence-Based Practice / Q000379:methods; D005260:Female; D019983:Guideline Adherence / Q000592:standards; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data*; D008297:Male; D000069342:Medical Overuse / Q000517:prevention & control*; D009569:Nitric Oxide / Q000627:therapeutic use*; D058996:Quality Improvement; D012131:Respiratory Insufficiency / Q000453:epidemiology / Q000628:therapy*; D012138:Respiratory Therapy / Q000379:methods / Q000706:statistics & numerical data
D009569:Nitric Oxide