Ribavirin therapy: implementation of hospital guidelines and effect on usage and cost of therapy.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends that ribavirin be reserved for infants who are severely ill and who are at high risk of morbidity and mortality, based on underlying clinical conditions. The purpose of this study was to evaluate current ribavirin use in our institution, implement hospital-specific guidelines for use, develop a prospective surveillance system to monitor ribavirin therapy, and evaluate the impact of these guidelines on subsequent use and cost of therapy. METHODS: Ribavirin use was compared with the recommendations of the AAP. Results were presented to the professional staff, and hospital guidelines were implemented. Ribavirin therapy was reevaluated in a 2-year period after hospital guidelines were implemented. RESULTS: In the initial evaluation period, only 67% of the ribavirin recipients met the AAP guidelines for use, and 19% received an inappropriate treatment regimen. The total cost and billed patient charges for ribavirin recipients who did not meet the guidelines for use in period 1 was $60,638 and $127,940, respectively. Over the next 2 years (period 2) after the implementation of hospital guidelines, the percentage of patients who received ribavirin decreased 35%, and approximately 96% of ribavirin recipients met the established criteria. Based on the decrease in the percentage of patients who received ribavirin in period 2 (41% versus 63%), the estimated cost avoidance and reduction in billed patient charges in period 2 was $55,540 and $117,334, respectively. This represents an estimated reduction in hospital costs and billed patient charges of $46,283 and $97,778 per 100 admissions for acute bronchiolitis. CONCLUSIONS: Before the implementation of hospital guidelines for use, a substantial percent of patients received ribavirin not consistent with the recommendations of the AAP. Following the adoption of a modified version of the AAP guidelines for our institution and the use of a multidisciplinary surveillance system for monitoring ribavirin therapy, we observed a substantial decrease in the overall ribavirin use. This has resulted in a significant savings in terms of cost avoidance and reduced billed patient charges.

Effect of PEEP-valve placement on function of a home-care ventilator.

BACKGROUND: The addition of a PEEP valve to the circuit of a home-care ventilator like the Aequitron LP-6 can be viewed as a consumer modification of the system. We sought to determine the effect that such a modification would have on ventilator function. METHODS & MATERIALS: Part 1. We tested the effect of PEEP level and PEEP-valve position on volume delivered at the ventilator Y-adapter, over a range of tidal volumes. Part 2. We held tidal volume, frequency, and inspiratory time constant, and varied PEEP level and PEEP-valve position to test the effect of PEEP-valve position on pressures measured at the ventilator outlet, patient-Y, and within the exhalation-valve pressurization line. RESULTS: Conventional placement of the PEEP value (distal to, or 'after,' the exhalation valve) in the LP-6 ventilator circuit resulted in statistically significant and potentially clinically important decreases in the volumes delivered to the patient at some ventilator settings. Proximal placement of the PEEP valve (proximal to, or 'before,' the exhalation valve) resulted in consistent volumes delivered to the patient at all levels tested, without changing the ventilatory performance characteristics of the ventilator as reflected by pressure waveforms. CONCLUSION: We recommend that appropriate observations and measurements be made to verify system function before a home-care ventilator modified to provide PEEP is applied to the patient.