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INTRODUCTION: High-cost medication administration, despite lacking evidence for use, results in poor healthcare value. This work aimed to reduce dornase-alfa utilization in critically ill mechanically ventilated children. METHODS: The project employed an observational pre-post design to develop a value-based clinical pathway to guide provider choice in mucolytic utilization in a quaternary pediatric intensive care unit. This pathway was designed to continue using low-cost mucolytic aerosols (hypertonic saline, N-acetylcysteine) but decrease new starts and total doses per 100 patient days (P100PD) dornase-alfa among patients for whom there is little to no supporting evidence. Interventions included a departmental journal club for fellow and attending physicians and a rolling introduction of the pathway to residents and respiratory therapists. Control charts serially tracked ordering changes and location-specific dornase alfa orders. RESULTS: New dornase-alfa starts P100PD decreased by 53% (1.17-0.55), and total doses P100PD decreased by 75% (16-4). N-acetylcysteine ordering more than doubled; however, total doses of P100PD remained unchanged after the intervention. The use of 3% sodium chloride increased significantly from 0.28 to 4.15 new starts and 4.37 to 38.84 total doses P100PD. Mechanical ventilation days P100PD decreased, suggesting there were no measured adverse effects of pathway implementation. The reduction in dornase-alfa utilization resulted in a cumulative and sustained 59% mucolytic cost reduction ($2183.08-$885.77 P100PD). CONCLUSION: A clinical pathway prioritizing pharmacoeconomics when evidence for use is lacking can improve health care value without adversely affecting patient outcomes.
RESUMO
BACKGROUND: Postpyloric feeding tube (PPFT) placement is essential for the ongoing nutrition care of critically ill children requiring noninvasive and invasive ventilation. PPFTs are placed by a variety of providers, including advanced practice nurses (APNs), surgeons, gastroenterologists, and radiologists. Complication rates, time to enteral nutrition (EN) following placement, and association with length of stay (LOS) have not been well documented. METHODS: A query of the electronic medical record identified patients in the pediatric intensive care unit (PICU) in whom PPFTs were placed. A retrospective chart review was performed to identify patient demographics; PPFT placement provider, indication, and duration; PICU LOS; hospital LOS; and patient pediatric risk of mortality (PRISM) scores. RESULTS: A total of 452 PPFTs were placed in 346 patients , with 318 placed by APNs. There was only one complication in 452 placed PPFTs. PRISM scores between patient groups for APN-placed PPFTs and non-APN-placed PPFTs were not significantly different. Mean time from hospital admission to PPFT placement was 1.5 days (APN) to 2.0 days (non-APN) (P < .02). Spearman correlation coefficients demonstrated shorter hospital and PICU LOS were associated with shorter duration to insertion. CONCLUSION: Overall complication rates of PPFT insertion is very low and do not significantly differ between provider type , even in patients with higher PRISM scores. Additionally, early time to insertion of PPFT is associated with decreased hospital and PICU LOS. Further research is needed to determine if the earlier time to insertion of PPFTs is associated with the achievement of goal feeds.
