Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway

Abstract

OBJECTIVES: Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization. DESIGN: A quality improvement study using a prospective cohort design with historical controls. SETTING: Four hundred seven-bed free standing quaternary care academic children’s hospital. PATIENTS: All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022. INTERVENTIONS: Unit-specific standard approaches to iNO initiation and weaning. MEASUREMENTS AND MAIN RESULTS: Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (–24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings. CONCLUSIONS: Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.