Achievement of a Better Value of Care for Nitric Oxide Utilization with Protocol Based Adherence and Implementation by Respiratory Therapists: A Multidisciplinary Approach to Deliver Cost-Effective Care

Abstract

Background Inhaled nitric oxide is a potent pulmonary vasodilator that can be used in various clinical situations to treat right ventricular failure, pulmonary hypertension and hypoxia. While clinical utility is evident in practice, randomized trials are rare and widespread availability is limited by lack of such evidence and cost of therapy. We report our initiative of cost saving while maintaining good outcomes by organizing protocols for utilization and expeditious weaning implemented by respiratory therapy. Methods In a multidisciplinary fashion a thorough literature search was performed to create a Protocol (Figure 1) for initiation of inhaled nitric oxide and strict weaning algorithms through a quality improvement committee. The protocol reflected consensus of all parties involved (Heart failure cardiologists, thoracic transplant surgeons, lung transplant pulmonologists, critical care physicians and respiratory therapists) Accountability of implementing the protocols rested with respiratory therapists with privileges to order confined to the groups of physicians mentioned above. Results Inhaled nitric oxide usage was up to 12000 hours in 2014. The above protocols were implemented in September 2015 with quarterly oversight of the quality improvement committee with respiratory therapy reporting. There was a steady decline in the utilization of number of hours of nitric oxide with a cost savings of a quarter million dollars (Figure 2). Of note the quality outcomes of patients during this time for all the programs (heart transplant, LVAD, heart failure and liver failure) that utilized nitric oxide had nationally reputable survival. Conclusions While nitric oxide utilization can be of great benefit for critically ill patients, uncontrolled use could lead to exuberant costs. By controlling the use and establishing protocols of not just use but timely and effective weaning, we were able to maintain quality of care while reducing costs being able to deliver care with a better value.