Fauzia Shakeel
Johns Hopkins All Children’s Hospital, USA
Title: Decreasing inappropriate use of anti-reflux medications by standardizing gastroesophageal reflux disease (GERD) management in the NICU
Biography
Biography: Fauzia Shakeel
Abstract
in management of signs, symptoms, and complications associated with GERD in the NICU, with no evidence to support an
empiric trial of anti-reflux medications. Premature infants have weakly acidic reflux rather than acidic reflux, and inappropriate
use of acid suppressive medication has been linked to adverse clinical outcomes, like necrotizing enterocolitis and sepsis.
Standardization decreases variations in practice, and the risk for medication errors, while improving patient outcomes.
Methodology: Retrospective chart review of EMR data extracted electronically from the clinical surveillance tool TheraDoc,
provided baseline data regarding the use and dosage of anti-reflux medications. A multidisciplinary group of providers
developed evidence-based GERD management guidelines with an algorithm. The guidelines outlined definitions for GERD
symptoms, non-pharmacological measures for neonatal patients until they reach 37 weeks corrected gestational age (CGA)
and criteria for appropriate intervention and testing prior to initiation of anti-reflux medications. Our primary outcome was to
reduce inappropriate use of anti-reflux medications, related to timing of initiation of medication, dosing and GERD testing in
neonatal patients. Secondary outcomes were appropriate timing for GERD testing with PH probe and 24-hour multi-channel
impedance test and use of recommended formula change or other feeding strategies as needed. All three classes and doses
of GERD medications including H2 receptor antagonist, proton pump inhibitors (PPI) and prokinetics were monitored for
all patients admitted to the NICU. Project process improvement measures included, development of GERD management
algorithm for preterm infants, GERD order sets and GERD education sheet for staff and parents. Electronic GERD order
sets with correct dosing for medication were developed for all providers and GERD education sheets for staff and parents
were provided. Multiple Plan-Do-Study-Act (PDSA) cycles allowed for effective implementation, with staff education on use
of algorithm at bedside and monthly multidisciplinary group meetings to address deviation from guidelines and removal of
barriers. Education and communication plan was developed for physicians, advanced practice providers and bedside nursing
Data shared monthly and drill down conducted if management deviated from algorithm and feedback provided to staff.
Results: Implementation of standardized GERD management guidelines in NICU decreased the overall use of GERD
medications in all neonates from 15% to 2.8% and in preterm newborns less than 37 weeks (CGA) from 19.3% to 0% (Figure
1). Individualized use of each class of anti-reflux medications including H2 receptor antagonists, proton pump inhibitors and
prokinetics decreased from 7.2%, 12%, and 2.7% to 0%, respectively, for all categories. . The PPI lansoprazole was identified as the
most frequently used GERD medication for patients under 37 weeks gestational age (GA) at the time GERD medications were
initiated .With revision of EMR medication dosing and introduction of GERD order sets, incorrect dosing of lansoprazole was
decreased from 55% to 0% .The standardized guidelines and algorithm promoted effective testing and eliminated unnecessary
use of anti-reflux medication. The overall rate of NEC and late-onset sepsis also showed significant decrease in trend from 6.4%
and 13.8% to 4.3% and 8.9% respectively.
Conclusion: Our project demonstrated that standardizing clinical management guidelines in NICU provided best practice
GERD management strategies for a complex patient population and significantly reduced inappropriate use of dangerous antireflux
medications. Evidence-based guidelines and electronic order sets promoted basic testing, while eliminating incorrect
dosing, leading to improved patient safety and outcomes. There was reduced in hospital length of stay from 89days to 42 days
to date with substantial impact on cost savings (85% reduction) from decreased use in PPI.