Letters RESEARCH LETTER “Nebs No More After 24”: A Pilot Program to Improve the Use of Appropriate Respiratory Therapies Nebulized bronchodilator therapies (“nebs”) are commonly used in the inpatient setting for the treatment of obstructive pulmonary symptoms. Nebs have equal efficacy when com- pared with metered-dose inhalers (MDIs) for patients with ob- structive pulmonary symptoms 1-3 but are significantly more costly because they need to be directly administered by a re- spiratory therapist (RT). Unnecessary neb administration in the hospital also represents a missed opportunity to educate in- patients on proper use of their MDIs. Press et al 4 found that while 86% of patients incorrectly administered their pre- scribed MDI, all were able to achieve mastery following in- struction. We created a program to decrease inappropriate neb administration, improve inpatient MDI teaching, and in- crease resident physician knowledge of appropriate respira- tory therapies. Methods | We performed a needs assessment at our 600-bed aca- demic medical center and determined that over $1 million in direct costs were spent for administration of nebs to non– intensive care unit patients in the medical ward during fiscal year 2012. Using direct cost financial data from our institution, we cre- ated a basic financial model. This model accounted for differ- ences in direct pharmacy costs of neb and MDI medications, as well as RT time directly spent administering nebs and teach- ing MDI technique. We assessed changes in resident physicians’ knowledge and attitudes regarding nebulizer and MDI use using preinter- vention and postintervention surveys. These anonymous sur- veys queried residents regarding the costs and efficacy of nebs vs MDIs, as well as their beliefs about MDI training adequacy. We analyzed changes in knowledge (percentage answer- ing a question correctly) before and after the intervention using χ 2 statistics and Fisher exact tests as appropriate. We implemented system changes, along with educa- tional and promotional efforts, to encourage transitions of nebs to MDIs “within the first 24 hours of admission” (interven- tions and timeline are shown in the Figure). We monitored neb administrations on the pilot unit, our high-acuity medical ward, to determine the impact. Results | Prior to implementation, we averaged approximately 5 neb administrations per admission (for any cause) on our high-acuity medical ward. Our preliminary results demon- strate that overall nebs administered per month and number of nebs per patient fell by more than 50% on the pilot unit fol- lowing our initial interventions (Figure). Based on our finan- cial model, these improvements on only this single ward would save an estimated average of $20 827 in direct costs for our medical center each month, resulting in approximately $250 000 annually. Prior to implementation, 49 of 74 eligible internal medi- cine residents (66%) completed our pretest survey. Thirty- two of 48 eligible residents (67%) completed the postinter- Figure. Multifaceted Intervention and Nebulizer Rates on a High-Acuity Medical Ward 0.00 May 2012 July 2012 August 2012 September 2012 October 2012 November 2012 7.00 6.00 5.00 4.00 3.00 2.00 1.00 8.00 1400 1200 1000 800 600 400 200 0 Neb Rate Total Admissions, No. June 2012 1235 1017 680 449 505 496 1113 Neb administrations per admission Neb administrations per month June-August: August: • Removed neb treatments from the “admit order set” (June 1, 2012) • Enlisted RTs and nurses to provide MDI teaching to patients • Conducted resident physician presurvey • Introduced project to hospitalist attending physicians, resident physicians, and clinical RTs September-December: • Launched an educational program for physicians • Created a promotional campaign including posters, flyers, and pens • Provided targeted feedback to health care providers Our intervention was associated with a significant decrease in nebulizer rates (as measured per month and normalized by total admissions) on a pilot medical ward. MDI indicates metered-dose inhaler; neb, nebulized bronchodilator therapy; RT, respiratory therapist. jamainternalmedicine.com JAMA Intern Med Published online July 22, 2013 E1 Downloaded From: http://archinte.jamanetwork.com/ by a University of California - San Francisco User on 07/22/2013