Nebs No More After 24:
Improving Use of Appropriate Respiratory Services
UCSF DIVISION OF HOSPITAL MEDICINE
Supported by Caring Wisely, a project of the UCSF Center for
Healthcare Value – Delivery Systems Initiative
Christopher Moriates MD, Maria Novelero MA MPA, Matthew Cascino MD, Katie Quinn MPH,
Theodore Omachi MD MBA, Sumant Ranji MD, Raman Khanna MD, Michelle Mourad MD
BACKGROUND
PILOT STUDY RESULTS: Nebulizer Utilization
 The delivery of a nebulized bronchodilator therapy (nebs) to
hospitalized patients is a resource-intensive treatment
involving direct care by a Respiratory Therapist (RT).
8.00
 Administering unnecessary nebs is a missed opportunity to
educate patients on the proper use of MDIs.
Phase 2: Aug – Dec
Phase 3: May-Jul
•Removed neb treatments
from the “admit order set”
•Launched educational
program, including prepared
facilitator guides for attending
physicians
• Introduce CPOE
intervention to link
neb orders with
automatic MDI
transitions
•Enlisted RTs and nurses
to provide MDI teaching to
inpatients
 Metered Dose Inhalers (MDIs) have been shown to be equally
1,2,3
effective as nebs when used correctly.
 A majority of patients misuse their prescribed MDI, but all are
able to achieve mastery with teaching.4
Phase 1: Jun – Aug
•
•Created promotional
campaign including posters,
flyers, and pens
• Expand project
medical center-wide
•Provided targeted feedback
to physicians
7.00
1235
6.00
CONCLUSIONS
A multifaceted intervention has been successful in simultaneously:
•Decreasing neb treatments by approximately 50%
•Enhancing MDI patient education
1400
•Improving evidence-based resident physician knowledge
1200
1113
1000
5.00
1017
800
4.00
600
 At our 600-bed academic medical center, we spent over $1
million in direct costs for administration of nebs to nonintensive care unit patients on the Medicine Service during
FY2012, averaging approximately 5 nebs for every admission
to the high-acuity medicine ward.
3.00
 To decrease neb usage in hospitalized patients on a highacuity medicine ward by at least 15%.
 To provide inpatient education on proper MDI selfadministration.
 To improve resident physician knowledge regarding the use
of appropriate respiratory therapies.
Nebs No More After 24!
Help us improve transitions from nebulizers to
MDIs and provide patient education about
proper MDI use.
Reducing utilization of these unnecessary treatments may provide
an ideal target for improving healthcare value (quality / cost).
680
505
2.00
449
400
496
References:
1.00
200
0.00
0
May-12
Jun-12
Jul-12
Aug-12
Neb administrations per month
GOALS
•Saving direct costs for the medical center
Sep-12
Oct-12
Nebs administrations per admission
Pre- and post-intervention survey used to assess changes to
resident physician knowledge and attitudes:
Awareness that neb treatments are more expensive than MDIs: (p=0.11)
Pre-Test
Post-Test
82%
94%
Misassumption that neb treatments are more efficacious than MDIs: (p<0.01)
26%
WHAT CAN YOU DO?
 Use MDIs at admission unless there is a clinical indication
for nebulizer therapy
 Transition your patients from nebs to MDIs after 24
hours, if appropriate, and write an order for RT to provide
MDI teaching
 Help us spread the word:
MDIs are as effective as nebulizer treatments!
3%
Agreement with the statement that “patients receive adequate inpatient MDI
teaching”: (p<0.01)
Pre-Test
Post-Test
2. Dolovich MB, et al. Chest. 2005;127(1):335–371.
4. Press VG, et al. JGIM. 2011;26(6):635–642.
Nov-12
PILOT STUDY RESULTS: Knowledge and Attitudes
Pre-Test
Post-Test
1. Turner MO, et al. Arch Intern Med. 1997;157(15):1736–1744.
3. Mandelberg A, et al. Chest. 1997;112(6):1501–1505.
0%
16%
MDIs provide high value, high quality patient care!
We can teach and train our patients on correct MDI use
while in the hospital!