(170) Optimizing IV Vasopressin Use for Septic Shock: QI Project

Introduction: The 2021 surviving sepsis guidelines suggest Arginine vasopressin (AVP) infusion as an adjunct to norepinephrine (NE) in the treatment of septic shock. AVP is costly compared to other vasopressors (e.g. norepinephrine and epinephrine). Our institution spent over $1 million US dollars in Fiscal Year 2020 on AVP. Initial studies utilized a dose of 0.03 units/min, however higher doses of 0.04 units/min are commonly used. A quality improvement project was implemented to examine ways in optimizing AVP use in septic shock at our institution.

Methods: In 2021, our critical care committee approved an institutional guideline standardizing AVP dose and the threshold NE dose prior to AVP initiation in septic shock. Guideline implementation also included an AVP order in EPIC with defaulted dosing options. We collaborated with 4 other academic medical centers targeting the following goals: 1) AVP selection as second line agent in septic shock (Goal >90%), 2) AVP dosed at 0.03 units/min (Goal >80%), 3) AVP added when NE is ≥ 0.2 mcg/kg/min (Goal >60%) and 4) AVP turned off before NE (Goal >70%). Implementation was a multi-pronged and interdisciplinary approach, with education to providers, nurses, and pharmacists.

Results: Post institutional guideline approval, AVP use in septic shock was reviewed monthly as part of a QI project using a PDSA format. A team of pharmacists provided ongoing education and information dissemination through presentations and at provider and nursing unit meetings to help increase awareness of the initiative and collect frontline feedback. By quarter 3 (9 months post guideline implementation), we achieved three of the four prespecified goals: goal #1 = 90%, goal #3 = 67%, and goal #4 = 81%. We were at 71% with goal #2. This resulted in an estimated annual savings of $100K.

Conclusions: Implementation of an institutional guideline improved the use of AVP in septic shock. Standardization of AVP dosing via EPIC enhanced compliance. In collaboration with partner academic medical centers, there is greater opportunity for creative problem-solving to facilitate implementation of new initiatives such as this. Moving forward, continuous education will be important to ensure guideline adherence