Hospital Pharmacy - June 2020 - 200

836644
research-article2019

HPXXXX10.1177/0018578719836644Hospital PharmacyTester et al

Original Article

Impact of Clinical, Unit-Specific
Guidelines on Dornase Alfa Use
in Critically Ill Pediatric Patients
Without Cystic Fibrosis

Hospital Pharmacy
2020, Vol. 55(3) 200--204
© The Author(s) 2019
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https://doi.org/10.1177/0018578719836644
DOI: 10.1177/0018578719836644
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Carson Tester1, Doug Raiff1, and Travis Heath1

Abstract
Purpose: The purpose of this study was to evaluate the impact of the implementation of pharmacist-guided, unit-specific
dornase alfa utilization guidelines for patients without cystic fibrosis in an academic medical institution. The study reviewed
the prescribing patterns in the institution's pediatric intensive care unit (PICU) and pediatric cardiac intensive care unit
(PCICU) before and after the implementation of these guidelines. The primary objective of this study was to determine
the effects of the guidelines on the number of dornase alfa doses prescribed in critically ill pediatric patients without
cystic fibrosis. We also evaluated the pharmacoeconomic effect of the guidelines and the impact on clinical outcomes in
these critically ill patients. Methods: This study was a single-center, retrospective evaluation of the implementation of
pharmacist-guided, unit-specific dornase alfa guidelines. The guidelines were piloted on November 1, 2015. Pre-guideline
implementation data were collected from February 1, 2015 to October 31, 2015. Post-guideline implementation data
were collected from December 1, 2016 to August 31, 2016. We included patients admitted to the PICU and PCICU who
had received at least 1 dose of dornase alfa and did not have a medical history or suspicion of cystic fibrosis. Results:
During the pre-guideline data collection period, 1067 doses of dornase alfa were administered, and following guideline
implementation, 239 doses were administered. The average total admission length of stay for patients admitted to the PICU
or PCICU before guideline implementation and after implementation was 16.22 and 13.14 days, respectively (P = .042).
Conclusions: The implementation of pharmacist-guided, unit-specific dornase alfa guidelines within the PICU and PCICU
resulted in a 77.6% reduction in the use of dornase alfa among these units. The implementation of these guidelines led to a
cost reduction of approximately US $87 707.76 over a 9-month period for the health system. During the study, the length
of stay for patients admitted to the PICU and PCICU did not increase, indicating that the reduction in use of dornase alfa
did not negatively affect the overall hospital length of stay for patients.
Keywords
cost-effectiveness, critical care, drug/medical use evaluation, pediatrics

Introduction
Dornase alfa reduces the viscosity and elasticity of mucus in
the lungs by hydrolyzing DNA in the sputum, thus making
mucus easier to clear and improving lung function.1 Through
improved mucus clearance, dornase alfa has been shown to
decrease pulmonary inflammation and reduce the risk of
infection and pulmonary exacerbation in patients with cystic
fibrosis with an FEV1 (forced expiratory volume in the first
second of expiration) of >40%.2
Critically ill pediatric patients have been found to have
increased amounts of DNA in their sputum, increasing the
viscosity of their sputum and making it more difficult for
them to adequately clear these secretions from their lungs.1
Because pediatric patients typically have less developed
lungs than adults, critically ill pediatric patients often have

decreased lung function, requiring respiratory support or
intubation. Increased secretions in these patients may lead to
severe consequences, such as mucus plugging or atelectasis.
Conditions increasing sputum production in pediatric
patients include infection, asthma, sickle cell disease, trauma,
acute respiratory distress, and congenital lung disease.1
Although compelling evidence exists for improved outcomes
with the use of dornase alfa in pediatric patients with cystic
fibrosis, the evidence in pediatric patients without cystic
1

Duke University Hospital, Durham, NC, USA

Corresponding Author:
Carson Tester, Duke University Hospital, 200 Trent Drive, Duke Clinics,
Durham, NC 27710, USA.
Email: carson.tester@duke.edu
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