Protocol-Driven Initiation and Weaning of High-Flow Nasal Cannula for Patients With Bronchiolitis: A Quality Improvement Initiative*

Abstract

Bronchiolitis is the most common cause for nonelective infant hospitalization in the United States with increasing utilization of high-flow nasal cannula (HFNC). We standardized initiation and weaning of HFNC for bronchiolitis and quantified the impact on outcomes. Our specific aim was to reduce hospital and ICU length of stay (LOS) by 10% between two bronchiolitis seasons after implementation.DESIGN: A quality improvement (QI) project using statistical process control methodology. SETTING:Tertiary-care children's hospital with 24 PICU and 48 acute care pediatric beds. PATIENTS:Children less than 24 months old with bronchiolitis without other respiratory diagnoses or underlying cardiac, respiratory, or neuromuscular disorders between December 2017 and November 2018 (baseline), and December 2018 and February 2020 (postintervention). INTERVENTIONS:Interventions included development of an HFNC protocol with initiation and weaning guidelines, modification of protocol and respiratory assessment classification, education, and QI rounds with a focus on efficient HFNC weaning, transfer, and/or discharge. MEASUREMENTS AND MAIN RESULTS:A total of 223 children were included (96 baseline and 127 postintervention). The primary outcome metric, average LOS per patient, decreased from 4.0 to 2.8 days, and the average ICU LOS per patient decreased from 2.8 to 1.9 days. The secondary outcome metric, average HFNC treatment hours per patient, decreased from 44.0 to 36.3 hours. The primary and secondary outcomes met criteria for special cause variation. Balancing measures included ICU readmission rates, 30-day readmission rates, and adverse events, which were not different between the two periods. CONCLUSIONS:A standardized protocol for HFNC management for patients with bronchiolitis was associated with decreased hospital and ICU LOS, less time on HFNC, and no difference in readmissions or adverse events.

Editor’s Choice Articles for February

“…In this context, please look at the recently published protocol for the randomized controlled trial on conservative versus liberal oxygenation targets in critically ill children (18). To close these readings on bronchiolitis, have a look at the single-center quality improvement initiative on using a protocol for the initiation and weaning of HFNC oxygen for patients with bronchiolitis (19). Accompanying this article, our editorial describes a robust and cogent call to action (20).…”

Editor’s Choice Articles for March

“…This work extends two themes in PCCM: bronchiolitis and diaphragmatic electrophysiology. Regarding bronchiolitis respiratory support, by way of recalling what was published in 2023, we had a systematic review and network meta-analyses on HFNO and other NIV therapies in bronchiolitis (17); two quality improvement studies of "protocolized NIV" in bronchiolitis (18)(19)(20); and a multicenter, retrospective study of variations in early PICU management during IMV (21,22). Regarding diaphragmatic electrophysiology, in 2021 PCCM had a descriptive study of transcutaneous electromyography (23,24), and in 2023 there was a retrospective report about the range in Edi measurements in the PICU population (25,26) from the current researchers in Canada (3).…”

Deaf Ears, Blind Eyes, and Driverless Cars*

“…Peterson also developed an RT-led protocol that decreased duration of HFNC by ~5 hours, PICU LOS by ~12 hours and hospital LOS by ~24 hours (10). Although impact on HFNC duration varied and was often of a lower magnitude, it is noteworthy that all three of these studies (and Huang et al [7]) improved LOS by roughly one day.…”

“…In this issue of Pediatric Critical Care Medicine , Huang et al (7) report a quality improvement (QI) project with the primary objective of decreasing PICU and hospital length of stay (LOS) in patients with critical bronchiolitis. Through multiple plan-do-study-act cycles, they standardized initiation and titration of HFNC in these patients in their PICU.…”

“…Control charts add upper and lower “control limits” (generally three SDs from the mean) to identify significant deviations from the center line, which represents the mean in a control chart. Huang et al (7) used X-bar-S charts, a type of control chart that is generally used with larger sample sizes of continuous data points and allows for visualization of changes in the mean (shown on the X chart) and SD (S chart) over time (11). Other HFNC QI projects of similar size have used X-bar-S charts, although some prefer X-bar-R charts, which show range instead of SD, when sample sizes are small (8,10−12).…”