Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology

Fritz, Cristin Q.; Martin, Blake; Riccolo, Megan; Fennell, Michelle; Rolison, Elise; Carpenter, Todd; Bajaj, Lalit; Tyler, Amy; Brittan, Mark

doi:10.1097/pq9.0000000000000506

Cited by 3 publications

(6 citation statements)

References 15 publications

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“…In that study, reduced time-to-transfer decisions, and increased proportion of transfers with HFOT > 6 L/min were noticed. However, the stay in the PICU was not shortened [29]. This kind of guidelines and transfer criteria probably helps clinicians to evaluate more effectively the safe time to transfer patient from the PICU to the pediatric ward.…”

Section: Discussionmentioning

confidence: 99%

Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis

et al. 2023

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To evaluate the management of bronchiolitis in the paediatric intensive care unit (PICU) before and after publication of the national bronchiolitis guidelines in June 2015. All infants treated between 2016–2020 for bronchiolitis in the PICU of Tampere University Hospital at < 12 months of age were included. The data were retrospectively collected from electronic patient records. The current results reflecting the post-guideline era were compared with previously published results for the pre-guideline 2000–2015 period. These two studies used identical protocols. Forty-six infants treated in the PICU were included. During the post-guideline era, inhaled adrenaline was given to 26 (57%), salbutamol to 7 (15%), and hypertonic saline inhalations to 35 (75%) patients. Forty-three patients (94%) received high-flow oxygen therapy (HFOT). Seventeen patients (37%) were treated with nasal continuous positive airway pressure (CPAP) and 4 (9%) with mechanical ventilation.Conclusion: When post-guideline years were compared with pre-guideline years, the use of bronchodilators decreased in agreement, but the use of inhaled saline increased in disagreement with the guidelines. The use of respiratory support increased, evidently because of an introduction of the non-invasive HFOT treatment modality. What is Known:• Oxygen supplementation and respiratory support, when needed, are the cornerstones of bronchiolitis treatment.• Medicines are frequently given to infants with bronchiolitis, especially if intensive care is needed, although evidence of their effectiveness is lacking. What is New:• Nearly all (94%) infants who needed intensive care were treated with HFOT and 37% with nasal CPAP, and finally, only 9% were intubated, which reflects the effectiveness of non-invasive techniques.• When pre- and post-guideline eras were compared, use of racemic adrenaline decreased from 84 to 57%, but use of hypertonic saline increased up to 75%, which disagrees with the current guidelines.

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Section: Discussionmentioning

confidence: 99%

Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis

et al. 2023

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“…As the original project was a QI initiative, we also evaluated the impact of CDS tool deployment via X-bar charts using statistical process control rules from Carey et al 3 with the QI phase patients serving as the project baseline. As in our original QI study 1 , special cause variation was determined to be present when any of the following criteria were met: Exclude if prior encounter ICD-10 codes are identified as reflecting a pediatric complex chronic condition (PCCC) using the algorithm from Feudtner et al 4 Receiving floor-appropriate level of respiratory support for 6-hours…”

Section: Methods: Study Of the Interventionsmentioning

confidence: 99%

“…Though several clinical decision support (CDS) tools have been developed to facilitate timely identification of children at risk for deterioration [1][2][3][4] , less attention has been paid to the development of tools able to identify children with an improving clinical trajectory who may be ready for transfer out of the pediatric intensive care unit (PICU). Such 'de-escalation' CDS tools could improve patient care by reducing PICU length of stay (LOS), hospital LOS, hospital and patient costs, and by allowing providers on inpatient acute care wards to practice at the top of their clinical scope.…”

Section: Background and Significancementioning

confidence: 99%

“…In prior work 8 , we learned that transfer of many children with viral bronchiolitis from our institution's PICU to the acute care ward was not occurring despite hours of clinical stability while receiving 8 LPM or less of HFNC. Manual chart review revealed that non-medicallycomplex children admitted for viral bronchiolitis who remained stable on ≤8 LPM of HFNC for at least six hours were very unlikely to require re-escalation of respiratory support and were likely safe for floor transfer.…”

Section: Background and Significancementioning

confidence: 99%

“…Prior work has demonstrated that targeted QI interventions can accelerate the transfer of children from the PICU to the floor 12 including among those admitted for common respiratory conditions such as status asthmaticus and viral bronchiolitis 8,13 . Karube et al 13 and Alali et al 12 reported that the time interval between a patient becoming clinically ready for transfer and provider awareness of transfer readiness contributed to significant delays in transfer out of the PICU.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

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Improving Pediatric Intensive Care Unit Discharge Timeliness of Infants with Bronchiolitis Using Clinical Decision Support

et al. 2023

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BACKGROUND: Identifying children ready for transfer out of the pediatric ICU (PICU) is an area that may benefit from clinical decision support (CDS). We previously implemented a quality improvement (QI) initiative to accelerate the transfer evaluation of non-medically-complex PICU patients with viral bronchiolitis receiving floor-appropriate respiratory support. OBJECTIVES: Design a CDS tool adaptation of this QI initiative to further accelerate transfer evaluation of appropriate patients. METHODS: The original initiative focused on identifying for transfer evaluation otherwise healthy children admitted to the PICU with bronchiolitis who had been receiving floor-appropriate levels of respiratory support for at least 6-hours. However, this initiative required that clinicians manually track the respiratory support of qualifying patients. We designed an electronic health record (EHR)-based CDS tool to automate identification of transfer-ready candidates. The tool parses EHR data to identify children meeting prior QI initiative criteria and alerts clinicians to assess transfer readiness once a child has been receiving floor-appropriate respiratory support for 6-hours. We compared time from reaching floor-appropriate support to placement of the transfer order (“time-to-transfer"), PICU LOS, and hospital LOS between patients admitted prior to our QI initiative (12/1/2018-10/19/2019, “pre-QI-phase”), during the initiative but before CDS tool implementation (10/20/2019-2/7/2022, “QI-phase”), and after CDS implementation (2/8/2022-11/11/2022, “CDS-phase”). RESULTS: CDS-phase patients (n=131) had a shorter median time-to-transfer of 5.23 (IQR 3.38-10.0) hours compared to QI-phase patients (n=304) at 5.93 (4.23-12.2) hours (p=0.04). PICU and hospital LOS values decreased from the pre-QI (n=150) to QI-phase. Though LOS reductions were sustained during the CDS-phase, further reductions from QI to CDS-phase were not statistically significant. CONCLUSIONS: An EHR-based CDS adaptation of a prior QI initiative facilitated timely identification of PICU patients with bronchiolitis ready for transfer evaluation. Such tools might allow PICU clinicians to focus on other high-acuity tasks while accelerating transfer evaluation of appropriate patients.

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Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU

Maue

Ealy

Hobson

et al. 2023

Pediatric Critical Care Medicine

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Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU OBJECTIVES: To decrease length of high-flow nasal cannula (HFNC), PICU, and hospital length of stay (LOS).DESIGN: Quality improvement project. SETTING:A quaternary academic PICU. PATIENTS:Patients with bronchiolitis less than 24 months old. INTERVENTIONS:After initial implementation of a respiratory therapist (RT)driven HFNC protocol (Plan-Do-Study-Act [PDSA] 1) in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. MEASUREMENTS AND MAIN RESULTS:Duration of HFNC was used as the primary outcome measure. PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use, and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 1,310 patients were included in this study. Patients in PDSA 2, PDSA 3 and 4 groups were older compared with pre-intervention and PDSA 1 (median of 9 and 10 mo compared with 8 mo; p = 0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2, and 1.5 days after PDSA 3 and 4. Hospital LOS decreased from 5.7 to 4.5 days after PDSA 1, 3.1 days after PDSA 2, and 2.7 days after PDSA 3 and 4. The use of noninvasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at the end of the project. The 7-day PICU and hospital readmission rates did not increase after implementation. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. CONCLUSIONS:Modifications to an existing RT-driven HFNC protocol and standardization of discharge criteria led to an improvement in outcomes for patients admitted to the PICU with bronchiolitis without an increase in adverse events.

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Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology

Abstract: Supplemental Digital Content is available in the text.

Cited by 3 publications

References 15 publications

Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis

Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis

Improving Pediatric Intensive Care Unit Discharge Timeliness of Infants with Bronchiolitis Using Clinical Decision Support

Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU

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