High-Flow Nasal Cannula for Bronchiolitis Management: A Quality Improvement Project for Acute Care Transition

Abstract

Background: Bronchiolitis is the leading cause of hospital admission for infants in the US and is commonly treated with HFNC. HFNC was not previously utilized in non-ICU wards at UC Davis Children’s Hospital. As part of an ongoing quality improvement (QI) effort, we identified the need to transition infants requiring HFNC for bronchiolitis out of the PICU.

Methods: In our single center QI project, we extended protocolized HFNC use to the acute care wards. A multidisciplinary team of physicians, nurses, respiratory therapists, and QI experts developed a HFNC protocol with an assessment tool; the Respiratory Assessment Classification (RAC). Preparing for safe deployment of protocolized HFNC in the non-ICU setting, we provided education for nurses, respiratory therapists, and physicians. QI meetings were held monthly and QI rounds daily to monitor adherence, implementation, outcomes, and adverse events. The pre-implementation period was December 2017 to March 2019, excluding December 2018 due to a short pilot program. The post-implementation period was March 2019 to February 2020. Analysis: Comparing pre and post groups, continuous variables (means or medians) were compared with t-test or STATA median test and categorical data (frequencies) were compared with X2 or Fisher’s exact test. IRB exemption was obtained through UC Davis.

Results: Patients were similar in both groups, however post implementation patients were older (10 vs 12 months mean, P=0.01). Following implementation, 73% of patients meeting out of ICU criteria were discharged home or transferred to the ward within 2 hours of meeting the criteria. Transferring to the ward while still receiving HFNC increased from 12% to 33% (P<0.001) in the post period. Patients in the post period had shorter ICU and hospital length of stay (LOS) than those in the pre period, by 12 hours and 1 day respectively (P < 0.001). Patients in the post period received oral feeds at higher HFNC flows than in the pre-period. Direct discharge from the PICU increased by 13% in our post-implementation group (P=0.05).

Conclusions: HFNC can be safely utilized outside of the ICU setting for the management of bronchiolitis. Standardization in care, education, and daily rounding leads to an increased focus in HFNC management in moderate to severe bronchiolitis. This may explain the increase in direct discharge from the ICU, as well as decreased hospital and ICU LOS. Our findings are encouraging and warrant future exploration in use of HFNC outside of the ICU setting.