Respiratory Therapist-Driven High-Flow Nasal Cannula Protocol: Non-Weight Based Versus Weight-Based for Pediatric Acute Bronchiolitis Patients

Abstract

Background: The purpose of this study is to evaluate a newly implemented Respiratory Therapist (RT) driven “weight-based” (WB) high flow nasal cannula (HFNC) pathway on Pediatric Intensive Care Unit (PICU) admission rates of acute bronchiolitis patients from the pediatric acute care unit.

Methods: This study was approved by the UCSF Benioff Children’s Hospital Oakland Institutional Review Board. Clinical data was retrospectively extracted from the electronic medical records for the month of February 2018 for the non-weight-based pathway (non-WB) and February 2019 weight-based pathway (WB). The non-WB pathway allowed RTs to adjust the HFNC to a maximum flow of 8 L/min and up to 50% FIO₂. If a patient’s condition deteriorated, this would prompt a PICU consult and transfer, in order to provide an escalation of care. The reconfigured 2019 WB pathway, implemented in December 2018, allowed RTs to provide a higher level of care on the pediatric acute care unit by administering a range of flows beyond the single rate and FIO₂ prescribed via a WB approach in terms of L/min delivered. Patients weighing under 5 kg could receive flows up to 8 L/min, 5-10 kg patients could receive flows up to 10 L/min, 10-15 kg patients could receive flows up to 12 L/min, and 15 kg patients could receive flows up to 15 L/min. Non-WB group was compared to WB using the following outcome variables: PICU admission rate, hospital length of stay (LOS), and hours spent on HFNC.

Results: There was a total of 71 patients diagnosed with acute bronchiolitis (non-WB n=43; WB n=28). The proportion of patients admitted to PICU significantly decreased in WB versus non-WB (28.6% versus 58.1%, P = 0.013, Eta=0.29). There was a significant reduction in mean hours spent on HFNC in the WB compared to the non-WB (78.8 ± 42.2 versus 123 ± 116, P=0.013; d=1.04). In addition, Hospital LOS also reduced in WB to 6.5 ± 3.5 from 8.0 ± 5.9 non-WB, P=0.11; d=0.43). There was a reduction in room and HFNC device charges on patients in the WB cohort.

Conclusions: In this preliminary study, there was a significant reduction in daily PICU admission rate, hours spent on HFNC, and a potential reduction of overall hospital costs/charges using the WB pathway. We believe this study will help pave the way for further exploration and implementation of RT driven pathways to be conducted in other facilities. Further analysis of the actual cost-savings for patients is required.