8/8/2023 0 Comments Nasal cannula pediatric![]() ![]() One hypothesis for this reduction in LOS is that, by defining an upper limit of flow rates for our inpatient units at 2 L/kg per minute, we were able to admit patients on HFNC to the inpatient ward at flow rates that would have previously caused them to be sent to the PICU. Given that the collective severity of illness of patients with bronchiolitis is likely steady year to year, it is possible that the postimplementation subjects spent a larger proportion of their entire hospital course on HFNC but were able to rapidly discontinue the therapy and discharge faster because of this new protocol. This was an unexpected finding in the setting of static total hours on HFNC. This change did not occur during the protocol implementation phase. We found an overall reduction in mean LOS from 4.1 to 3.0 days greater than 1 year after SCRATCH implementation ( Fig 3). ![]() There were no inpatient ward-to-PICU transfers after a SCRATCH Trial, no patients started on noninvasive positive pressure ventilation after a SCRATCH Trial, and there was no change in the 7-day or 30-day readmission rates between the 2 groups. There was no significant reduction in the total hours of treatment with HFNC after SCRATCH Trial implementation ( Fig 3). Mean LOS decreased from 4.1 to 3.0 days, with special cause variation first identified on Janu( Fig 3). The mean hours of treatment with ≤8 LPM of HFNC decreased from 36.3 to 16.8 hours after SCRATCH Trial implementation, with special cause variation first identified on Ma( Fig 2). The mean hours of treatment with ≤6 LPM HFNC decreased from 31.4 hours to 12.1 hours after SCRATCH implementation, with special cause variation first identified on February 24, 2019. The mean hours of treatment with ≤4 LPM HFNC decreased from 19.5 hours to 5.8 hours after SCRATCH Trial implementation, with special cause variation (8 consecutive points below the center line) first identified on February 10, 2019. The specific aim of this QI project was to reduce the hours of treatment with ≤8 L per minute (LPM) of HFNC by 25% within 1 year of trial implementation ( Fig 1). 13 We developed the Simple Cannula/Room Air Trial for Children (SCRATCH Trial), a standard daily trial off HFNC for eligible infants. We modeled our work after the concept of a spontaneous breathing trial for an intubated patient already acculturated at our institution. 12 Building off this evidence, we developed our own process to trial patients off lower flows of HFNC. 11 Previous literature described protocols for a trial off HFNC as a safe and effective method of weaning HFNC. Our first major aim was to reduce HFNC waste, targeting patients no longer benefiting from the device and those treated at subtherapeutic flow rates, at which any potential benefit from increased end expiratory volumes would be lost. The overall aim of the BIG is to improve the value of care provided to infants hospitalized for bronchiolitis. We formalized an institutional leadership structure to focus on bronchiolitis quality improvement (QI), the Bronchiolitis Improvement Group (BIG), with stakeholder representatives from nursing, respiratory therapy (RT), and physician teams in the emergency department (ED), PICU, and pediatric hospital medicine. 8, 9 Other consequences of wasteful use of HFNC include prolonged discomfort and delayed enteral nutrition. 6, 7 Evidence from randomized controlled trials reveals that early use of HFNC may be unnecessary because it does not reduce the need for ICU transfer, noninvasive ventilation, or the total time of oxygen therapy. 4, 5 More recent observational literature documents the cost of early adoption from no change in outcomes including length of stay (LOS) or intubation rates, to increased PICU use with adoption of ward-based HFNC protocols. 3 Early observational literature in the critical care setting indicated reduced rates of intubation in infants with severe bronchiolitis when HFNC therapy was provided at flow rates of 2 L/kg per minute. 1, 2 Whereas supportive care is the mainstay of treatment, the use of heated and humidified high-flow nasal cannula (HFNC) in the treatment of bronchiolitis has increased dramatically over the last 10 years, and in part has driven increased health care costs. Viral bronchiolitis is a leading cause of hospitalization in the first year of life, with direct medical costs increasing annually. ![]()
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