Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis

Abstract

Background: Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months. Methods: This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics. Results: We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions. Conclusions: Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.

Emergency Department Initiative to Decrease High-flow Nasal Cannula Use for Admitted Patients with Bronchiolitis

“…However, their outcome measure was a reduction in HFNC for all bronchiolitis admissions, whereas our pathway specifically targeted patients admitted with m/m disease. 24 Another study demonstrated a reduction in the use of HFNC by trialing low-flow oxygen for breathing work first, and only if that failed was HFNC initiated. 25 However, low-flow oxygen reinforces the “do something” mentality that can lead to overuse of resources.…”

A randomized, embedded, pragmatic, Bayesian clinical trial examining clinical decision support for high flow nasal cannula management in children with bronchiolitis: design and statistical analysis plan

“…As both a demonstration and potential solution to overutilization, single and multicenter de-implementation campaigns have recently worked to reduce the use of HFNC specifically for bronchiolitis, without any reported negative impact on patient care [ 16 , 24 , 25 ]. Importantly, calls for HFNC de-implementation have commonly cited the lack of efficacy data for improving outcomes such as duration of hospitalization or intensive care admission.…”

“…The collective findings of observational studies have been similarly inconclusive, with the use of HFNC associated with decreased [ 8 – 11 ], increased [ 12 ], or no difference [ 13 , 14 ] in the need for intensive care admission or invasive mechanical ventilation. The rise in the use of HFNC for bronchiolitis in the absence of high-quality data regarding efficacy has led to scrutiny regarding the financial costs and personnel time associated with HFNC, while raising the question “is HFNC being overutilized?” [ 15 , 16 ]. The American Academy of Pediatrics guidelines for the management of bronchiolitis were last updated in 2014 and do not advise on the use of noninvasive respiratory support, underscoring uncertainty regarding how to use HFNC in the management of children with bronchiolitis [ 17 ].…”