SCRATCH Trial: An Initiative to Reduce Excess Use of High-Flow Nasal Cannula

Noelck, Michelle; Foster, Alex; Kelly, Serena; Arehart, Ashley; Rufener, Christina; Wagner, Tamara S.; Ibsen, Laura M.; Burns, Erin

doi:10.1542/hpeds.2020-003913

Cited by 19 publications

(12 citation statements)

References 13 publications

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“…This aligns with a quality initiative using an RT‐driven protocol for bronchiolitis patients to decrease the length of HFNC therapy and LOS 20 . Another QI project took a different approach and implemented once or twice daily standardized trials directly off HFNC, demonstrating decreased LOS and reduced hours of subtherapeutic flow rates 21 . The weaning guidance within our HFNC pathway provided both RT notification to wean improving patients as well as the opportunity for providers to trial a patient directly from HFNC to room air.…”

Section: Discussionmentioning

confidence: 72%

“… 20 Another QI project took a different approach and implemented once or twice daily standardized trials directly off HFNC, demonstrating decreased LOS and reduced hours of subtherapeutic flow rates. 21 The weaning guidance within our HFNC pathway provided both RT notification to wean improving patients as well as the opportunity for providers to trial a patient directly from HFNC to room air. While this weaning guidance remained identical in Interventions 1 and 2, it is possible that weaning guidance was a key factor in driving the outcomes that we saw as providers gained experience with the pathway.…”

Section: Discussionmentioning

confidence: 99%

“…18 National experts recommend greater standardization in HFNC use, including providing a protocol for HFNC initiation, 19 with practice standardization projects being developed to reduce excessive use. 20,21 In a PICU quality improvement/pre-post intervention study, standardizing HFNC use with a protocol using higher initial flow rates was associated with faster weaning and decreased HFNC failure. 22 Likewise, an RTdriven PICU protocol for HFNC initiation and weaning was associated with decreased LOS and therapy duration.…”

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confidence: 99%

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Is implementation of a hospital pathway for high‐flow nasal cannula initiation and weaning associated with reduced high‐flow duration in bronchiolitis?

Tarantino

Goodrich

Kerns

et al. 2022

Pediatric Pulmonology

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Background High‐flow nasal cannula (HFNC) therapy is widely used for children with bronchiolitis, but its optimal role remains uncertain. Our institution created and later revised a clinical pathway guiding HFNC initiation and weaning. Methods A retrospective review of 1690 bronchiolitis encounters was conducted. Trends in the duration of HFNC and hours spent weaning HFNC as proportions of the monthly hospital length of stay (LOS) for bronchiolitis, hospital LOS, and escalation of care were compared using interrupted time series (ITS) models across three study periods: Baseline (HFNC managed at provider discretion), Intervention 1 (pathway with initiation at 0.5 L/kg/min and escalation up to 2 L/kg/min), and Intervention 2 (revised pathway, initiation at the maximum rate of 2 L/kg/min). Both pathway iterations provided titration and weaning guidance. Maximum respiratory scores were used to adjust for case severity. Results After adjustment for severity and time, both HFNC duration and HFNC weaning time (as a proportion of monthly LOS) decreased at the start of Intervention 1, but subsequently increased. During Intervention 2, both these measures trended downward, returning to baseline. Total LOS did not change in the baseline or intervention periods. Escalation of care did not differ from baseline to the end of Intervention 2. Conclusion Initiating HFNC at higher flow rates with weaning guidance for children hospitalized with bronchiolitis was associated with a reduction in HFNC duration without differences in LOS or escalation of care. These findings suggest that standardization through clinical pathways can limit HFNC duration in bronchiolitis.

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Section: Discussionmentioning

confidence: 72%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Is implementation of a hospital pathway for high‐flow nasal cannula initiation and weaning associated with reduced high‐flow duration in bronchiolitis?

Tarantino

Goodrich

Kerns

et al. 2022

Pediatric Pulmonology

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“…RT-driven HFNC management protocols have been largely successful across PICUs (14, 16, 23). While different protocols vary slightly, they are very similar to one another overall.…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies have shown that adaptation of a respiratory therapist (RT)-driven HFNC management protocol can decrease length of HFNC, PICU LOS, and hospital LOS (14)(15)(16). RT-driven standardized management protocols have been successful in demonstrating effective and efficient care previously in a PICU setting (17)(18)(19)(20).…”

mentioning

confidence: 99%

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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Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients

Maue,

Cater,

Rogerson

et al. 2023

Pediatric Pulmonology

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IntroductionThis study aimed to determine if a respiratory therapist (RT)‐driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma.MethodsThis was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of an RT‐driven HFNC protocol [Plan‐Do‐Study‐Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7‐day PICU and hospital readmission rates were used as balancing measures.ResultsA total of 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. After PDSA 2, mean HFNC duration decreased (26.8–18.1 h). Mean PICU LOS decreased (41–31.8 h). Mean hospital LOS also decreased (86.5–68 h). These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use were unchanged, while IMV use decreased.ConclusionsAn RT‐driven HFNC protocol led to decreased length of HFNC and PICU and hospital LOS for pediatric patients with critical asthma without an increase in adverse events.

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SCRATCH Trial: An Initiative to Reduce Excess Use of High-Flow Nasal Cannula

Cited by 19 publications

References 13 publications

Is implementation of a hospital pathway for high‐flow nasal cannula initiation and weaning associated with reduced high‐flow duration in bronchiolitis?

Is implementation of a hospital pathway for high‐flow nasal cannula initiation and weaning associated with reduced high‐flow duration in bronchiolitis?

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

Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients

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