(1272) Development of an Evidence-Based High-Flow Nasal Cannula Holiday Protocol for Bronchiolitis

Introduction: In recent years, High Flow Nasal Cannula (HFNC) has been accepted as standard therapy for infants with acute respiratory failure from viral bronchiolitis, and has been associated with decreased rates of mechanical ventilation. Nonetheless, HFNC use has been associated with longer hospital stays and increased hospital costs. Given these divergent outcomes, we developed a quality improvement (QI) project to implement use of an evidence-based HFNC holiday protocol to decrease HFNC duration and length of stay (LOS) in our pediatric intensive care unit (PICU).

Methods: With IRB exemption, we included children ages 30 days to 24 months who were admitted to the PICU with bronchiolitis and treated with HFNC. In the planning phase of this initiative, we performed a retrospective chart review to determine baseline protocol compliance and surveyed respiratory therapists (RTs) about compliance and barriers to protocol use. Our multidisciplinary team of PICU physicians, RTs, and nurses developed and implemented changes through Plan-Do-Study-Act (PDSA) cycles, informed by our survey results. In PDSA 1, we enhanced protocol visibility and streamlined documentation of patient assessments and interventions. Additional cycles will include standardization of scoring and weaning and introduction of a holiday. Run charts were developed to depict baseline outcomes of HFNC duration and PICU and hospital LOS, and to measure change following each intervention.

Results: We measured a baseline compliance of 15% (n=20 patients), defined as patients who had ≥90% of the every 4 hour assessments that led to changes according to the protocol. Following PDSA 1, compliance increased to 50% (n=6 patients); however, when considering the total number of assessments (n=60) rather than patients it increased to 90%. Our baseline HFNC duration, PICU LOS, and hospital LOS decreased from 39.7±5.7 to 35.5±5.8 hours, 49.1±7.1 to 47.2±9.5 hours, and 90.1±11.4 to 81.7±7.7 hours, respectively; however, there are insufficient data points following PDSA 1 to measure significant change.

Conclusions: Our preliminary results demonstrate feasibility of this study and highlight the importance of optimizing compliance. These results show a trend toward improvement in our outcome measures, however further study is needed to confirm findings.