(1390) High-Flow Nasal Cannula Weaning Protocol for Bronchiolitis in a Pediatric Intensive Care Unit

Introduction: Bronchiolitis is a leading cause of health care utilization for infants in the US, with 1 in 5 presenting to care and up to 3% requiring hospitalization. High flow nasal cannula (HFNC) use in the PICU continues to rise and the lack of standardized protocols often leads to longer treatment than clinically necessary. Our quality improvement project goal was to establish a safe and effective HFNC weaning protocol for patients with bronchiolitis in a single-center PICU, reducing HFNC time and PICU length-of-stay (LOS).

Methods: A weaning protocol was designed based on existing literature and common care practices. Respiratory therapy and provider teams were trained on a standardized respiratory assessment scoring tool and protocol guidelines. The protocol was then implemented and Plan-Do-Study-Act (PDSA) cycles were employed to improve enrollment and protocol compliance, including establishing recurring provider orientations, developing an EMR order-set, and integrating nursing in protocol workflow. The primary outcome measure was total HFNC time, with secondary measures of PICU LOS and hospital LOS. Outcome data was collected from the EMR and analyzed via QI Macros.

Results: Pre-implementation group included all admitted patients that met inclusion criteria over a 12-month period (n=133). Mean HFNC time was 41 hours, mean PICU LOS was 75 hours, and mean hospital LOS was 88 hours.

Over a 17-month period, 4 PDSA cycles were completed with 111 total patients enrolled out of 142 eligible (78% enrollment). When compared to the pre-implementation group, this group (all eligible) showed a significant reduction in all outcome measures: mean HFNC time 30 hours (27% reduction, p< 0.01), mean PICU LOS 57 hours (24% reduction, p< 0.01), and mean hospital LOS 64 hours (27% reduction, p< 0.01). Re-escalation, defined as requiring a higher level of respiratory support (e.g. NIPPV) after >4 hours on protocol, occurred at a rate of 2%.

Conclusions: Implementation of a HFNC weaning protocol can safely and effectively reduce total HFNC time, PICU LOS, and hospital LOS in pediatric patients admitted for bronchiolitis. Further PDSA cycles can be employed for continued improvement in enrollment and protocol compliance. Further study is indicated to assess the effect of comorbidities (e.g. pneumonia) on HFNC time.