Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis.

Importance: Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown. Objective: To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission. Design, Setting, and Participants: This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024. Exposure: Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey. Main Outcomes and Measures: Proportion of patients with bronchiolitis admitted to the ICU. Results: A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups. Conclusions and Relevance: Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

The Current State of High-Flow Nasal Cannula Protocols at Children's Hospitals.

OBJECTIVES: To describe the current state of non-ICU high flow nasal cannula (HFNC) protocols at children's hospitals and explore associations between HFNC protocol type and utilization outcomes. METHODS: We performed a cross-sectional study of the Pediatric Health Information Systems (PHIS) database. First, we designed a survey with the purpose of classifying HFNC protocols used at hospitals currently contributing data to PHIS. Next, we categorized hospitals based on their current HFNC protocol (ICU only, age-based non-ICU, or weight-based non-ICU). Finally, using the PHIS database, we compared hospital characteristics and patient-level bronchiolitis outcomes by HFNC protocol group. RESULTS: We received survey responses from 36 of 44 (82%) hospitals contributing data to PHIS in 2021. During the time period studied, there was a steady increase in adoption of non-ICU HFNC protocols, with 71% of responding children's hospitals reporting non-ICU HFNC protocols in 2021 compared with 11% before 2010. No differences in hospital characteristics were observed between ICU-only hospitals, age-based hospitals, or weight-based hospitals. Age-based hospitals had the highest proportion of bronchiolitis patients treated in the ICU (36.1%), whereas weight-based hospitals had the lowest proportion of patients treated in the ICU (21.0%, P < .001). Length of stay was longer at age-based hospitals (2.9 days) as compared with weight-based and ICU-only hospitals (1.9 days, P < .001). CONCLUSIONS: Most children's hospitals have adopted non-ICU HFNC protocols for patients with bronchiolitis, the majority of which are now utilizing weight-based maximum flow rates. Weight-based HFNC protocols were associated with decreased ICU utilization compared with age-based HFNC protocols.

Quality Improvement to Reduce High-Flow Nasal Cannula Overuse in Children With Bronchiolitis.

BACKGROUND: High-flow nasal cannula oxygen therapy (HFNC) is increasingly used to treat bronchiolitis. However, HFNC has not reduced time on supplemental oxygen, length of stay (LOS), or ICU admission. Our objective was to reduce HFNC use in children admitted for bronchiolitis from 41% to 20% over 2 years. METHODS: Using quality improvement methods, our multidisciplinary team formulated key drivers, including standardization of HFNC use, effective communication, knowledgeable staff, engaged providers and families, data transparency, and high-value care focus. Interventions included: (1) standardized HFNC initiation criteria, (2) staff education, (3) real-time feedback to providers, (4) a script for providers to use with families about expectations during admission, (5) team huddle for patients admitted on HFNC to discuss necessity, and (6) distribution of a bronchiolitis toolkit. We used statistical process control charts to track the percentage of children with bronchiolitis who received HFNC. Data were compared with a comparison institution not actively involved in quality improvement work around HFNC use to ensure improvements were not secondary to the COVID-19 pandemic alone. RESULTS: Over 10 months of interventions, we saw a decrease in HFNC use for patients admitted with bronchiolitis from 41% to 22%, which was sustained for >12 months. There was no change in HFNC use at the comparison institution. The overall mean LOS for children with bronchiolitis decreased from 60 to 45 hours. CONCLUSIONS: We successfully reduced HFNC use in children with bronchiolitis, improving delivery of high-value and evidence-based care. This reduction was associated with a 25% decrease in LOS.

Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS. METHODS: In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors. RESULTS: Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively. CONCLUSIONS: We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.

Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions.

BACKGROUND: Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE: Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS: We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS: We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION: We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES: The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS: Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION: We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.

Variation in Diagnostic Testing and Empiric Acyclovir Use for HSV Infection in Febrile Infants.

BACKGROUND AND OBJECTIVES: Clinicians evaluating for herpes simplex virus (HSV) in febrile infants must balance detection with overtesting, and there is no universally accepted approach to risk stratification. We aimed to describe variation in diagnostic evaluation and empirical acyclovir treatment of infants aged 0 to 60 days presenting with fever and determine the association between testing and length of stay (LOS). METHODS: In this retrospective 44-hospital observational study, we used the Pediatric Health Information System database to identify infants aged ≤60 days evaluated for fever in emergency departments from January 2016 through December 2017. We described hospital-level variation in laboratory testing, including HSV, imaging and other diagnostic evaluations, acyclovir use, and LOS. We assessed the relationship between HSV testing and LOS using generalized linear mixed effects models adjusted for age and illness severity. RESULTS: In 24 535 encounters for fever, the median HSV testing frequency across hospitals was 35.6% (interquartile range [IQR]: 28.5%-53.5%) for infants aged 0 to 21 days and 12% (IQR: 8.6%-15.7%) for infants aged 22 to 60 days. Among HSV-tested patients, median acyclovir use across hospitals was 79.2% (IQR: 68.1%-89.7%) for those aged 0 to 21 days and 63.6% (IQR: 44.1%-73%) for those aged 22 to 60 days. The prevalence of additional testing varied substantially by hospital and age group. Risk-adjusted LOS for HSV-tested infants was significantly longer than risk-adjusted LOS for those not tested (2.6 vs 1.9 days, P < .001). CONCLUSIONS: Substantial variation exists in diagnostic evaluation and acyclovir use, and infants who received HSV testing had a longer LOS than infants who did not. This variability supports the need for further studies to help clinicians better risk-stratify febrile infants and to guide HSV testing and treatment decisions.

Improving Efficiency of Pediatric Hospital Medicine Team Daily Workflow.

BACKGROUND AND OBJECTIVES: Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year. METHODS: Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time. RESULTS: Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable. CONCLUSIONS: Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.