De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative.

Bronchiolitis is the most common cause for hospitalization in the first year of life, with hypoxemia and acute respiratory failure as major determinants leading to hospitalization. In addition, the lack of existing guidelines for weaning and discontinuing supplemental oxygen, including high-flow nasal cannula, may contribute to prolonged hospitalization and increased resource utilization. Methods: This single-center quality improvement initiative assessed the effect of implementing a standardized care process for weaning and discontinuing high-flow oxygen for patients hospitalized with bronchiolitis. Patients aged 1-24 months with bronchiolitis admitted to the general wards or ICU step-down unit from February 1, 2018, and January 31, 2020 were included in the study. Primary outcomes included length of stay and time on supplemental oxygen, with time on high-flow oxygen and length of time in ICU step-down unit as secondary outcomes. Balancing measures included transfer rate to Pediatric Intensive Care Unit, intubation rate, 7- and 30-day readmission rates, and 7- and 30-day ED visits after discharge. Results: Following the standardized care process implementation, the mean length of stay decreased from 60.7 hours to 46.7 hours (P < 0.01). In addition, the mean time on any supplemental oxygen decreased by 47% (P < 0.01), the mean time on high-flow oxygen decreased by 45% (P < 0.01), and the mean time in the ICU step-down unit decreased by 27% (P =< 0.01). Balancing measures remained unchanged with no statistically significant differences. Conclusion: Implementing a standardized care process for weaning and discontinuing high-flow oxygen may reduce the length of stay and resource utilization for patients hospitalized with bronchiolitis.

Quality Improvement Project to Improve Screening for Tobacco Use in Adolescent Inpatients at a Children's Hospital.

Tobacco use begins in adolescence for the majority of smokers. The purpose of this study was to increase screening and reporting of tobacco use in hospitalized adolescents at a tertiary care children's hospital. We completed a nursing focus group to understand challenges and completed four iterative Plan-Do-Study-Act cycles, which included: (1) in-person nursing education regarding tobacco use screening, (2) addition of an e-cigarette-specific screening question, (3) the creation and dissemination of an educational video for nursing, and (4) adding the video as a mandatory component of nursing orientation. Run charts of the percentage of patients screened who reported tobacco use were created. Absolute counts of tobacco products used were also captured. From January 2016 to September 2018, 12,999 patients ≥13 years of age were admitted to the hospital. At baseline, 90.1% of patients were screened and 4.8% reported tobacco use. While the absolute number of adolescents reporting e-cigarette use increased from zero patients per month at baseline to five, the percentage of patients screened and reporting tobacco use was unchanged; the majority of e-cigarette users reported use of other tobacco products. This study demonstrates that adding e-cigarettes to screening increases reporting and suggests systems level changes are needed to improve tobacco use reporting.