Reducing High-flow Nasal Cannula Overutilization in Viral Bronchiolitis.

INTRODUCTION: Heated high-flow nasal cannula (HHFNC) therapy for bronchiolitis has become increasingly prevalent without evidence that this therapy impacts patient outcomes. Lack of criteria for appropriate use may lead to overutilization, resulting in increased costs without patient benefit. Our primary aim was to decrease use of HHFNC in patients with bronchiolitis over one season. METHODS: Patients with Bronchiolitis younger than 2 years of age admitted to the Hospital Medicine Service were included in this study. Using the model for improvement framework, we identified key drivers for HHFNC overuse and revised our bronchiolitis protocol to include low-flow nasal cannula trials before HHFNC initiation. We compared preintervention HHFNC utilization (December 2018-April 2019) with postintervention HFNC utilization (December 2019-March 2020). RESULTS: One hundred ninety patients met inclusion criteria, 98 of them in the preintervention cohort and 92 in the postintervention cohort. Overall, the median age was 9 months and 65% of patients were male. Our HHFNC utilization rate decreased from 62% (61/98) to 43% (40/92) in the postintervention period. Our SPC analysis suggested special cause variation based on 7 points below the preintervention mean. CONCLUSIONS: This QI intervention implementing a specified low-flow nasal cannula trial before the initiation of HHFNC shows promise in reducing overall HHFNC use. Future studies should focus on clear initiation and discontinuation criteria for HHFNC use in bronchiolitis.

The bronchiolitis severity score: An assessment of face validity, construct validity, and interobserver reliability.

OBJECTIVE: To assess face validity, interobserver reliability, and the ability to discriminate escalations of care within 24-h of admission (late rescues) for the bronchiolitis severity score (BSS) for children hospitalized for acute bronchiolitis. HYPOTHESES: The BSS will yield variable face validity, have clinically relevant interobserver reliability (kappa > 0.7), and distinguish late rescues during hospitalization. METHODS: We performed a combined retrospective and prospective, mixed methods study where (1) interobserver agreement was prospectively assessed by overall and subcategory congruence (kappa) calculations, (2) face value were qualitatively assessed from aggregate questionnaire responses, and (3) construct validity for late rescues were assessed using receiver operator characteristic (ROC) curve analyses. RESULTS: Face validity, assessed from 39 questionnaire respondents, were generally positive for BSS utility, reliability, and usability. The BSS exhibited weak interobserver reliability (kappa = 0.22, 95% confidence interval [CI]: 0.11-0.31) calculated from 72 sequential, blinded calculations. Retrospectively, 181 children less than 2 years of age admitted to the general pediatric ward for acute bronchiolitis from November 2017 to April 2019 were identified of which 18 (9.9%) experienced late rescues. Admission BSS values were no different for children with and without late rescues (6[3,6] vs. 4[3,6]; p = .09). An ROC curve analysis revealed an area under the curve of 0.61 (95% CI: 0.48-0.75; threshold ≥6 with sensitivity = 56%, specificity = 69%) for BSS to discriminate late rescues. CONCLUSION: Although clinicians expressed favorable perceptions of BSS face and content validity, we noted weak interobserver reliability and limited construct validity. Further development and validation are needed to strengthen the BSS before routine use.

Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus.

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

A pilot, double-blind, placebo-controlled trial of pregabalin (Lyrica) in the treatment of essential tremor.

We performed a pilot, double-blind, placebo-controlled, randomized trial to evaluate the efficacy and tolerability of pregabalin (PGB, Lyrica), an antiepileptic agent, in treating essential tremor (ET). Twenty two patients with ET were randomly assigned to receive PGB or placebo. PGB was initiated at 50 mg/day and was escalated by 75 mg/day every 4 days to a maximum dose of 600 mg/day. Patients were evaluated by accelerometry and the Fahn-Tolosa-Marin (FTM) rating scale. There was a significant reduction in tremor amplitude in the PGB group compared with the placebo group, as measured by accelerometry, at a mean dose of 286.76+/-100.05 mg/day. Action tremor limb scores on the FTM also improved in the PGB group compared with the placebo group (P-value for multilevel modeling=0.04). PGB was fairly well tolerated, with about one-third of patients dropping out of the study because of adverse events. PGB provided significant improvements in accelerometry and in action tremor limb scores on the FTM. However, larger studies are needed to further evaluate the potential effect of PGB on ET.

Evaluation of a summer research institute in behavioral health for undergraduate students.

Because of the need for additional researchers in the interdisciplinary field of behavioral health services research, the Florida Mental Health Institute at the University of South Florida developed and pilot tested a summer research institute for undergraduate students. Participants completed a 6-week program in which they developed a research project with a mentor and participated in a research seminar. The long-term objectives of the program were to attract promising students to the field and encourage them to pursue careers in behavioral health services research; short-term goals of the program were to strengthen participants' research skills and knowledge, provide an intensive and enjoyable learning experience, and positively impact participants' intentions to pursue graduate education in behavioral health. These goals were evaluated using a pre-post design with 6-month follow-up. Findings suggested that short-term goals were met. Suggestions for future improvements and implementation at other research settings are discussed.