Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis.

Background: Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months. Methods: This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics. Results: We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions. Conclusions: Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.

Optimizing Resident Education during Family-centered Rounds: An Educational Improvement Initiative.

Family-centered rounding (FCR) allows the medical team to partner with patients in medical decision-making, improving communication, and enhancing safety. However, FCR may compromise aspects of the resident education experience. In a survey of pediatric residents at our children's hospital, only 20% felt FCR provided the best educational experience. We designed this project to increase the percentage of residents with a positive perception of the educational experience on FCR from 20% to 80% in 6 months. Methods: This project utilized The Model for Improvement and sequential plan-do-study-act cycles. A needs assessment identified educational activities negatively impacted by FCR. We then designed a hybrid FCR process with formal presentations outside patient rooms followed by traditional bedside FCR. Our primary measure was the percentage of residents positively perceiving the FCR educational experience. Our balancing measures included rounding duration and family satisfaction and comprehension. Results: Residents who perceive FCR to be the best educational experience improved from a baseline of 21% to 76%, with a calculated response rate of 79%. Patients receiving FCR remained above 80%. All surveyed families understood their care plans and remained satisfied with the information provided, although 21% were concerned about the number of people present on rounds during the COVID-19 pandemic. Forty-three percent of hospitalist rounds exceeded the allotted time. Conclusions: The hybridization of FCR to include formal presentations may improve the resident learning experience while preserving family satisfaction and comprehension.

Acceptability of Deimplementing High-Flow Nasal Cannula in Pediatric Bronchiolitis.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) in children hospitalized with bronchiolitis does not significantly improve clinical outcomes but can increase costs and intensive care unit use. Given widespread HFNC use, it is imperative to reduce use. However, there is limited information on key factors that affect deimplementation. To explore acceptability of HFNC deimplementation, perceptions of HFNC benefits, and identify barriers and facilitators to deimplementation. METHODS: We conducted a study of health care providers that included quantitative survey data supplemented by semistructured interviews. Data were analyzed using univariate tests and thematic content analysis. RESULTS: A total of 152 (39%) providers completed the survey; 9 participated in interviews. Eighty-three (55%) providers reported feeling positively about deimplementing HFNC. Reports of feeling positively increased as perceived familiarity with evidence increased (P = .04). Physicians were more likely than nurses and respiratory therapists to report feeling positively (P = .003). Hospital setting and years of clinical experience were not associated with feeling positively (P = .98 and .55, respectively). One hundred (66%) providers attributed nonevidence-based clinical benefits to HFNC. Barriers to deimplementation included discomfort with not intervening, perception that HFNC helps, and variation in risk tolerance and clinical experience. Facilitators promoting deimplementation include staff education, a culture of safely doing less, and enhanced multidisciplinary communication. CONCLUSIONS: Deimplementation of HFNC in children with bronchiolitis is acceptable among providers. Hospital leaders should educate staff, create a culture for safely doing less, and enhance multidisciplinary communication to facilitate deimplementation.