PC1033: Bronchiolitis Pathway Implementation to Decrease High Flow Nasal Cannula Utilization

Purpose/Objectives: Bronchiolitis is one of the most common reasons for pediatric hospital admission. High flow nasal cannula (HFNC) is an expensive therapy that has been shown to decrease the progression to invasive ventilation in patients with severe bronchiolitis. However, HFNC is often used in patients with less severe disease, increasing length of stay and cost. We aimed to decrease the rate of use of HFNC in patients with mild and moderate (m/m) bronchiolitis, admitted to the hospital from the emergency department (ED), from a baseline of 46% to less than 23%.

Design/Methods: A multidisciplinary team formed in spring 2019 created a combined ED-inpatient bronchiolitis pathway. A respiratory score (RS) was utilized to objectively limit the use of HFNC to patients with severe disease. We tracked HFNC utilization among admitted patients with m/m bronchiolitis as our primary outcome measure between December 2019 and December 2021 (Figure 1). We monitored the percent of patients with a RS entered over the same time period as a process measure (Figure 2). We followed the mean hospital length of stay as a balancing measure. Prior to implementation, the RS tool within the EMR was made accessible for all clinicians to document and visualize easily. The bronchiolitis order set was updated with clinical decision support. Four plan-do-study-act cycles were completed to understand barriers, provide feedback to clinical teams, and further drive improvement. Additional interventions included updating the hospital oxygen therapy policy to reflect use of HFNC for bronchiolitis in severe distress alone, applying the RS to all patients in respiratory distress to increase utilization, and requiring RS entry in the bronchiolitis order set.

Results: 315 patients were admitted with m/m bronchiolitis in the 11 months prior to pathway implementation and 634 patients in the 25 months post implementation. Forty-six percent of these patients were admitted on HFNC prior to pathway implementation. Post implementation, the mean rate of HFNC utilization decreased to 19% (Figure 1). During the early stages of the pandemic, the volume of bronchiolitis decreased dramatically. The mean rate of HFNC utilization continued to be 19% in the spring of 2021 with a return to near normal patient volumes. RS entry increased from an average of 70% in the pre-implementation phase to 85% in the post-implementation phase. (Figure 2) The mean hospital length of stay was 38.5 hours in the pre-implementation phase and 40.7 hours in the post-implementation phase.

Conclusion/Discussion: A bronchiolitis clinical pathway implemented using quality improvement techniques can lead to a significant decrease in the inappropriate use of HFNC for patients with m/m bronchiolitis. Consistent RS, order set development with decision support, and education led to sustained improvement despite changes in volume and seasonality driven by the COVID-19 pandemic.