PM2030: Taking a Holiday from High Flow: Standardizing Inpatient Management of Bronchiolitis

Purpose/Objectives: Bronchiolitis is a leading cause of hospitalization in patients ages 0-24 months. Use of high flow nasal cannula (HFNC) in bronchiolitis increased following initial studies that noted improved outcomes (Ralston, 2014; Kalburgi, 2020) leading to increased usage of HFNC therapy (Kalburgi, 2020). However, more recent studies have proven that early initiation of HFNC ultimately produces no difference in hospital length of stay (LOS), does not contribute to decreased rates of transfer to intensive care unit (ICU), and does not decrease intubation rates or decrease duration of oxygen therapy (Lin, 2019). Given the absence of standardized protocols for initiation and discontinuation, frequent use of HFNC persists in the management of bronchiolitis with varying thresholds for weaning. This project, known as High-flow Interventions to Facilitate Less Overuse or HIFLO, is part of a national QI initiative whose goal is to standardize initiation and weaning of HFNC in the management of children admitted for bronchiolitis. The primary aim was to reduce total HFNC duration in children with bronchiolitis by 30% by March 2022. The primary outcome measure was the total number of hours of treatment with HFNC.

Design/Methods: The study included children hospitalized for management of bronchiolitis aged 30 days to 23 months. Baseline data was collected from 11/24/2019- 3/14/2020 and compared to intervention data collected from 11/28/2021- 3/29/2022. Factors evaluated included LOS, total duration of HFNC use and whether patients experienced rapid clinical deterioration. The intervention introduced a standardized weaning protocol for HFNC in patients with mild to moderate bronchiolitis that did not meet exclusion criteria, known as the HIFLO Holiday. In HIFLO Holiday, the HFNC is turned off and patient monitored. Based on vital signs and clinical exam, a decision is made whether to remain on room air, transition instead to low flow nasal cannula, or to return to HFNC.

Results: Among 119 patients in the intervention phase, 61 underwent HIFLO Holiday. LOS was decreased in the intervention phase, with exception of cycle 15 as seen in figure 1. Duration of HFNC use downtrended throughout the study as seen in figure 2.

Conclusion/Discussion: Approximately 51% of patients hospitalized with bronchiolitis on HFNC underwent HIFLO Holiday. Overall decreased LOS and duration of HFNC use by 25% and 29%, respectively, in comparison of means from pre- to post-intervention cycles. While HIFLO Holiday was easy to implement without considerable increase in resources, there was decreased documentation and initiation of holiday as cycles progressed, which may indicate need for continued education of staff. Limited sample size, particularly in later cycles, made it difficult to qualify the lasting effects of the protocol. Lack of adverse effects or clinical deterioration allows to safely continue implementing HIFLO Holiday in the future.