P2A230: Improving PICU Length of Stay for Bronchiolitis Patients by Introducing the High Flow Nasal Cannula Challenge

Purpose/Objectives: The care for bronchiolitis patients requiring continuous positive airway pressure (CPAP) in the pediatric intensive care unit (PICU) is frequent and highly variable across PICUs. Our institution does not have standardization of weaning CPAP support once children improve. The utilization of CPAP is not without consequences, as such usage increases time spent without nutrition (NPO) and overall PICU length of stay. Our aim in introducing the “high flow nasal cannula challenge” weaning protocol in our community PICU, is that previously healthy infants less than one year of age using CPAP will have a median 20% reduction in CPAP utilization, time spent NPO, and ICU medical length of stay within six months of introduction.

Design/Methods: Retrospective chart review identified patients between April 2021 and August 2022 for pre-intervention baseline data. Exclusion criteria included chronic respiratory support needs, chronic medical conditions, progression to intubation, and BiPAP utilization. Meetings were held amongst key operational leadership stakeholders prior to providing this option for weaning respiratory support to clinicians. Once a patient was ready to wean CPAP, the medical team elected whether to use the “high flow nasal cannula challenge” to wean. Post intervention data was collected retrospectively following discharge from the ICU. Balancing measures included resumption of CPAP support following HFNC challenge and readmission to the ICU.

Results: A total of 230 patients were initially identified from April 2021 to February 2023. Of 137 pre-intervention patient encounters, 28 encounters were excluded, leaving 109 for review. Post intervention, 93 patient encounters were initially identified and 17 were excluded, leaving 76 for review. The weaning protocol was adopted for 40 encounters (53% of post intervention group). Overall median time on CPAP decreased by 41%, from 27 to 16 hours. Median time spent NPO decreased from 39 to 25.5 hours (35%). Median medical ICU length of stay decreased from 41 to 35 hours (15%). One patient had to resume CPAP following initiation of the high flow nasal cannula challenge, and one patient was readmitted to the ICU.

Conclusion/Discussion: Despite 53% adoption of the weaning protocol, our ICU was able to meet two out of the three goals on our first PDSA cycle safely, without a significant risk of readmission or weaning failure. We hypothesize that increasing adoption of the weaning protocol will continue to improve all three metrics. Our goal is to introduce this weaning protocol to other PICUs across our health care system. In doing so, we will provide safe, timely, and efficient health care to the most commonly admitted patient population in our PICUs.