Changes in High Flow Management Leads to Better Patient Outcomes

Abstract

Background:

In 2020, we implemented changes to our inpatient high-flow initiation and management protocol for patients less than 2 years old who were admitted with a diagnoses of bronchiolitis. These changes led to the following outcomes: decrease in patients receiving aerosolized treatments, decreased length of stay and time on high-flow oxygen, and a reduction in called rapid response teams. Additionally, there was no increase in the number of patients who were intubated after a rapid response team.

Methods:

Inclusion criteria: age > 28 days–2 years old, patient meets inclusion criteria for Bronchiolitis Pathway, and none of the following exclusion criteria: severe respiratory distress manifested as deep retractions, grunting, head bobbing; oxygen saturation < 90% while awake and < 88% while asleep despite standard nasal cannula therapy. Previous practice: initial flows and oxygen support 29 days–90 days: 4 L/min and 50%; 91 days–2 years old: 6 L/min and 50%; reassess at 30 min if patient condition worsens. If no improvement, increase flow by 1 L/min. Activate rapid response team if HFNC support exceeded, 29–90 days = 8 L/min, 91 days–2 years = 10 L/min. Albuterol nebulizer every 4 hours PRN per bronchiolitis protocol auto-checked at admission. Updated practice: Initial flows and oxygen support 1 L/kg/min flow to start, titrate up if inadequate response up to 2 L/kg/min; assess for capture of patient improved HR, RR, work of breathing. Adjust until captured. Start at 40-60% FIO₂; reassess in 30 min adjust HFNC settings as needed to capture, wean FIO₂ if oxygenation improved. Activate rapid response team if impending acute respiratory failure or shock. Albuterol nebulized solution was no longer auto-checked and needed to be manually added by provider.

Results:

Prior to the change in management, we administered 14,542 SVN treatments in November and December of 2019. After initiating this change, we saw a reduction of administered SVN by 23%. This was even with a markedly higher number of patients in this diagnosis group. We also realized a reduced number of rapid response team calls by nearly 50% with no change in the percentage of patients being transferred to a higher level of care or needing to be intubated. Finally, we saw an 11% reduction in our average length of stay in patients with a primary diagnosis of bronchiolitis.

Conclusions:

Revision of our high-flow management protocol and changes to our bronchiolitis pathway resulted in a reduction in SVN treatments, LOS, and rapid response team activation with no increase adverse events or readmissions.