Resident The Barbara Bush Children's Hospital at Maine Medical Center Portland, Maine, United States
Background: The pediatric intensive care unit (PICU) at Maine Medical Center (MMC) is an 8-bed unit that serves Maine and Southern New Hampshire. Bronchiolitis is a common respiratory illness that accounts for a substantial volume of admissions to pediatric hospitals as a whole and a substantial burden on PICUs, as approximately 25% of bronchiolitis patients require ICU admission. High flow nasal cannula (HFNC) is used to treat bronchiolitis in PICUs, and its use has been extended to inpatient units (IPUs). Research has shown that HFNC implementation in non-critical care units appears safe, but guidance is lacking on what patient factors and unit-level safety mechanisms should be utilized as criteria escalation. Objective: This quality improvement study aims to safely decrease PICU transfers for bronchiolitis requiring HFNC by 20% within one year by instituting a HFNC escalation guideline on the inpatient unit. This study also aims to define safe parameters for HFNC on the IPU using deterioration scoring and a rapid response team. Design/Methods: This study was approved by the IRB at MMC. All patients admitted to the IPU with bronchiolitis aged 2 months to 2 years and placed on HFNC were collected 6 months before escalation guideline implementation on April 10, 2023. Patients were identified using an electronic medical record reporting system. The primary outcome measure is the percentage of patients with bronchiolitis on HFNC transferred to the PICU. Using this baseline data, our aim was generated using a p-chart, where the mean percent transfer rate was 64% without special cause variation before guideline implementation. Our process measures include guideline adherence to exclusion criteria and adherence to oxygen and flow limits. Our balancing measures are the percentage of patients with rapid responses and unplanned/emergent PICU admissions. Our first PDSA cycle included increasing HFNC flow limits from 1L/kg/min to 2L/kg/min, and the study team will determine subsequent cycles. Control charts will be used to analyze outcome, process, and balancing measures over time.
