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Published on: September 24, 2020
Impact of Weight-Based High-Flow Nasal Cannula Flow Limits on Intensive Care Unit Utilization in Bronchiolitis
Gerald B Moody1, Sachin Shah2, Ali Hasan3
1Mr. Moody is affiliated with Department of Respiratory Care, Children's Health-Children's Medical Center Plano, Plano, Texas, USA.
Insights
Implementing weight-based flow limits for high-flow nasal cannula (HFNC) in pediatric bronchiolitis care significantly reduced intensive care unit (ICU) admissions and hospital stays. This change improved ICU bed allocation while maintaining patient safety and outcomes.
Area of Science:
- Pediatric critical care medicine
- Respiratory support technologies
- Hospital operational efficiency
Background:
- High-flow nasal cannula (HFNC) is a standard respiratory support for pediatric bronchiolitis.
- Existing age-based HFNC flow limits may not align with current evidence, potentially leading to unnecessary intensive care unit (ICU) admissions.
- Transitioning to evidence-based flow limits is crucial for optimizing resource allocation and patient care.
Purpose of the Study:
- To evaluate the impact of implementing weight-based flow limits for HFNC on ICU utilization in pediatric bronchiolitis patients.
- To assess changes in ICU admission rates, ward-to-ICU transfers, and overall hospital length of stay.
- To determine if weight-based flow limits affect escalation of respiratory support or adverse respiratory events.
Main Methods:
- Retrospective study at a community-based hospital comparing 12 months before and after implementing weight-based HFNC flow limits.
- Included patients under 2 years old admitted for bronchiolitis and treated with HFNC.
- Primary outcomes: Emergency Department disposition and ICU transfer rates. Secondary outcomes: Adverse respiratory events and length of stay.
Main Results:
- A total of 1,207 patients were analyzed (558 pre-implementation, 649 post-implementation).
- ICU admissions decreased by 8.6% (16.5% vs 7.9%, P < .001) and ward-to-ICU transfers by 3% (6% vs 3%, P = .034).
- Overall median hospital stay decreased by 15.9 hours (P < .001), with no significant difference in respiratory support escalation.
Conclusions:
- Transitioning from age-based to weight-based HFNC flow limits, with appropriate safeguards, can significantly improve ICU bed utilization.
- Weight-based HFNC flow limits maintain comparable patient outcomes to age-based limits.
- This strategy offers a practical approach for hospital systems to optimize resource allocation in pediatric respiratory care.
Abstract:
Background: High-flow nasal cannula (HFNC) is a common respiratory support device utilized in the management of children hospitalized with bronchiolitis. Early adoption in many pediatric wards was developed using age-based flow limits. However, age-based limits do not align with current evidence and potentially contribute to ICU admissions. To align with current evidence and improve ICU bed allocation, we implemented weight-based flow limits within our wards. The primary objective of this study was to evaluate the impact of these changes on ICU utilization. Methods: This retrospective study was conducted at Children's Medical Center in Plano, Texas, a free-standing, community-based hospital affiliated with an academic quaternary center. Subjects were patients < 2 years of age admitted for bronchiolitis and supported via HFNC in the 12 months before and after implementation of weight-based flow limits. Primary outcomes were ED disposition and ICU transfer rates. Secondary outcomes were evaluation of adverse respiratory events and stay. Results: A total of 1,207 subjects met inclusion criteria; 558 pre- and 649 post-implementation. There were no differences between groups in age, weight, or gender. Compared with the pre-implementation group, we observed an 8.6% absolute decrease in ICU admissions [92 (16.5%) vs 51 (7.9%), P < .001], a 3% absolute decrease in ward to ICU transfers [28 (6%) vs 19 (3%), P = .034], and no difference in escalation of respiratory support [6 (1.1%) vs 4 (0.6%), P = .38] or escalation within one hour of transfer [0 (0%) vs 2 (50%), P > .99]. Overall median stay decreased by 15.9 h in the post-implementation group, [59.4 (IQR 39.1- 85.9) vs 43.5 (IQR 26.9-67.2), P < .001]. Conclusions: These findings suggest that for hospital systems utilizing similar age-based HFNC flow limits, transitioning to weight-based flows, with safeguards in place, may improve ICU bed utilization while maintaining comparable patient outcomes.
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