Standardizing HFNC for bronchiolitis: a quality improvement protocol in an Italian children's hospital

Bronchiolitis is the leading cause of non-elective hospitalizations in infants, with an increasing use of high-flow nasal cannula (HFNC) therapy outside the Pediatric Intensive Care Unit (PICU). At our hospital, HFNC was used to treat pediatric bronchiolitis patients without a standardized protocol for initiation, flow titration, escalation, or a PICU alert system in cases of clinical deterioration. This quality improvement project aimed to evaluate the feasibility of a multidisciplinary protocol designed to standardize HFNC use for bronchiolitis in patients under 24 months of age, admitted to the emergency department (ED) during the 2021-2023 winter seasons and through the first 72 h of hospitalization. The primary outcomes were healthcare provider adherence and staff satisfaction. The protocol utilized the Clinical Respiratory Score (CRS) to guide therapy: low-flow oxygen for CRS < 4, HFNC with PICU notification for CRS 4-7, and consideration for non-invasive ventilation (NIV) and PICU transfer for CRS > 7. Satisfaction was assessed via a questionnaire stratified by clinical experience. As a secondary objective, CRS and clinical outcomes (length of stay [LOS] and PICU admission rates) of the per-protocol group were compared to a historical cohort admitted to our hospital during the two preceding winter seasons. The CRS used for comparison with the prospective group were retrospectively calculated from clinical chart review. Prospective data from 114 patients were analyzed; 97 were managed in full compliance with the protocol, yielding an adherence rate of 85.1%. Staff satisfaction was 100% among pediatric residents (n = 5) and junior physicians (< 5 years of experience, n = 15), while senior physicians (≥ 5 years of experience, n = 15) reported a 70% satisfaction rate. No significant differences were observed in LOS (6.13 ± 2.60 days per-protocol vs. 7.12 ± 8.95 days pre-protocol; p = 0.303) or PICU admission rates (20.6% per-protocol vs. 11.6% pre-protocol; p = 0.150). In the retrospective cohort (n = 86), the mean CRS at ED admission was significantly lower than in the per-protocol group (p < 0.001). However, the per-protocol group exhibited significantly lower CRS values at 48 h and 72 h (p < 0.001), despite higher baseline severity.

The implementation of a structured HFNC protocol based on CRS scores is feasible in a tertiary pediatric setting, achieving high adherence (85%) and overall staff satisfaction (85.7%). While clinical outcomes remained comparable, the standardized approach encouraged early monitoring and was associated with earlier improvement in respiratory scores. Future initiatives should focus on optimizing adherence and addressing the specific concerns of senior clinical staff.

• Current evidence does not support high-flow nasal cannula (HFNC) as a superior first-line therapy compared to standard low-flow oxygen. However, implementing a structured hospital protocol that reserves HFNC for selected patients who fail low-flow therapy can optimize clinical management and ensure timely intervention for those in urgent need.

• This study demonstrates that a structured multidisciplinary protocol for HFNC - based on the Clinical Respiratory Score (CRS) and with a formal "PICU alert system" - is highly feasible in a tertiary Italian setting, achieving an overall adherence rate of 85.1%. The protocol was well-received by healthcare providers, with a global staff satisfaction rate of 85.7%.