Process mapping to design theory-informed strategies reducing inappropriate HFNC use in emergency bronchiolitis care

High-flow nasal cannula (HFNC) in bronchiolitis is widely used beyond guideline recommendations. This study developed targeted, theory-informed implementation strategies to improve appropriate HFNC use in regional and rural emergency departments (EDs), to be evaluated in a cluster randomised controlled trial (cRCT).

A 3-phase process mapping and implementation science approach was embedded in a clinician co-design study involving 12 senior clinicians (5 nurses, 7 doctors) from Australian regional and rural EDs. International and Australian literature informed discussions. Barriers were coded using the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR 2.0) with strategy co-design guided by CFIR-ERIC and TDF-BCT linkages.

Five HFNC decision nodes were identified: assessment of hypoxaemia, low-flow oxygen trial and reassessment, escalation to HFNC, weaning and cessation, and escalation of care. Behavioural factors included fear of deterioration, limited confidence in respiratory assessment, and norms favouring early escalation. Contextual factors included limited paediatric expertise, staff turnover, and unclear de-escalation. Findings informed strategies including targeted education, clinical pathways and audit and feedback.

Process mapping identified behavioural and contextual drivers of inappropriate HFNC use informing implementation strategies and offering a practical, scalable approach to translating guidelines into routine ED practice.

This study identifies behavioural and contextual drivers of inappropriate high-flow nasal cannula use in infants with bronchiolitis across regional and rural emergency departments. Using structured process mapping and clinician co-design, we mapped decision-making at key clinical nodes and developed targeted, theory-informed implementation strategies to address identified barriers. Findings directly informed educational content and implementation strategies being evaluated in a cluster randomised controlled trial across 30 regional and rural hospitals. This work provides a practical, scalable framework for translating guidelines into routine emergency department practice, with relevance beyond bronchiolitis to other high-variation clinical behaviours in acute care.