Is implementation of a hospital pathway for high-flow nasal cannula
initiation and weaning associated with shorter treatment duration and
length of hospital stay in bronchiolitis?
Abstract
BACKGROUND: High-flow nasal cannula therapy (HFNC) is increasingly used
for children with bronchiolitis, but its optimal role remains relatively
uncertain. Our institution created and later revised a ward-based
clinical pathway guiding initiation and weaning of HFNC. METHODS: A
retrospective review of 664 encounters was conducted. Total duration of
HFNC, duration of weaning from maximum flow rate, hospital length of
stay (LOS), and escalation of care were compared across 3 study periods
using generalized linear models: Baseline (HFNC managed at provider
discretion, 5/1/2015-4/30/2017, n = 215), Intervention 1 (first pathway,
initiation at 0.5 L/kg/min and escalation up to 2 L/kg/min,
5/1/2017-2/28/2018, n = 155), and Intervention 2 (revised pathway,
initiation at the maximum rate of 2 L/kg/min, 3/1/2018-1/31/2020, n =
294). Both pathway iterations provided specific titration and weaning
guidance. Models controlled for initial SpO2 and maximum respiratory
rate to adjust for the possibility of differing case severity. RESULTS:
After adjustment for severity, total duration of HFNC was significantly
reduced in the second intervention, but not the first. Adjusted LOS was
shorter in Intervention 1 and Intervention 2 compared to the baseline
period. Adjusted weaning time and escalation of care did not differ
significantly between periods. CONCLUSION: Pathway implementation was
associated with modestly decreased LOS and – when initial flow rates
were increased to 2 L/kg/min – reduced duration of HFNC, without
differences in escalation of care or weaning time. These findings
highlight the potential role of standardization of practice with
clinical pathways in safely reducing unnecessary care.