Implementation of Weight-Based HFNC Guidelines in Pediatric Ward

Background: High-flow nasal cannula (HFNC) is a common respiratory support device utilized in the management of children hospitalized with bronchiolitis. Around 2010, early adoption of HFNC in many pediatric wards was developed using age-based flow limits, primarily based on limited neonatal literature of the time. However, age-based flow limits do not align with current evidence and potentially contribute to unnecessary ICU admissions. To align with current evidence and improve ICU bed allocation, we implemented new weight-based flow guidelines within our pediatric wards. The primary objective of this study was to evaluate the impact of HFNC weight-based flow guidelines on ICU admission rates and adverse respiratory events for bronchiolitis. 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 and UT Southwestern. Subjects were infants admitted for bronchiolitis and supported via HFNC in the 12 months before and after implementation of weight-based flow guidelines (March 22 – Feb 24). Primary outcomes were ED disposition and ICU transfer rates. Secondary outcomes were escalation of respiratory support (NIV or intubation), escalation within 1 h of ICU admission and hospital length of stay (LOS). Descriptive statistics, t-test, and z-test were used for statistical analysis. This study was designated as non-regulated research by our institutional review board. Results: A total of 1,409 patients met inclusion criteria; 652 were admitted pre- and 757 post-implementation of weight-based flow guidelines. There were no differences between groups in age, weight, or gender. Compared to the pre-implementation group, we observed a 53% decrease in ICU admissions 111 (17%) vs 63 (8%); P < .001 and a 38% decrease in ICU transfers 44 (8%) vs 34 (5%); P = .03 with no difference in escalation of respiratory support 3 (7%) vs 5 (15%); P = .25 or escalation within 1 h of ICU admission 0 (0%) vs 2 (40%); P = .21. Mean LOS decreased by 17.3 h in the post-implementation group, 73.0 (52.2) vs 55.7 (39.9); P < .001. Full demographics, results, and subgroup analysis shown in Table 1. Conclusions: Implementation of weight-based flow guidelines resulted in fewer low-acuity bronchiolitis patients admitted to the ICU. This was associated with higher ICU patient complexity, requiring increased provider coverage. Other hospitals should plan for a similar ICU acuity pattern.