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Host Kyle B. Enfield, MD, FSHEA, FCCM is joined by Danielle K. Maue, MD, to discuss improving outcomes for bronchiolitis patients through a high-flow nasal cannula protocol, as discussed in the Pediatric Critical Care Medicine article, “Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU.” (Maue DK, et al. Pedtr Crit Care Med. 2023 Mar;24:233-244). Together, they explore groundbreaking initiatives that significantly improved outcomes for bronchiolitis patients using a high-flow nasal cannula protocol, the key interventions, and their impact. Dr. Maue is an Assistant Professor of Clinical Pediatrics for Riley Hospital for Children at Indiana University in Indianapolis, Indiana.
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Transcript:
Dr. Enfield: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Kyle Enfield. Today, I’ll be sitting down with Dr. Danielle K. Maue, MD, to discuss the article, “Improving Outcomes for Bronchiolitis Patients After Implementation of A High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU,” published in Pediatric Critical Care Medicine. To access the full article, visit pccmjournal.org.
Bronchiolitis is the most common indication for inpatient pediatric care in the United States. During the last decade, admissions and costs for bronchiolitis have increased. Studies have shown that adopting a respiratory therapist-driven high-flow nasal cannula management protocol can decrease the length of high-flow nasal cannula, PICU length of stay, and hospital length of stay.
Dr. Maue is an assistant professor of clinical pediatrics for Riley Hospital for Children and Indiana University in Indianapolis, Indiana. She and her colleagues performed a quality improvement project to determine if modifications to an existing RT-driven high-flow nasal cannula management protocol could safely further decrease the duration of high-flow nasal cannula, PICU length of stay, and hospital length of stay. Welcome, Dr. Maue. Before we start, do you have any disclosures to report?
Dr. Maue: No, I do not.
Dr. Enfield: Wonderful. For those people out there who may not know what bronchiolitis is, can you describe it for us and describe why it’s an issue for the pediatric population?
Dr. Maue: Sure. Bronchiolitis is caused by a virus. We generally think of RSV causing bronchiolitis, but there are other viruses that can cause it as well. Essentially what happens is their airways get inflamed, particularly the lower airways, which is a bigger problem for small children because their airways are smaller. So when there’s more inflammation, it causes more problems for them.
Dr. Enfield: And why do you think that we’ve seen a rise in admissions for bronchiolitis in the United States recently?
Dr. Maue: Well, over the last couple years, I think that we have seen kind of a delayed illness because during the early stages of the COVID pandemic, everybody was at home, so there was a large population of kids who weren’t exposed to a lot of things. Then as the world started opening up again, all those kids started becoming exposed. With the young babies who were young then and then the older infants to toddlers, we had a whole group of people who were experiencing viral infections for the first time.
Dr. Enfield: Makes total sense to me and kind of tracks with what we’ve seen in adult critical care as well with individuals not being exposed to lots of diseases for a couple of years and now opening that back up. I was curious when I read your article about the concept of an RT-driven management protocol and how that differed from traditional management protocols in the PICU.
Dr. Maue: When we say RT-driven, we mean respiratory therapist-driven, just to clarify that. When I first started residency and fellowship, a lot of the decisions about weaning respiratory support, weaning albuterol and asthmatics, that was all done by the physicians and usually the resident or fellow physician or, in some units, an advanced practice provider. What we would see would happen is, the physician would get busy doing admissions and doing other things, then we would go all night without anything being weaned when the patient would have been able to wean. What this did is essentially standardized a protocol for when we need to escalate support and then when we can de-escalate support based on different parameters. The respiratory therapist who is assigned to that patient can make those decisions independently with safeguards that, if we’re needing to escalate support, they notify the physician or the APP taking care of that patient.
Dr. Enfield: This sounds a lot like many of the things that we’ve implemented across the country to really help providers work at the full extent of their license. I imagine that respiratory therapists generally are very happy to have these protocols in place.
Dr. Maue: Yes. The first respiratory therapist-driven protocol we did in the ICU was actually a continuous albuterol weaning protocol. That was started back in 2016, and when that first concept was introduced, all of our core respiratory therapists who worked in the PICU for a long time were really excited about it. Then when the high-flow nasal cannula weaning protocol was introduced, they had already been used to the idea and were excited about that as well.
Dr. Enfield: I know from my experience that quality improvement projects can be really hard to design and implement and then analyze at the end. When you all were thinking about doing these interventions and then ultimately publishing them, what was your overall approach?
Dr. Maue: Yep. Full disclosure, when this was first started, I was a fellow and was not directly involved in the initial implementation. One of my mentors was. One of the first things we had to do was get buy-in, first from the respiratory therapists, which as I kind of already alluded to was pretty easy to do because they were excited about it. Then we also had to make sure that the physicians, all of our attendings, were comfortable with the idea. While there was some initial hesitation about it, eventually, once we explained the process, they became much more open to it.
Dr. Enfield: Then as the study rolled out, were there challenges or barriers that you encountered along the way?
Dr. Maue: Yeah. One of the things that we had to do was make electronic medical record changes to account for the respiratory therapist charting. That can take a little bit of time and I think there were some hiccups along the way there. The other thing that I think with any quality improvement project we see is there’s a lot of momentum at the beginning of the project. Then as time passes, people get busy and we do other things. We kind of forget about it or some of the things go to the wayside, then you have to reeducate and, not completely reimplement, but do another PDSA cycle with new things.
Dr. Enfield: That was going to be one of the follow-up questions I had as I was thinking about your study. I’ve experienced it oftentimes in our medical ICU. We have a lot of forward momentum for the first several weeks and people are really excited. Then things come along and people become less excited. What tips do you have for people who are experiencing that in their ICU? How did you reengage the providers, the attendings, the respiratory therapists in keeping momentum for this study going?
Dr. Maue: Yep. One thing that I think we’re really lucky on is that we have a group of core respiratory therapists who only work in the PICU and, among them, they have a director or a leader who is a respiratory therapist and is a PICU core respiratory therapist but has a little bit of protected time for administrative things. And we have gotten buy-in from the two respiratory therapy leaders who we’ve had over the years, and they have really been key in reminding and reeducating and keeping the respiratory therapists engaged.
Dr. Enfield: What about from the house staff, the fellows, the attendings, were there any barriers or frustrations along the way that had to be addressed by the study team?
Dr. Maue: Honestly, for the most part, our house staff were pretty excited about it because this took one thing off of their plate overnight, going in and manually weaning high-flow. There was some initial worry that perhaps they wouldn’t get notified if things were escalating and they were worried that they would be left out of that notification. But as time went on and things were implemented and we saw that we weren’t having any core outcomes related to it, I think that reassured everyone.
Dr. Enfield: Well, that sounds great. I wonder, for you, what was one of the most significant takeaways from this study?
Dr. Maue: Yep. I think the one of the significant takeaways is that respiratory therapist-driven protocols can work and they’re great for a lot of reasons. They can help improve outcomes. We found that, with some of our interventions, we were able to decrease length of high-flow nasal cannula. Throughout all of this, we were able to cut down on PICU length of stay. We were able to cut down on hospital length of stay; we actually cut that in less than half. It can improve workflow for the physicians and it also gives more independence to the respiratory therapist, which an experienced respiratory therapist really does like, in general.
Dr. Enfield: Were you surprised by any of the outcomes?
Dr. Maue: I guess, overall, not really. I was surprised by how much we were able to cut down on hospital length of stay by doing this. I mean, it was more than a 50% decrease, which is great and is a huge savings in terms of cost and it also is great for freeing up beds for patients who also need it. But I guess, no. I’m not super surprised by any of our positive outcomes.
Dr. Enfield: What about maintenance now? Have you guys been able to maintain this protocol and do you still feel like you’re seeing the same benefits to your patient populations? And along those lines, as a quick follow-up to that, are you still monitoring PICU length of stay and hospital length of stay for this patient population?
Dr. Maue: Overall, I think, yes. We are still doing the protocol. Since we adopted the high-flow nasal cannula holiday, one thing that we have overall struggled with is—this is a nationwide problem—we have a lot of traveler respiratory therapists who aren’t as familiar with our protocols. They’re great and they do great work, but they’re just not as familiar with some of our institution-specific things. So we’ve had to do a lot of reeducation with that group about some of these things, like the high-flow nasal cannula holiday. So I think if we’ve had struggles, that’s where it has been, just kind of reminding and reeducating. I haven’t rerun the data since the last time I have looked at it, but we are able to track our metrics and rerun if we need to.
Dr. Enfield: Yeah. I think the challenge that we’re experiencing across the nation with travelers who, like you said, are awesome clinicians and really have made it possible for us to continue to do our work but aren’t familiar with local protocols and other things is probably one for an entire podcast to do at some other point in time.
Dr. Maue: Yeah. Absolutely.
Dr. Enfield: I wonder what advice you would give to a student, fellow, or new faculty member who’s interested in doing quality improvement research. Where should they start and what tips should they take away? What tips would you give them as they look in that career pathway?
Dr. Maue: Yes. I think specifically for a resident or a fellow, my advice would be: Do not do this on your own; find an engaged faculty to work with you, because you’re theoretically only at your institution for a short period of time for your fellowship, and if you want the changes to sustain beyond when you leave, you’re going to need to have some faculty to help with buy-in. So I think that would be my advice specific to that group.
Just overall, I think we always say that if you want to start a quality improvement project, you look around in your day-to-day work and find out what are the barriers to getting things done effectively and finding and coming up and brainstorming a solution that could potentially make that better. Even if it’s a small change, sometimes the smaller changes are easier to implement just because there’s less involved. So brainstorming that first idea and then getting buy-in from everybody involved.
Dr. Enfield: That’s great advice for both fellows and residents. If you have somebody to continue the project once they leave, because I’ve seen a lot of great projects start and then sort of die off as as the person with the most motivation moves on to the next stage of their career. Thinking about your career, what is the next step for you? You’ve got a really great project here. What can we look forward to seeing from you in the future?
Dr. Maue: Right now, I’m looking at more data in relation to the high-flow nasal cannula weaning with pediatric patients with critical asthma. One of the interventions we did with the high-flow nasal cannula weaning protocol a few years ago is that we allowed high-flow and continuous albuterol to be weaned at the same time. That was a PDSA cycle directly related to the asthmatic population. And right now we’re looking at the outcomes in that population as opposed to the bronchiolitis population. We’ve done some initial data analysis. The manuscript should be ready here in the next couple months.
Dr. Enfield: I look forward to reading that. I think it’s great that there are people out there who are taking some of the things that have been shown in centers and really showing how they impact the outcomes in local hospitals, that implementation science is so crucial for us to get things moving forward for all of us. Before I sign off here, is there anything that we should have covered that we didn’t in this talk?
Dr. Maue: I think we pretty much covered all the high points, and I think we covered everything that was on your list.
Dr. Enfield: Well, I appreciate the time you’ve taken away this morning and encourage everyone to go to pccmjournal.org and find the March 2023 issue of Pediatric Critical Care Medicine and read the article because there’s a lot of great data in there, and I think it will be encouraging to people who are looking to implement this in their own hospital. This is going to conclude another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you like what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Kyle Enfield.
Announcer: Kyle B. Enfield, MD, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.
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