PDSA cycles 1-4
The original HFNC management protocol (PDSA 1) (supplement figure 1) was
implemented in October 2017, and it allowed the RT to make decisions
regarding the escalation and weaning of HFNC. Exclusion criteria at the
beginning included patients requiring nitric oxide, heliox, and
continuous albuterol. Prior to this, these decisions were made by the
physician or advanced practice provider.
The protocol was continuously re-evaluated throughout this study. Key
stakeholders met and hypothesized that continuous albuterol and HFNC
could potentially be weaned together. A continuous albuterol weaning
protocol had already been implemented in 2016 (supplement figure 2)
based on the Pediatric Asthma Severity Score (PASS). In March 2019, a
modified version of the HFNC management protocol was implemented (PDSA
2) that allowed simultaneous albuterol and HFNC weaning. We included
PDSA 1 as described above since there was likely early adoption in
including patients on continuous albuterol.
In July 2020, two modifications of the HFNC management protocol were
implemented for patients 13 years and older (PDSA 3)(Supplement figure
3). First, it allowed for an increase in the wean increment from 2
liters per minute to 5 liters per minute. Second, it changed the point
at which one could switch to simple nasal cannula from 4 liters per
minute to 10 liters per minute.
Key stakeholders, including pediatric intensivists, PICU RTs and
information technology specialists met again in May 2021 to re-evaluate
the existing protocol and discuss further interventions to decrease
length of HFNC and ultimately length of PICU and hospital LOS
(supplement figure 4). Given the success of another study (13), the HFNC
holiday (PDSA 4) was added as a modification to the existing protocol
(Figure 1). Re-education of the RTs occurred and the HFNC holiday was
implemented in October 2021. Adjustments to the EMR coincided to reflect
these changes to allow the RT to chart appropriately.