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.