Multicenter Quality Collaborative to Reduce Overuse of High-Flow Nasal Cannula in Bronchiolitis

Abstract

BACKGROUND AND OBJECTIVES High-flow nasal cannula (HFNC) for bronchiolitis increased over the past decade without clear benefit. This quality improvement collaborative aimed to reduce HFNC initiation and treatment duration by 30% from baseline. METHODS Participating hospitals either reduced HFNC initiation (Pause) or treatment duration (Holiday) in patients aged <24 months admitted for bronchiolitis. Participants received either Pause or Holiday toolkits, including: intervention protocol, training/educational materials, electronic medical record queries for data acquisition, small-group coaching, webinars, and real-time access to run charts. Pause arm primary outcome was proportion of patients initiated on HFNC. Holiday arm primary outcome was geometric mean HFNC treatment duration. Length of stay (LOS) was balancing measure for both. Each arm served as contemporaneous controls for the other. Outcomes analyzed using interrupted time series (ITS) and linear mixed-effects regression. RESULTS Seventy-one hospitals participated, 30 in the Pause (5746 patients) and 41 in the Holiday (7903 patients). Pause arm unadjusted HFNC initiation decreased 32% without LOS change. ITS showed immediate 16% decrease in initiation (95% confidence interval [CI] −27% to −5%). Compared with contemporaneous controls, Pause hospitals reduced HFNC initiation by 23% (95% CI −35% to −10%). Holiday arm unadjusted HFNC duration decreased 28% without LOS change. ITS showed immediate 11.8 hour decrease in duration (95% CI −18.3 hours to −5.2 hours). Compared with contemporaneous controls, Holiday hospitals reduced duration by 11 hours (95% CI −20.7 hours to −1.3 hours). CONCLUSIONS This quality improvement collaborative reduced HFNC initiation and duration without LOS increase. Contemporaneous control analysis supports intervention effects rather than secular trends toward less use.