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The Use of Increased Flow Rates for High Flow Nasal Cannula (HFNC) on the General Pediatric Wards
Description
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A2017 - The Use of Increased Flow Rates for High Flow Nasal Cannula (HFNC) on the General Pediatric Wards
Author Block: J. Popler1, J. Tejedor-Sojo2, F. Campo2, S. Sharma3; 1Children's Physician Group-Pulmonology at Scottish Rite, Children's Healthcare of Atlanta, Atlanta, GA, United States, 2Children's Healthcare of Atlanta, Atlanta, GA, United States, 3Pediatric Emergency Medicine Assocates, LLC, Atlanta, GA, United States.
RATIONALE
High-flow oxygen circuits are designed to deliver warm, humidified gas at flow rates between 4 to 60 liters per minute. Flow rates of 1-2 liters per kilogram of body weight per minute appear to be well-tolerated in pediatric patients. Most literature cites a maximum flow rate of 20-30 liters per minute. However, concerns have been raised that high-flow oxygen circuits may actually be delivering positive pressure ventilation and may not be safe for general pediatric wards.
METHODS
In January 2017, the Scottish Rite campus of Children's Healthcare of Atlanta (CHOA) increased the flow rate limits for the use of HFNC on the general pediatric wards. In prior years, the use of high-flow oxygen delivered via nasal cannula (HFNC) on the general pediatric wards was limited to between 4-8 liters per minute depending on patient weight. The use of higher flow rates required transfer to the intensive care unit (ICU). In 2017, the use of HFNC was expanded to higher flow rates, although still closely tied to body weight. The expanded limits allowed flows of up to 6 LPM in patients between 3-5 kilograms (kg), 10 LPM in patients between 5-10 kg, and 12 LPM in patients > 10 kg. In evaluating the impact of the expanded limits, the system began tracking Rapid Response (RR) calls and unplanned intubations within 6 hours of transfer to the intensive care unit. We also monitored the impact on ICU bed utilization.
RESULTS
In the 4 month period of analysis after the expanded guidelines were put in place, we did not identify a trend towards increased serious safety events. We did find a higher rate of rapid response calls for patients with bronchiolitis (this was not demonstrated for all patients on HFNC). We found a significant increase in ICU bed capacity after instituting higher flow limits on the general patient care areas.
CONCLUSION
The patient care areas where the number of rapid response calls increased most significantly were in areas that overall had low usage of HFNC. In patient care areas where patients with respiratory conditions were preferentially placed and where there was a greater usage of HFNC, there was an overall decrease in the rate of number of rapid response calls, suggesting that staff comfort in the use of HFNC may have played a significant role. Benefits of the expanded guidelines included less utilization of the ICU and increase in ICU bed capacity.
Author Block: J. Popler1, J. Tejedor-Sojo2, F. Campo2, S. Sharma3; 1Children's Physician Group-Pulmonology at Scottish Rite, Children's Healthcare of Atlanta, Atlanta, GA, United States, 2Children's Healthcare of Atlanta, Atlanta, GA, United States, 3Pediatric Emergency Medicine Assocates, LLC, Atlanta, GA, United States.
RATIONALE
High-flow oxygen circuits are designed to deliver warm, humidified gas at flow rates between 4 to 60 liters per minute. Flow rates of 1-2 liters per kilogram of body weight per minute appear to be well-tolerated in pediatric patients. Most literature cites a maximum flow rate of 20-30 liters per minute. However, concerns have been raised that high-flow oxygen circuits may actually be delivering positive pressure ventilation and may not be safe for general pediatric wards.
METHODS
In January 2017, the Scottish Rite campus of Children's Healthcare of Atlanta (CHOA) increased the flow rate limits for the use of HFNC on the general pediatric wards. In prior years, the use of high-flow oxygen delivered via nasal cannula (HFNC) on the general pediatric wards was limited to between 4-8 liters per minute depending on patient weight. The use of higher flow rates required transfer to the intensive care unit (ICU). In 2017, the use of HFNC was expanded to higher flow rates, although still closely tied to body weight. The expanded limits allowed flows of up to 6 LPM in patients between 3-5 kilograms (kg), 10 LPM in patients between 5-10 kg, and 12 LPM in patients > 10 kg. In evaluating the impact of the expanded limits, the system began tracking Rapid Response (RR) calls and unplanned intubations within 6 hours of transfer to the intensive care unit. We also monitored the impact on ICU bed utilization.
RESULTS
In the 4 month period of analysis after the expanded guidelines were put in place, we did not identify a trend towards increased serious safety events. We did find a higher rate of rapid response calls for patients with bronchiolitis (this was not demonstrated for all patients on HFNC). We found a significant increase in ICU bed capacity after instituting higher flow limits on the general patient care areas.
CONCLUSION
The patient care areas where the number of rapid response calls increased most significantly were in areas that overall had low usage of HFNC. In patient care areas where patients with respiratory conditions were preferentially placed and where there was a greater usage of HFNC, there was an overall decrease in the rate of number of rapid response calls, suggesting that staff comfort in the use of HFNC may have played a significant role. Benefits of the expanded guidelines included less utilization of the ICU and increase in ICU bed capacity.
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