High-flow nasal cannula bronchiolitis treatment outside ICU tied to long stays, high costs

Pediatric patients with bronchiolitis who are admitted to hospitals that use more high-flow nasal cannula outside the ICU face longer stays and greater total costs, according to study results published in Hospital Pediatrics.

Jeffrey C. Winer

“It is important for hospitalists and other clinicians caring for children with bronchiolitis to be mindful about the initiation of high-flow nasal cannula (HFNC) in these patients,” Jeffrey C. Winer, MD, MA, MSHS, FAAP, associate professor of pediatrics and associate fellowship program director of pediatric academic hospital medicine at the University of Tennessee Health Science Center, told Healio. “HFNC is not without its own adverse effects, including discomfort, lack of mobility, potential limitations in oral intake and potential prolongation in hospitalization. Other measures such as suctioning and repositioning may relieve transient respiratory distress and should be utilized first.”

In a multicenter retrospective cohort study, Winer and colleagues analyzed 15,155 children (48.3% aged younger than 6 months; 58.6% boys) aged younger than 2 years hospitalized with bronchiolitis between Sept. 1, 2018, and March 21, 2019, from 20 hospitals to determine if hospital-level HFNC usage outside of the ICU is related to changes in length of stay and total cost.

Winer and colleagues also sought to observe the variability of HFNC use outside of the ICU in hospitals.

Researchers split the studied hospitals into three groups that were characterized by the proportion of patients receiving/using HFNC outside of the ICU (non-ICU HFNC): low (range, 1.1%-6.6%; n = 3,385), moderate (range, 19.4%-31.2%; n = 6,130) or high (range, 38.6%-80.1%; n = 5,640) non-ICU HFNC usage.

In terms of non-ICU HFNC usage, researchers found significant variation (P < .001) and an average of 31.9% of patients using it.

“While we weren’t surprised that there was variation in high-flow nasal cannula usage in non-intensive care patients, we were very surprised with the degree of variation,” Winer told Healio.

To find the estimated association between non-ICU HFNC usage and length of stay and cost, researchers conducted hierarchical mixed-model linear regression and calculated both unadjusted and adjusted multiplicative ratios (MRs).

In an unadjusted analysis, patients experienced an extended length of stay in moderate (MR = 1.14; 95% CI, 1.11-1.18) and high (MR = 1.26; 95% CI, 1.22-1.3) non-ICU HFNC usage hospitals compared with those with low non-ICU HFNC usage. Researchers found similar results after adjusting for demographics, clinical characteristics and individual utilization of HFNC and/or ICU, with longer stays in moderate (adjusted MR [aMR] = 1.03; 95% CI, 1.01-1.06) and high (aMR = 1.08; 95% CI, 1.05-1.11) non-ICU HFNC usage hospitals.

Using both analyses, researchers estimated a 5% to 30% increased length of stay in hospitals with high non-ICU HNFC usage (> 32%) compared with low hospitals.

Compared with low non-ICU HFNC usage, researcher observed greater total cost amounts in moderate (MR = 1.2; 95% CI, 1.16-1.25) and high (MR = 1.26; 95% CI, 1.22-1.31) non-ICU HFNC usage in unadjusted analysis.

Adjusted analysis further demonstrated the same results of higher costs in moderate (aMR = 1.05; 95% CI, 1.03-1.08) and high (aMR = 1.05; 95% CI, 1.02-1.08) non-ICU HNFC usage hospitals. From both analyses, researcher estimated a 2% to 31% greater total cost in high non-ICU HNFC usage hospitals compared with low hospitals.

“Future studies are likely to focus on identifying patients who are unlikely to improve with HFNC and adding guardrails to its initiation,” Winer told Healio. “The American Academy of Pediatrics’ Value in Inpatient Pediatrics Network recently completed a project in which a pre-initiation huddle was utilized to ensure reasonable supportive care was performed prior to initiating HFNC.”

Winer would like to thank his co-authors, Elizabeth O. Mertens, MD, Kristen Bettin, MD, MEd, Elisha McCoy, MD, and Sandra R. Arnold, MD, MSc, as well as the Children’s Hospital Association and the Pediatric Health Information System.

For more information:

Jeffrey C. Winer, MD, MA, MSHS, FAAP, can be reached at jwiner1@uthsc.edu.

Reference:

• High-flow nasal cannula usage outside of intensive care associated with longer hospital stays, higher costs. https://www.eurekalert.org/news-releases/981507. Published March 2, 2023. Accessed March 3, 2023.