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Staff come together to reduce length of stay for Pediatric ICU patients


Team members involved in the high-flow nasal cannula clinical redesign project included (l-r): Matthew Grossman, MD, quality and safety officer, YNHCH; Desmond Talento, RN, patient service manager, PICU; Christina Walsh, MD, PICU fellow; Crystal Clemons, consultant, Internal Consulting Group; Rebecca Ciaburri, RN, performance manager, quality and safety, YNHCH; Josep Panisello, MD, PICU medical director; Lauren Edwards, RN, performance improvement coordinator, YNHCH; Christopher Goodell, respiratory therapist; and Thomas Martin, APRN, service line educator, PICU.

A group of clinicians who care for patients in Yale New Haven Children’s Hospital’s Pediatric Intensive Care Unit (PICU) are proving that clinical redesign is truly a team sport.

Their clinical redesign project started with staff in Respiratory Therapy, who wondered whether a particular type of oxygen therapy provided only in the PICU was keeping patients there longer than necessary.

Some PICU patients need oxygen delivered via high-flow nasal cannulas, but previously there was no standard protocol to guide clinicians on how long to use the cannulas and when to wean patients off them.

“The concern was that we might have patients in the PICU who could be transitioned and managed appropriately on standard oxygen therapy, and by weaning them appropriately we could decrease their length of stay in the ICU,” said Sarah Kenyon, operations manager, Respiratory Therapy.

Kenyon was on the clinical redesign team formed to develop a high-flow nasal cannula weaning protocol that would standardize respiratory care. The team of respiratory therapists, nurses and physicians found there wasn’t a lot of published research nationally on the issue, so they worked with Yale New Haven Health System’s Joint Data Analytics Team to gather baseline data from the PICU. As expected, data showed a lot of variability in high-flow nasal cannula treatment duration and weaning.

Team members spent three months developing and implementing a protocol that calls for the nurse and respiratory therapist to assess and discuss high-flow nasal cannula patients during daily rounds. If they feel the patient can be weaned, they consult with the PICU physician fellow, who initiates a weaning order.

The team continues to monitor results for sustainability. Data from July 2015 - January 2017 show a 37 percent improvement in PICU length of stay and a 46 percent improvement in total time on high-flow nasal cannulas, compared to the pre-intervention period of June 2014 - May 2015.