Beam Nicholas, Long Allison, Nicholson Adam, Jary Lauren, Veele Rebecca, Kalinowski Nicole, Phad Matthew, Hadley Andrea
From the Corewell Health Helen Devos Children's Hospital, Grand Rapids, Mich.
Michigan State University College of Human Medicine, Grand Rapids, Mich.
Pediatr Qual Saf. 2024 Jun 11;9(3):e735. doi: 10.1097/pq9.0000000000000735. eCollection 2024 May-Jun.
Recent studies have identified enteral feeding as a safe alternative to intravenous fluid hydration for inpatients with bronchiolitis receiving respiratory support. Specifically, it can improve vital signs, shorten time on high-flow nasal cannula, and is associated with reduced length of stay. We aimed to increase the percentage of patients receiving enteral feeding on admission with mild-to-moderate bronchiolitis, including those on high-flow nasal cannula, from 83% to 95% within 6 months.
A multidisciplinary quality improvement team identified key drivers preventing enteral feeding as lack of standardization, perception of aspiration risk, and lack of familiarity with feeding orders. PDSA cycles focused on developing and implementing a bronchiolitis clinical practice pathway with an embedded guideline and order set as decision support to prioritize enteral feeding. Additionally, educational sessions were provided for trainees and attendings who were impacted by this pathway.
Following interventions, initiation of enteral feeding increased (83%-96%). Additionally, intravenous line placement decreased (37%-12%) with a mirrored increase in nasogastric tube placement (4%-21%). This was associated with a shorter overall length of stay and no increased transfer rate to intensive care.
Using quality improvement methodology to standardize enteral feeding and hydration increased the initiation rate of enteral feeding in patients admitted with bronchiolitis. These changes were seen immediately after the implementation of the clinical pathway and sustained throughout the bronchiolitis season.
最近的研究已确定，对于接受呼吸支持的细支气管炎住院患者，肠内喂养是静脉补液的一种安全替代方法。具体而言，它可改善生命体征，缩短高流量鼻导管吸氧时间，并与缩短住院时间相关。我们的目标是在6个月内将轻度至中度细支气管炎入院患者（包括使用高流量鼻导管吸氧的患者）接受肠内喂养的比例从83%提高到95%。
一个多学科质量改进团队确定了阻碍肠内喂养的关键因素，即缺乏标准化、对误吸风险的认知以及对喂养医嘱不熟悉。计划-实施-检查-处理（PDSA）循环聚焦于制定和实施一条细支气管炎临床实践路径，其中嵌入指南和医嘱集作为决策支持，以优先考虑肠内喂养。此外，还为受该路径影响的实习医生和主治医生提供了教育课程。
干预后，肠内喂养的启动率有所提高（从83%提高到96%）。此外，静脉置管减少（从37%降至12%），鼻胃管置管相应增加（从4%增至21%）。这与总体住院时间缩短相关，且转入重症监护病房的比率未增加。
采用质量改进方法对肠内喂养和补液进行标准化，提高了细支气管炎入院患者的肠内喂养启动率。这些变化在临床路径实施后立即显现，并在整个细支气管炎季节持续存在。
