Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis

Abstract

Background and objectives: Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months.

Methods: We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration.

Results: Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis.

Conclusions: We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

FIGURE 1

Key driver diagram.

FIGURE 2

A summary of the study population. Some patients had >1 disqualifying criteria. “Other” includes concerns about nasal hemangioma, a difficult airway, social concerns, or multiple laboratories obtained for concerns other than bronchiolitis. G-tube, gastric tube.

FIGURE 3

Weeks T1 to T15 correspond to data collection in 2015 (January 5–April 18). The break in the x-axis indicates the break in time between 2015 and the 2016 data collection period. The 2016 data collection period was from January 5, 2016 to April 18, 2016. Each PDSA cycle was 4 weeks long with a 3-week sustainment phase at the end of the last cycle. CL, control limit; LCL, lower control limit; UCL, upper control limit.