# Management of patients requiring high-flow nasal cannula in a pediatric observation unit: a single-center experience

## TL;DR

During a shortage of pediatric ICU beds, a hospital used a special breathing treatment in a less intensive unit, successfully avoiding the need for more serious interventions.

## Contribution

Demonstrates a practical approach to managing high-flow nasal cannula patients in a pediatric observation unit during a surge in respiratory illnesses.

## Key findings

- 66.6% of patients on HFNC in the observation unit were transferred to PICU, but none required intubation.
- Managing HFNC patients in the observation unit saved 293.2 PICU-bed-hours without severe complications.
- Common diagnoses included bronchiolitis and pneumonia, with no deaths or emergency department returns within a week of discharge.

## Abstract

Due to widespread shortages of pediatric intensive care unit (PICU) beds during the 2022–2023 respiratory virus surge, a protocol was implemented to identify and manage patients on high-flow nasal cannula (HFNC) in a pediatric observation unit (POU). This study aims to describe the characteristics and outcomes of patients who received HFNC in the observation unit.

We performed a retrospective chart review of all patients admitted to a community pediatric observation unit who received HFNC between October 2022 and January 2023. Patients were grouped by disposition from the observation unit, either discharged home or transferred to PICU. Descriptive analysis was conducted, presented as median and interquartile range (IQR) or number and percentage.

Among 18 patients, 6 patients were discharged from the POU and 12 were transferred to the PICU, with an escalation rate of 66.6%. The most common pathogens in the sample were RSV (10 [55.5%]) and influenza (5 [27.8%]). Final diagnoses included bronchiolitis (8 [44.4%]), pneumonia (6 [33.3%]), bronchiolitis with secondary pneumonia (3 [16.7%]), and asthma exacerbation (1 [5.6%]). Median length of stay in the observation unit was 33.9 h (IQR 16.5–48.8). 4 of the 12 patients transferred to the PICU required higher forms of respiratory support, but none required intubation. There were no deaths in our sample, and no patients returned to the emergency department within 7 days of discharge. 293.2 PICU-bed-hours were saved.

In this study, several patients were able to be de-escalated from HFNC in a community pediatric observation unit setting without severe complications, including a zero-intubation rate. In a resource-strained setting, managing patients on HFNC in an observation unit may be a reasonable alternative to conserve PICU resources.