Daniel J Sklansky, MD

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

Bronchiolitis is the most common cause of nonbirth hospitalization in children in the United States less than one year of age.¹ For children with severe bronchiolitis, high-flow nasal cannula (HFNC) is increasingly used^2-4 to reduce work of breathing and prevent the need for further escalation of ventilatory support.^5,6 Although previous studies suggest that enteral feeding is recommended in the management of patients hospitalized with bronchiolitis,^7-9 limited evidence exists to guide feeding practices for patients receiving HFNC support.^5,10,11

Respiratory support with HFNC has been associated with prolonged periods without enteral hydration/nutrition (ie, nil per os [NPO])¹² primarily due to anticipation of further escalation of respiratory support or concern for increased risk of aspiration. The majority of patients with bronchiolitis managed with HFNC, however, do not require escalation of care.^5,13 When feeding is attempted during HFNC support, it is frequently interrupted.⁵ Moreover, keeping all children NPO when receiving HFNC may be associated with weight loss and longer length of stay (LOS).^12,14 Two small studies found that children admitted to the intensive care unit who received HFNC support for bronchiolitis did not have increased rates of emesis, worsening respiratory distress or aspiration pneumonia when enterally fed.^10,11 However, no comparison of adverse events or LOS has been made between patients who were fed and those who were not fed during HFNC therapy, and previous studies have included only patients who have received HFNC in the intensive care setting.

Supporting safe feeding early in hospitalizations for bronchiolitis may facilitate expedited clinical improvement and discharge. As part of an ongoing bronchiolitis quality improvement initiative at our hospital, we sought to characterize feeding practices during HFNC therapy and assess whether feeding exposure was associated with (1) time to discharge after HFNC or (2) feeding-related adverse events. We hypothesized that feeding during HFNC therapy would be associated with a shorter time to discharge after HFNC cessation.

Study Design, Setting, Participants

This was a retrospective cohort study of patients aged 1-24 months receiving HFNC support for respiratory failure due to bronchiolitis at an academic children’s hospital between January 1, 2015 and March 1, 2017. Our institution has had a clinical practice guideline, associated order set, and respiratory therapy protocol for general care patients with bronchiolitis since 2009. Patients with bronchiolitis who were weaning HFNC have been cared for in both the intensive and general care settings since 2013. A formal process for initiation of HFNC on general care units was instituted in January of 2017. During the study period, no patients with HFNC support for bronchiolitis had all their care entirely outside the intensive care unit at our institution. However, initiation and subsequent use of HFNC may have occurred in either the intensive care or general care setting. No specific guidance for feeding during HFNC existed during this period.

Patients were identified using the Virtual PICU Systems database, (VPS LLC, myvps.org, Los Angeles, California) and, by definition, all patients received at least some of their care in the intensive care unit. Patients with comorbid conditions of prematurity (<35 weeks) and those with cardiopulmonary, neuromuscular, and genetic diseases were included. Patients with preexisting dysphagia, defined as ongoing outpatient speech therapy for swallowing concerns, an admission diagnosis of aspiration pneumonia or on home respiratory support, were excluded. Children (n = 7) were excluded if they had more than one period of HFNC during admission. This study was determined to be exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Data Collection and Study Variables

The following variables were collected from VPS administrative data: patient gender, age, admission and discharge date and time, type and total hours of respiratory support, intensive care admission, and LOS (in hours). Additional demographic, clinical, and feeding exposure variables were abstracted manually from the electronic medical record (Epic, Verona, Wisconsin) using a structured data collection tool and stored in REDCap (Research Electronic Data Capture)¹⁵ including prematurity, race/ethnicity, insurance status, primary language, and passive tobacco smoke exposure. Clinical variables included duration of illness (days) at the time of admission, unit of HFNC initiation (emergency department, general care, intensive care, respiratory rate and oxygen saturation at HFNC initiation (<90%, 91%-92%, or >92%), acquisition of blood gas at HFNC admission, duration of time on HFNC (hours) and need for intubation or noninvasive ventilation prior to HFNC. The Pediatric Index of Mortality 2 Risk of Mortality (PIM 2 ROM)¹⁶ was used to estimate the severity of illness. The PIM2ROM uses clinical variables (systolic blood pressure, fixed pupils, measure of hypoxia using PaO₂/FiO₂ ratio, base excess, mechanical ventilation, elective admission, recovery from surgery, cardiac bypass, high-risk diagnosis, low-risk diagnosis) collected at the time of intensive care admission to generate a score that predicts the risk of mortality for an individual patient.¹⁷

Feeding exposures were documented in three-hour intervals from HFNC initiation to completion using a structured protocol. At each interval the following feeding information was abstracted from a review of nursing and physician documentation and relevant clinical flowsheets: presence or absence of feeding during the interval, route of feeding (oral, nasogastric [NG] or nasojejunal [NJ]). Feeding exposure was categorized a priori as fed at any point during HFNC (vs not fed at any point). Fed children were further characterized as (1) mixed feeding consisting of oral and tube feeds (NG or NJ) or (2) exclusive oral feeding throughout HFNC support (Appendix 1).

The primary outcome was the number of hours to discharge from HFNC cessation. Secondary outcomes were time to discharge from HFNC initiation, all-cause readmissions within seven days of discharge, and potential feeding-related adverse events. Potential adverse events included: (1) aspiration, defined as initiation of antibiotic AND either chest radiograph official interpreted as evidence for aspiration and/or documented concern for aspiration from the treating physician, or (2) intubation after feeding during HFNC.

Statistical Analysis

Descriptive statistics evaluated differences in demographics and clinical variables for feeding exposure groups. We used chi-squared tests for differences in proportions and t-tests or Wilcoxon Rank-Sum tests for differences in means or medians for continuous variables, respectively. Associations between feeding exposure during HFNC and time to discharge (measured in hours) after HFNC completion were modeled with Cox proportional hazards regression. Using this approach, hazard ratios (HR)>1 indicate a higher hazard (rate) of discharge for children with a feeding exposure than for children without the exposure. For example, a hazard ratio equal to two indicates that the exposed population is discharged at twice the rate per unit time as the nonexposed population. Death or censoring events did not occur. Feeding exposure was first modeled dichotomously as not fed or fed. To further explore associations between feeding modality and our outcome, we then modeled feeding exposure categorically as not fed (reference), mixed (oral and tube) feeding, or exclusive oral feeding throughout HFNC.

After constructing a set of unadjusted models, we then adjusted the models for variables having independent (bivariate P < .10) associations with time to discharge: age, unit of HFNC initiation, highest respiratory support required before HFNC, and HFNC duration. Finally, to attempt to account for residual confounding from latent constructs, we also created a set of propensity-weighted Cox proportional hazards models. Propensity weights¹⁸ reflecting the probability of being fed or never being fed during HFNC were created using logistic regression with predictors we hypothesized a priori that may have influenced the clinical decision to feed during HFNC: age, day of illness on admission, prematurity, PIM2 ROM score, respiratory rate, oxygen saturation and blood gas acquisition at HFNC initiation, and highest respiratory support required before HFNC. All analyses were conducted using STATA 14.0 (StataCorp, College Station, Texas), and adjusted hazard ratios (aHR) with 95% confidence intervals (95% CIs) were reported.

Patients (n = 123) had a mean age of 7.3 months (standard deviation [SD] 7.1) and presented on day of illness 4.8 (SD 2.3). Prior to HFNC, 10% required higher respiratory support (3% mechanical ventilation). Former preterm children were 12% of the overall sample.

During HFNC, 37% of patients were never fed, 41% were exclusively orally fed, and 23% had tube or mixed oral and tube feedings (Table 1 and Appendix 2). Children who were not fed were older, but groups were otherwise similar in terms of gender, race/ethnicity, passive smoke exposure, day of illness, unit of HFNC initiation, respiratory support required prior to HFNC, and respiratory rate at HFNC initiation.

This observational study found that being fed during HFNC was associated with shorter time to discharge after HFNC support was completed. Exclusive oral feeding was associated with the shortest time to discharge, and these results were consistent across a variety of analytical approaches. Adverse events were rare and occurred in both fed and unfed children.

These findings advance research on relationships between nutrition and bronchiolitis outcomes. Studies of general care patients with bronchiolitis without HFNC have observed associations between poor nutrition and prolonged LOS.^19,20 Two previous studies of patients receiving HFNC therapy for bronchiolitis concluded that frequent interruption¹¹ and later initiation of enteral nutrition¹⁰ during ICU stay was associated with longer time to discharge.¹¹ To our knowledge, this is the first study of patients with bronchiolitis treated with HFNC in both general care and ICU settings that compared outcomes according to whether children were fed during HFNC therapy. Our results extend previous work demonstrating that delays in feeding may be associated with longer LOS.

Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those who are not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

Acknowledgments

The authors would like to acknowledge the valuable feedback on earlier drafts from members of the University of Wisconsin Division of Pediatric Hospital Medicine CREATE writing group.

Bronchiolitis is the most common cause of nonbirth hospitalization in children in the United States less than one year of age.¹ For children with severe bronchiolitis, high-flow nasal cannula (HFNC) is increasingly used^2-4 to reduce work of breathing and prevent the need for further escalation of ventilatory support.^5,6 Although previous studies suggest that enteral feeding is recommended in the management of patients hospitalized with bronchiolitis,^7-9 limited evidence exists to guide feeding practices for patients receiving HFNC support.^5,10,11

Respiratory support with HFNC has been associated with prolonged periods without enteral hydration/nutrition (ie, nil per os [NPO])¹² primarily due to anticipation of further escalation of respiratory support or concern for increased risk of aspiration. The majority of patients with bronchiolitis managed with HFNC, however, do not require escalation of care.^5,13 When feeding is attempted during HFNC support, it is frequently interrupted.⁵ Moreover, keeping all children NPO when receiving HFNC may be associated with weight loss and longer length of stay (LOS).^12,14 Two small studies found that children admitted to the intensive care unit who received HFNC support for bronchiolitis did not have increased rates of emesis, worsening respiratory distress or aspiration pneumonia when enterally fed.^10,11 However, no comparison of adverse events or LOS has been made between patients who were fed and those who were not fed during HFNC therapy, and previous studies have included only patients who have received HFNC in the intensive care setting.

Supporting safe feeding early in hospitalizations for bronchiolitis may facilitate expedited clinical improvement and discharge. As part of an ongoing bronchiolitis quality improvement initiative at our hospital, we sought to characterize feeding practices during HFNC therapy and assess whether feeding exposure was associated with (1) time to discharge after HFNC or (2) feeding-related adverse events. We hypothesized that feeding during HFNC therapy would be associated with a shorter time to discharge after HFNC cessation.

Study Design, Setting, Participants

This was a retrospective cohort study of patients aged 1-24 months receiving HFNC support for respiratory failure due to bronchiolitis at an academic children’s hospital between January 1, 2015 and March 1, 2017. Our institution has had a clinical practice guideline, associated order set, and respiratory therapy protocol for general care patients with bronchiolitis since 2009. Patients with bronchiolitis who were weaning HFNC have been cared for in both the intensive and general care settings since 2013. A formal process for initiation of HFNC on general care units was instituted in January of 2017. During the study period, no patients with HFNC support for bronchiolitis had all their care entirely outside the intensive care unit at our institution. However, initiation and subsequent use of HFNC may have occurred in either the intensive care or general care setting. No specific guidance for feeding during HFNC existed during this period.

Patients were identified using the Virtual PICU Systems database, (VPS LLC, myvps.org, Los Angeles, California) and, by definition, all patients received at least some of their care in the intensive care unit. Patients with comorbid conditions of prematurity (<35 weeks) and those with cardiopulmonary, neuromuscular, and genetic diseases were included. Patients with preexisting dysphagia, defined as ongoing outpatient speech therapy for swallowing concerns, an admission diagnosis of aspiration pneumonia or on home respiratory support, were excluded. Children (n = 7) were excluded if they had more than one period of HFNC during admission. This study was determined to be exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Data Collection and Study Variables

The following variables were collected from VPS administrative data: patient gender, age, admission and discharge date and time, type and total hours of respiratory support, intensive care admission, and LOS (in hours). Additional demographic, clinical, and feeding exposure variables were abstracted manually from the electronic medical record (Epic, Verona, Wisconsin) using a structured data collection tool and stored in REDCap (Research Electronic Data Capture)¹⁵ including prematurity, race/ethnicity, insurance status, primary language, and passive tobacco smoke exposure. Clinical variables included duration of illness (days) at the time of admission, unit of HFNC initiation (emergency department, general care, intensive care, respiratory rate and oxygen saturation at HFNC initiation (<90%, 91%-92%, or >92%), acquisition of blood gas at HFNC admission, duration of time on HFNC (hours) and need for intubation or noninvasive ventilation prior to HFNC. The Pediatric Index of Mortality 2 Risk of Mortality (PIM 2 ROM)¹⁶ was used to estimate the severity of illness. The PIM2ROM uses clinical variables (systolic blood pressure, fixed pupils, measure of hypoxia using PaO₂/FiO₂ ratio, base excess, mechanical ventilation, elective admission, recovery from surgery, cardiac bypass, high-risk diagnosis, low-risk diagnosis) collected at the time of intensive care admission to generate a score that predicts the risk of mortality for an individual patient.¹⁷

Feeding exposures were documented in three-hour intervals from HFNC initiation to completion using a structured protocol. At each interval the following feeding information was abstracted from a review of nursing and physician documentation and relevant clinical flowsheets: presence or absence of feeding during the interval, route of feeding (oral, nasogastric [NG] or nasojejunal [NJ]). Feeding exposure was categorized a priori as fed at any point during HFNC (vs not fed at any point). Fed children were further characterized as (1) mixed feeding consisting of oral and tube feeds (NG or NJ) or (2) exclusive oral feeding throughout HFNC support (Appendix 1).

The primary outcome was the number of hours to discharge from HFNC cessation. Secondary outcomes were time to discharge from HFNC initiation, all-cause readmissions within seven days of discharge, and potential feeding-related adverse events. Potential adverse events included: (1) aspiration, defined as initiation of antibiotic AND either chest radiograph official interpreted as evidence for aspiration and/or documented concern for aspiration from the treating physician, or (2) intubation after feeding during HFNC.

Statistical Analysis

Descriptive statistics evaluated differences in demographics and clinical variables for feeding exposure groups. We used chi-squared tests for differences in proportions and t-tests or Wilcoxon Rank-Sum tests for differences in means or medians for continuous variables, respectively. Associations between feeding exposure during HFNC and time to discharge (measured in hours) after HFNC completion were modeled with Cox proportional hazards regression. Using this approach, hazard ratios (HR)>1 indicate a higher hazard (rate) of discharge for children with a feeding exposure than for children without the exposure. For example, a hazard ratio equal to two indicates that the exposed population is discharged at twice the rate per unit time as the nonexposed population. Death or censoring events did not occur. Feeding exposure was first modeled dichotomously as not fed or fed. To further explore associations between feeding modality and our outcome, we then modeled feeding exposure categorically as not fed (reference), mixed (oral and tube) feeding, or exclusive oral feeding throughout HFNC.

After constructing a set of unadjusted models, we then adjusted the models for variables having independent (bivariate P < .10) associations with time to discharge: age, unit of HFNC initiation, highest respiratory support required before HFNC, and HFNC duration. Finally, to attempt to account for residual confounding from latent constructs, we also created a set of propensity-weighted Cox proportional hazards models. Propensity weights¹⁸ reflecting the probability of being fed or never being fed during HFNC were created using logistic regression with predictors we hypothesized a priori that may have influenced the clinical decision to feed during HFNC: age, day of illness on admission, prematurity, PIM2 ROM score, respiratory rate, oxygen saturation and blood gas acquisition at HFNC initiation, and highest respiratory support required before HFNC. All analyses were conducted using STATA 14.0 (StataCorp, College Station, Texas), and adjusted hazard ratios (aHR) with 95% confidence intervals (95% CIs) were reported.

Patients (n = 123) had a mean age of 7.3 months (standard deviation [SD] 7.1) and presented on day of illness 4.8 (SD 2.3). Prior to HFNC, 10% required higher respiratory support (3% mechanical ventilation). Former preterm children were 12% of the overall sample.

During HFNC, 37% of patients were never fed, 41% were exclusively orally fed, and 23% had tube or mixed oral and tube feedings (Table 1 and Appendix 2). Children who were not fed were older, but groups were otherwise similar in terms of gender, race/ethnicity, passive smoke exposure, day of illness, unit of HFNC initiation, respiratory support required prior to HFNC, and respiratory rate at HFNC initiation.

This observational study found that being fed during HFNC was associated with shorter time to discharge after HFNC support was completed. Exclusive oral feeding was associated with the shortest time to discharge, and these results were consistent across a variety of analytical approaches. Adverse events were rare and occurred in both fed and unfed children.

These findings advance research on relationships between nutrition and bronchiolitis outcomes. Studies of general care patients with bronchiolitis without HFNC have observed associations between poor nutrition and prolonged LOS.^19,20 Two previous studies of patients receiving HFNC therapy for bronchiolitis concluded that frequent interruption¹¹ and later initiation of enteral nutrition¹⁰ during ICU stay was associated with longer time to discharge.¹¹ To our knowledge, this is the first study of patients with bronchiolitis treated with HFNC in both general care and ICU settings that compared outcomes according to whether children were fed during HFNC therapy. Our results extend previous work demonstrating that delays in feeding may be associated with longer LOS.

Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those who are not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

Acknowledgments

The authors would like to acknowledge the valuable feedback on earlier drafts from members of the University of Wisconsin Division of Pediatric Hospital Medicine CREATE writing group.

Bronchiolitis is the most common cause of nonbirth hospitalization in children in the United States less than one year of age.¹ For children with severe bronchiolitis, high-flow nasal cannula (HFNC) is increasingly used^2-4 to reduce work of breathing and prevent the need for further escalation of ventilatory support.^5,6 Although previous studies suggest that enteral feeding is recommended in the management of patients hospitalized with bronchiolitis,^7-9 limited evidence exists to guide feeding practices for patients receiving HFNC support.^5,10,11

Respiratory support with HFNC has been associated with prolonged periods without enteral hydration/nutrition (ie, nil per os [NPO])¹² primarily due to anticipation of further escalation of respiratory support or concern for increased risk of aspiration. The majority of patients with bronchiolitis managed with HFNC, however, do not require escalation of care.^5,13 When feeding is attempted during HFNC support, it is frequently interrupted.⁵ Moreover, keeping all children NPO when receiving HFNC may be associated with weight loss and longer length of stay (LOS).^12,14 Two small studies found that children admitted to the intensive care unit who received HFNC support for bronchiolitis did not have increased rates of emesis, worsening respiratory distress or aspiration pneumonia when enterally fed.^10,11 However, no comparison of adverse events or LOS has been made between patients who were fed and those who were not fed during HFNC therapy, and previous studies have included only patients who have received HFNC in the intensive care setting.

Supporting safe feeding early in hospitalizations for bronchiolitis may facilitate expedited clinical improvement and discharge. As part of an ongoing bronchiolitis quality improvement initiative at our hospital, we sought to characterize feeding practices during HFNC therapy and assess whether feeding exposure was associated with (1) time to discharge after HFNC or (2) feeding-related adverse events. We hypothesized that feeding during HFNC therapy would be associated with a shorter time to discharge after HFNC cessation.

Study Design, Setting, Participants

This was a retrospective cohort study of patients aged 1-24 months receiving HFNC support for respiratory failure due to bronchiolitis at an academic children’s hospital between January 1, 2015 and March 1, 2017. Our institution has had a clinical practice guideline, associated order set, and respiratory therapy protocol for general care patients with bronchiolitis since 2009. Patients with bronchiolitis who were weaning HFNC have been cared for in both the intensive and general care settings since 2013. A formal process for initiation of HFNC on general care units was instituted in January of 2017. During the study period, no patients with HFNC support for bronchiolitis had all their care entirely outside the intensive care unit at our institution. However, initiation and subsequent use of HFNC may have occurred in either the intensive care or general care setting. No specific guidance for feeding during HFNC existed during this period.

Patients were identified using the Virtual PICU Systems database, (VPS LLC, myvps.org, Los Angeles, California) and, by definition, all patients received at least some of their care in the intensive care unit. Patients with comorbid conditions of prematurity (<35 weeks) and those with cardiopulmonary, neuromuscular, and genetic diseases were included. Patients with preexisting dysphagia, defined as ongoing outpatient speech therapy for swallowing concerns, an admission diagnosis of aspiration pneumonia or on home respiratory support, were excluded. Children (n = 7) were excluded if they had more than one period of HFNC during admission. This study was determined to be exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Data Collection and Study Variables

The following variables were collected from VPS administrative data: patient gender, age, admission and discharge date and time, type and total hours of respiratory support, intensive care admission, and LOS (in hours). Additional demographic, clinical, and feeding exposure variables were abstracted manually from the electronic medical record (Epic, Verona, Wisconsin) using a structured data collection tool and stored in REDCap (Research Electronic Data Capture)¹⁵ including prematurity, race/ethnicity, insurance status, primary language, and passive tobacco smoke exposure. Clinical variables included duration of illness (days) at the time of admission, unit of HFNC initiation (emergency department, general care, intensive care, respiratory rate and oxygen saturation at HFNC initiation (<90%, 91%-92%, or >92%), acquisition of blood gas at HFNC admission, duration of time on HFNC (hours) and need for intubation or noninvasive ventilation prior to HFNC. The Pediatric Index of Mortality 2 Risk of Mortality (PIM 2 ROM)¹⁶ was used to estimate the severity of illness. The PIM2ROM uses clinical variables (systolic blood pressure, fixed pupils, measure of hypoxia using PaO₂/FiO₂ ratio, base excess, mechanical ventilation, elective admission, recovery from surgery, cardiac bypass, high-risk diagnosis, low-risk diagnosis) collected at the time of intensive care admission to generate a score that predicts the risk of mortality for an individual patient.¹⁷

Feeding exposures were documented in three-hour intervals from HFNC initiation to completion using a structured protocol. At each interval the following feeding information was abstracted from a review of nursing and physician documentation and relevant clinical flowsheets: presence or absence of feeding during the interval, route of feeding (oral, nasogastric [NG] or nasojejunal [NJ]). Feeding exposure was categorized a priori as fed at any point during HFNC (vs not fed at any point). Fed children were further characterized as (1) mixed feeding consisting of oral and tube feeds (NG or NJ) or (2) exclusive oral feeding throughout HFNC support (Appendix 1).

The primary outcome was the number of hours to discharge from HFNC cessation. Secondary outcomes were time to discharge from HFNC initiation, all-cause readmissions within seven days of discharge, and potential feeding-related adverse events. Potential adverse events included: (1) aspiration, defined as initiation of antibiotic AND either chest radiograph official interpreted as evidence for aspiration and/or documented concern for aspiration from the treating physician, or (2) intubation after feeding during HFNC.

Statistical Analysis

Descriptive statistics evaluated differences in demographics and clinical variables for feeding exposure groups. We used chi-squared tests for differences in proportions and t-tests or Wilcoxon Rank-Sum tests for differences in means or medians for continuous variables, respectively. Associations between feeding exposure during HFNC and time to discharge (measured in hours) after HFNC completion were modeled with Cox proportional hazards regression. Using this approach, hazard ratios (HR)>1 indicate a higher hazard (rate) of discharge for children with a feeding exposure than for children without the exposure. For example, a hazard ratio equal to two indicates that the exposed population is discharged at twice the rate per unit time as the nonexposed population. Death or censoring events did not occur. Feeding exposure was first modeled dichotomously as not fed or fed. To further explore associations between feeding modality and our outcome, we then modeled feeding exposure categorically as not fed (reference), mixed (oral and tube) feeding, or exclusive oral feeding throughout HFNC.

After constructing a set of unadjusted models, we then adjusted the models for variables having independent (bivariate P < .10) associations with time to discharge: age, unit of HFNC initiation, highest respiratory support required before HFNC, and HFNC duration. Finally, to attempt to account for residual confounding from latent constructs, we also created a set of propensity-weighted Cox proportional hazards models. Propensity weights¹⁸ reflecting the probability of being fed or never being fed during HFNC were created using logistic regression with predictors we hypothesized a priori that may have influenced the clinical decision to feed during HFNC: age, day of illness on admission, prematurity, PIM2 ROM score, respiratory rate, oxygen saturation and blood gas acquisition at HFNC initiation, and highest respiratory support required before HFNC. All analyses were conducted using STATA 14.0 (StataCorp, College Station, Texas), and adjusted hazard ratios (aHR) with 95% confidence intervals (95% CIs) were reported.

Patients (n = 123) had a mean age of 7.3 months (standard deviation [SD] 7.1) and presented on day of illness 4.8 (SD 2.3). Prior to HFNC, 10% required higher respiratory support (3% mechanical ventilation). Former preterm children were 12% of the overall sample.

During HFNC, 37% of patients were never fed, 41% were exclusively orally fed, and 23% had tube or mixed oral and tube feedings (Table 1 and Appendix 2). Children who were not fed were older, but groups were otherwise similar in terms of gender, race/ethnicity, passive smoke exposure, day of illness, unit of HFNC initiation, respiratory support required prior to HFNC, and respiratory rate at HFNC initiation.

This observational study found that being fed during HFNC was associated with shorter time to discharge after HFNC support was completed. Exclusive oral feeding was associated with the shortest time to discharge, and these results were consistent across a variety of analytical approaches. Adverse events were rare and occurred in both fed and unfed children.

These findings advance research on relationships between nutrition and bronchiolitis outcomes. Studies of general care patients with bronchiolitis without HFNC have observed associations between poor nutrition and prolonged LOS.^19,20 Two previous studies of patients receiving HFNC therapy for bronchiolitis concluded that frequent interruption¹¹ and later initiation of enteral nutrition¹⁰ during ICU stay was associated with longer time to discharge.¹¹ To our knowledge, this is the first study of patients with bronchiolitis treated with HFNC in both general care and ICU settings that compared outcomes according to whether children were fed during HFNC therapy. Our results extend previous work demonstrating that delays in feeding may be associated with longer LOS.

Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those who are not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

Acknowledgments

The authors would like to acknowledge the valuable feedback on earlier drafts from members of the University of Wisconsin Division of Pediatric Hospital Medicine CREATE writing group.

Hospitalizations for nutritional rehabilitation of patients with restrictive eating disorders are increasing.¹ Among primary mental health admissions at free-standing children’s hospitals, eating disorders represent 5.5% of hospitalizations and are associated with the longest length of stay (LOS; mean 14.3 days) and costliest care (mean $46,130).² Admission is necessary to ensure initial weight restoration and monitoring for symptoms of refeeding syndrome, including electrolyte shifts and vital sign abnormalities.^3-5

Supervision is generally considered an essential element of caring for hospitalized patients with eating disorders, who may experience difficulty adhering to nutritional treatment, perform excessive movement or exercise, or demonstrate purging or self-harming behaviors. Supervision is presumed to prevent counterproductive behaviors, facilitating weight gain and earlier discharge to psychiatric treatment. Best practices for patient supervision to address these challenges have not been established but often include meal time or continuous one-to-one supervision by nursing assistants (NAs) or other staff.^6,7 While meal supervision has been shown to decrease medical LOS, it is costly, reduces staff availability for the care of other patient care, and can be a barrier to caring for patients with eating disorders in many institutions.⁸

Although not previously used in patients with eating disorders, centralized video monitoring (CVM) may provide an additional mode of supervision. CVM is an emerging technology consisting of real-time video streaming, without video recording, enabling tracking of patient movement, redirection of behaviors, and communication with unit nurses when necessary. CVM has been used in multiple patient safety initiatives to reduce falls, address staffing shortages, reduce costs,^9,10 supervise patients at risk for self-harm or elopement, and prevent controlled medication diversion.^10,11

We sought to pilot a novel use of CVM to replace our institution’s standard practice of continuous one-to-one nursing assistant (NA) supervision of patients admitted for medical stabilization of an eating disorder. Our objective was to evaluate the supervision cost and feasibility of CVM, using LOS and days to weight gain as balancing measures.

Setting and Participants

This retrospective cohort study included patients 12-18 years old admitted to the pediatric hospital medicine service on a general unit of an academic quaternary care children’s hospital for medical stabilization of an eating disorder between September 2013 and March 2017. Patients were identified using administrative data based on primary or secondary diagnosis of anorexia nervosa, eating disorder not other wise specified, or another specified eating disorder (ICD 9 3071, 20759, or ICD 10 f5000, 5001, f5089, f509).^12,13 This research study was considered exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Supervision Interventions

A standard medical stabilization protocol was used for patients admitted with an eating disorder throughout the study period (Appendix). All patients received continuous one-to-one NA supervision until they reached the target calorie intake and demonstrated the ability to follow the nutritional meal protocol. Beginning July 2015, patients received continuous CVM supervision unless they expressed suicidal ideation (SI), which triggered one-to-one NA supervision until they no longer endorsed suicidality.

Centralized Video Monitoring Implementation

Institutional CVM technology was AvaSys TeleSitter Solution (AvaSure, Inc). Our institution purchased CVM devices for use in adult settings, and one was assigned for pediatric CVM. Mobile CVM video carts were deployed to patient rooms and generated live video streams, without recorded capture, which were supervised by CVM technicians. These technicians were NAs hired and trained specifically for this role; worked four-, eight-, and 12-hour shifts; and observed up to eight camera feeds on a single monitor in a centralized room. Patients and family members could refuse CVM, which would trigger one-to-one NA supervision. Patients were not observed by CVM while in the restroom; staff were notified by either the patient or technician, and one-to-one supervision was provided. CVM had two-way audio communication, which allowed technicians to redirect patients verbally. Technicians could contact nursing staff directly by phone when additional intervention was needed.

Supervision Costs

NA supervision costs were estimated at $19/hour, based upon institutional human resources average NA salaries at that time. No additional mealtime supervision was included, as in-person supervision was already occurring.

CVM supervision costs were defined as the sum of the device cost plus CVM technician costs and two hours of one-to-one NA mealtime supervision per day. The CVM device cost was estimated at $2.10/hour, assuming a 10-year machine life expectancy (single unit cost $82,893 in 2015, 3,944 hours of use in fiscal year of 2018). CVM technician costs were $19/hour, based upon institutional human resources average CVM technician salaries at that time. Because technicians monitored an average of six patients simultaneously during this study, one-sixth of a CVM technician’s salary (ie, $3.17/hour) was used for each hour of CVM monitoring. Patients with mixed (NA and CVM) supervision were analyzed with those having CVM supervision. These patients’ costs were the sum of their NA supervision costs plus their CVM supervision costs.

Data Collection

Descriptive variables including age, gender, race/ethnicity, insurance, and LOS were collected from administrative data. The duration and type of supervision for all patients were collected from daily staffing logs. The eating disorder protocol standardized the process of obtaining daily weights (Appendix). Days to weight gain following admission were defined as the total number of days from admission to the first day of weight gain that was followed by another day of weight gain or maintaining the same weight. CVM acceptability and feasibility were assessed by family refusal of CVM, conversion from CVM to NA, technological failure, complaints, and unplanned discontinuation, which were prospectively documented by the unit nurse manager.

Data Analysis

Patient and hospitalization characteristics were summarized. A sample size of at least 14 in each group was estimated as necessary to detect a 50% reduction in supervision cost between the groups using alpha = 0.05, a power of 80%, a mean cost of $4,400 in the NA group, and a standard deviation of $1,600.Wilcoxon rank-sum tests were used to assess differences in median supervision cost between NA and CVM use. Differences in mean LOS and days to weight gain between NA and CVM use were assessed with t-tests because these data were normally distributed.

Patient Characteristics and Supervision Costs

The study included 37 consecutive admissions (NA = 23 and CVM = 14) with 35 unique patients. Patients were female, primarily non-Hispanic White, and privately insured (Table 1). Median supervision cost for the NA was statistically significantly more expensive at $4,104/admission versus $1,166/admission for CVM (P < .001, Table 2).

Balancing Measures, Acceptability, and Feasibility

Mean LOS was 11.7 days for NA and 9.8 days for CVM (P = .27; Table 2). The mean number of days to weight gain was 3.1 and 3.6 days, respectively (P = .28). No patients converted from CVM to NA supervision. One patient with SI converted to CVM after SI resolved and two patients required ongoing NA supervision due to continued SI. There were no reported refusals, technology failures, or unplanned discontinuations of CVM. One patient/family reported excessive CVM redirection of behavior.

This is the first description of CVM use in adolescent patients or patients with eating disorders. Our results suggest that CVM appears feasible and less costly in this population than one-to-one NA supervision, without statistically significant differences in LOS or time to weight gain. Patients with CVM with any NA supervision (except mealtime alone) were analyzed in the CVM group; therefore, this study may underestimate cost savings from CVM supervision. This innovative use of CVM may represent an opportunity for hospitals to repurpose monitoring technology for more efficient supervision of patients with eating disorders.

This pediatric pilot study adds to the growing body of literature in adult patients suggesting CVM supervision may be a feasible inpatient cost-reduction strategy.^9,10 One single-center study demonstrated that the use of CVM with adult inpatients led to fewer unsafe behaviors, eg, patient removal of intravenous catheters and oxygen therapy. Personnel savings exceeded the original investment cost of the monitor within one fiscal quarter.⁹ Results of another study suggest that CVM use with hospitalized adults who required supervision to prevent falls was associated with improved patient and family satisfaction.¹⁴ In the absence of a gold standard for supervision of patients hospitalized with eating disorders, CVM technology is a tool that may balance cost, care quality, and patient experience. Given the upfront investment in CVM units, this technology may be most appropriate for institutions already using CVM for other inpatient indications.

The results of this pilot study suggest that supervision costs for patients admitted for medical stabilization of eating disorders were statistically significantly lower with CVM when compared with one-to-one NA supervision, without a change in hospitalization LOS or time to weight gain. These findings are particularly important as hospitals seek opportunities to reduce costs while providing safe and effective care. Future efforts should focus on evaluating clinical outcomes and patient experiences with this technology and strategies to maximize efficiency to offset the initial device cost.

Disclosures

The authors have no financial relationships relevant to this article to disclose. The authors have no conflicts of interest relevant to this article to disclose.

Hospitalizations for nutritional rehabilitation of patients with restrictive eating disorders are increasing.¹ Among primary mental health admissions at free-standing children’s hospitals, eating disorders represent 5.5% of hospitalizations and are associated with the longest length of stay (LOS; mean 14.3 days) and costliest care (mean $46,130).² Admission is necessary to ensure initial weight restoration and monitoring for symptoms of refeeding syndrome, including electrolyte shifts and vital sign abnormalities.^3-5

Supervision is generally considered an essential element of caring for hospitalized patients with eating disorders, who may experience difficulty adhering to nutritional treatment, perform excessive movement or exercise, or demonstrate purging or self-harming behaviors. Supervision is presumed to prevent counterproductive behaviors, facilitating weight gain and earlier discharge to psychiatric treatment. Best practices for patient supervision to address these challenges have not been established but often include meal time or continuous one-to-one supervision by nursing assistants (NAs) or other staff.^6,7 While meal supervision has been shown to decrease medical LOS, it is costly, reduces staff availability for the care of other patient care, and can be a barrier to caring for patients with eating disorders in many institutions.⁸

Although not previously used in patients with eating disorders, centralized video monitoring (CVM) may provide an additional mode of supervision. CVM is an emerging technology consisting of real-time video streaming, without video recording, enabling tracking of patient movement, redirection of behaviors, and communication with unit nurses when necessary. CVM has been used in multiple patient safety initiatives to reduce falls, address staffing shortages, reduce costs,^9,10 supervise patients at risk for self-harm or elopement, and prevent controlled medication diversion.^10,11

We sought to pilot a novel use of CVM to replace our institution’s standard practice of continuous one-to-one nursing assistant (NA) supervision of patients admitted for medical stabilization of an eating disorder. Our objective was to evaluate the supervision cost and feasibility of CVM, using LOS and days to weight gain as balancing measures.

Setting and Participants

This retrospective cohort study included patients 12-18 years old admitted to the pediatric hospital medicine service on a general unit of an academic quaternary care children’s hospital for medical stabilization of an eating disorder between September 2013 and March 2017. Patients were identified using administrative data based on primary or secondary diagnosis of anorexia nervosa, eating disorder not other wise specified, or another specified eating disorder (ICD 9 3071, 20759, or ICD 10 f5000, 5001, f5089, f509).^12,13 This research study was considered exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Supervision Interventions

A standard medical stabilization protocol was used for patients admitted with an eating disorder throughout the study period (Appendix). All patients received continuous one-to-one NA supervision until they reached the target calorie intake and demonstrated the ability to follow the nutritional meal protocol. Beginning July 2015, patients received continuous CVM supervision unless they expressed suicidal ideation (SI), which triggered one-to-one NA supervision until they no longer endorsed suicidality.

Centralized Video Monitoring Implementation

Institutional CVM technology was AvaSys TeleSitter Solution (AvaSure, Inc). Our institution purchased CVM devices for use in adult settings, and one was assigned for pediatric CVM. Mobile CVM video carts were deployed to patient rooms and generated live video streams, without recorded capture, which were supervised by CVM technicians. These technicians were NAs hired and trained specifically for this role; worked four-, eight-, and 12-hour shifts; and observed up to eight camera feeds on a single monitor in a centralized room. Patients and family members could refuse CVM, which would trigger one-to-one NA supervision. Patients were not observed by CVM while in the restroom; staff were notified by either the patient or technician, and one-to-one supervision was provided. CVM had two-way audio communication, which allowed technicians to redirect patients verbally. Technicians could contact nursing staff directly by phone when additional intervention was needed.

Supervision Costs

NA supervision costs were estimated at $19/hour, based upon institutional human resources average NA salaries at that time. No additional mealtime supervision was included, as in-person supervision was already occurring.

CVM supervision costs were defined as the sum of the device cost plus CVM technician costs and two hours of one-to-one NA mealtime supervision per day. The CVM device cost was estimated at $2.10/hour, assuming a 10-year machine life expectancy (single unit cost $82,893 in 2015, 3,944 hours of use in fiscal year of 2018). CVM technician costs were $19/hour, based upon institutional human resources average CVM technician salaries at that time. Because technicians monitored an average of six patients simultaneously during this study, one-sixth of a CVM technician’s salary (ie, $3.17/hour) was used for each hour of CVM monitoring. Patients with mixed (NA and CVM) supervision were analyzed with those having CVM supervision. These patients’ costs were the sum of their NA supervision costs plus their CVM supervision costs.

Data Collection

Descriptive variables including age, gender, race/ethnicity, insurance, and LOS were collected from administrative data. The duration and type of supervision for all patients were collected from daily staffing logs. The eating disorder protocol standardized the process of obtaining daily weights (Appendix). Days to weight gain following admission were defined as the total number of days from admission to the first day of weight gain that was followed by another day of weight gain or maintaining the same weight. CVM acceptability and feasibility were assessed by family refusal of CVM, conversion from CVM to NA, technological failure, complaints, and unplanned discontinuation, which were prospectively documented by the unit nurse manager.

Data Analysis

Patient and hospitalization characteristics were summarized. A sample size of at least 14 in each group was estimated as necessary to detect a 50% reduction in supervision cost between the groups using alpha = 0.05, a power of 80%, a mean cost of $4,400 in the NA group, and a standard deviation of $1,600.Wilcoxon rank-sum tests were used to assess differences in median supervision cost between NA and CVM use. Differences in mean LOS and days to weight gain between NA and CVM use were assessed with t-tests because these data were normally distributed.

Patient Characteristics and Supervision Costs

The study included 37 consecutive admissions (NA = 23 and CVM = 14) with 35 unique patients. Patients were female, primarily non-Hispanic White, and privately insured (Table 1). Median supervision cost for the NA was statistically significantly more expensive at $4,104/admission versus $1,166/admission for CVM (P < .001, Table 2).

Balancing Measures, Acceptability, and Feasibility

Mean LOS was 11.7 days for NA and 9.8 days for CVM (P = .27; Table 2). The mean number of days to weight gain was 3.1 and 3.6 days, respectively (P = .28). No patients converted from CVM to NA supervision. One patient with SI converted to CVM after SI resolved and two patients required ongoing NA supervision due to continued SI. There were no reported refusals, technology failures, or unplanned discontinuations of CVM. One patient/family reported excessive CVM redirection of behavior.

This is the first description of CVM use in adolescent patients or patients with eating disorders. Our results suggest that CVM appears feasible and less costly in this population than one-to-one NA supervision, without statistically significant differences in LOS or time to weight gain. Patients with CVM with any NA supervision (except mealtime alone) were analyzed in the CVM group; therefore, this study may underestimate cost savings from CVM supervision. This innovative use of CVM may represent an opportunity for hospitals to repurpose monitoring technology for more efficient supervision of patients with eating disorders.

This pediatric pilot study adds to the growing body of literature in adult patients suggesting CVM supervision may be a feasible inpatient cost-reduction strategy.^9,10 One single-center study demonstrated that the use of CVM with adult inpatients led to fewer unsafe behaviors, eg, patient removal of intravenous catheters and oxygen therapy. Personnel savings exceeded the original investment cost of the monitor within one fiscal quarter.⁹ Results of another study suggest that CVM use with hospitalized adults who required supervision to prevent falls was associated with improved patient and family satisfaction.¹⁴ In the absence of a gold standard for supervision of patients hospitalized with eating disorders, CVM technology is a tool that may balance cost, care quality, and patient experience. Given the upfront investment in CVM units, this technology may be most appropriate for institutions already using CVM for other inpatient indications.

The results of this pilot study suggest that supervision costs for patients admitted for medical stabilization of eating disorders were statistically significantly lower with CVM when compared with one-to-one NA supervision, without a change in hospitalization LOS or time to weight gain. These findings are particularly important as hospitals seek opportunities to reduce costs while providing safe and effective care. Future efforts should focus on evaluating clinical outcomes and patient experiences with this technology and strategies to maximize efficiency to offset the initial device cost.

Disclosures

The authors have no financial relationships relevant to this article to disclose. The authors have no conflicts of interest relevant to this article to disclose.

Hospitalizations for nutritional rehabilitation of patients with restrictive eating disorders are increasing.¹ Among primary mental health admissions at free-standing children’s hospitals, eating disorders represent 5.5% of hospitalizations and are associated with the longest length of stay (LOS; mean 14.3 days) and costliest care (mean $46,130).² Admission is necessary to ensure initial weight restoration and monitoring for symptoms of refeeding syndrome, including electrolyte shifts and vital sign abnormalities.^3-5

Supervision is generally considered an essential element of caring for hospitalized patients with eating disorders, who may experience difficulty adhering to nutritional treatment, perform excessive movement or exercise, or demonstrate purging or self-harming behaviors. Supervision is presumed to prevent counterproductive behaviors, facilitating weight gain and earlier discharge to psychiatric treatment. Best practices for patient supervision to address these challenges have not been established but often include meal time or continuous one-to-one supervision by nursing assistants (NAs) or other staff.^6,7 While meal supervision has been shown to decrease medical LOS, it is costly, reduces staff availability for the care of other patient care, and can be a barrier to caring for patients with eating disorders in many institutions.⁸

Although not previously used in patients with eating disorders, centralized video monitoring (CVM) may provide an additional mode of supervision. CVM is an emerging technology consisting of real-time video streaming, without video recording, enabling tracking of patient movement, redirection of behaviors, and communication with unit nurses when necessary. CVM has been used in multiple patient safety initiatives to reduce falls, address staffing shortages, reduce costs,^9,10 supervise patients at risk for self-harm or elopement, and prevent controlled medication diversion.^10,11

We sought to pilot a novel use of CVM to replace our institution’s standard practice of continuous one-to-one nursing assistant (NA) supervision of patients admitted for medical stabilization of an eating disorder. Our objective was to evaluate the supervision cost and feasibility of CVM, using LOS and days to weight gain as balancing measures.

Setting and Participants

This retrospective cohort study included patients 12-18 years old admitted to the pediatric hospital medicine service on a general unit of an academic quaternary care children’s hospital for medical stabilization of an eating disorder between September 2013 and March 2017. Patients were identified using administrative data based on primary or secondary diagnosis of anorexia nervosa, eating disorder not other wise specified, or another specified eating disorder (ICD 9 3071, 20759, or ICD 10 f5000, 5001, f5089, f509).^12,13 This research study was considered exempt by the University of Wisconsin School of Medicine and Public Health’s Institutional Review Board.

Supervision Interventions

A standard medical stabilization protocol was used for patients admitted with an eating disorder throughout the study period (Appendix). All patients received continuous one-to-one NA supervision until they reached the target calorie intake and demonstrated the ability to follow the nutritional meal protocol. Beginning July 2015, patients received continuous CVM supervision unless they expressed suicidal ideation (SI), which triggered one-to-one NA supervision until they no longer endorsed suicidality.

Centralized Video Monitoring Implementation

Institutional CVM technology was AvaSys TeleSitter Solution (AvaSure, Inc). Our institution purchased CVM devices for use in adult settings, and one was assigned for pediatric CVM. Mobile CVM video carts were deployed to patient rooms and generated live video streams, without recorded capture, which were supervised by CVM technicians. These technicians were NAs hired and trained specifically for this role; worked four-, eight-, and 12-hour shifts; and observed up to eight camera feeds on a single monitor in a centralized room. Patients and family members could refuse CVM, which would trigger one-to-one NA supervision. Patients were not observed by CVM while in the restroom; staff were notified by either the patient or technician, and one-to-one supervision was provided. CVM had two-way audio communication, which allowed technicians to redirect patients verbally. Technicians could contact nursing staff directly by phone when additional intervention was needed.

Supervision Costs

NA supervision costs were estimated at $19/hour, based upon institutional human resources average NA salaries at that time. No additional mealtime supervision was included, as in-person supervision was already occurring.

CVM supervision costs were defined as the sum of the device cost plus CVM technician costs and two hours of one-to-one NA mealtime supervision per day. The CVM device cost was estimated at $2.10/hour, assuming a 10-year machine life expectancy (single unit cost $82,893 in 2015, 3,944 hours of use in fiscal year of 2018). CVM technician costs were $19/hour, based upon institutional human resources average CVM technician salaries at that time. Because technicians monitored an average of six patients simultaneously during this study, one-sixth of a CVM technician’s salary (ie, $3.17/hour) was used for each hour of CVM monitoring. Patients with mixed (NA and CVM) supervision were analyzed with those having CVM supervision. These patients’ costs were the sum of their NA supervision costs plus their CVM supervision costs.

Data Collection

Descriptive variables including age, gender, race/ethnicity, insurance, and LOS were collected from administrative data. The duration and type of supervision for all patients were collected from daily staffing logs. The eating disorder protocol standardized the process of obtaining daily weights (Appendix). Days to weight gain following admission were defined as the total number of days from admission to the first day of weight gain that was followed by another day of weight gain or maintaining the same weight. CVM acceptability and feasibility were assessed by family refusal of CVM, conversion from CVM to NA, technological failure, complaints, and unplanned discontinuation, which were prospectively documented by the unit nurse manager.

Data Analysis

Patient and hospitalization characteristics were summarized. A sample size of at least 14 in each group was estimated as necessary to detect a 50% reduction in supervision cost between the groups using alpha = 0.05, a power of 80%, a mean cost of $4,400 in the NA group, and a standard deviation of $1,600.Wilcoxon rank-sum tests were used to assess differences in median supervision cost between NA and CVM use. Differences in mean LOS and days to weight gain between NA and CVM use were assessed with t-tests because these data were normally distributed.

Patient Characteristics and Supervision Costs

The study included 37 consecutive admissions (NA = 23 and CVM = 14) with 35 unique patients. Patients were female, primarily non-Hispanic White, and privately insured (Table 1). Median supervision cost for the NA was statistically significantly more expensive at $4,104/admission versus $1,166/admission for CVM (P < .001, Table 2).

Balancing Measures, Acceptability, and Feasibility

Mean LOS was 11.7 days for NA and 9.8 days for CVM (P = .27; Table 2). The mean number of days to weight gain was 3.1 and 3.6 days, respectively (P = .28). No patients converted from CVM to NA supervision. One patient with SI converted to CVM after SI resolved and two patients required ongoing NA supervision due to continued SI. There were no reported refusals, technology failures, or unplanned discontinuations of CVM. One patient/family reported excessive CVM redirection of behavior.

This is the first description of CVM use in adolescent patients or patients with eating disorders. Our results suggest that CVM appears feasible and less costly in this population than one-to-one NA supervision, without statistically significant differences in LOS or time to weight gain. Patients with CVM with any NA supervision (except mealtime alone) were analyzed in the CVM group; therefore, this study may underestimate cost savings from CVM supervision. This innovative use of CVM may represent an opportunity for hospitals to repurpose monitoring technology for more efficient supervision of patients with eating disorders.

This pediatric pilot study adds to the growing body of literature in adult patients suggesting CVM supervision may be a feasible inpatient cost-reduction strategy.^9,10 One single-center study demonstrated that the use of CVM with adult inpatients led to fewer unsafe behaviors, eg, patient removal of intravenous catheters and oxygen therapy. Personnel savings exceeded the original investment cost of the monitor within one fiscal quarter.⁹ Results of another study suggest that CVM use with hospitalized adults who required supervision to prevent falls was associated with improved patient and family satisfaction.¹⁴ In the absence of a gold standard for supervision of patients hospitalized with eating disorders, CVM technology is a tool that may balance cost, care quality, and patient experience. Given the upfront investment in CVM units, this technology may be most appropriate for institutions already using CVM for other inpatient indications.

The results of this pilot study suggest that supervision costs for patients admitted for medical stabilization of eating disorders were statistically significantly lower with CVM when compared with one-to-one NA supervision, without a change in hospitalization LOS or time to weight gain. These findings are particularly important as hospitals seek opportunities to reduce costs while providing safe and effective care. Future efforts should focus on evaluating clinical outcomes and patient experiences with this technology and strategies to maximize efficiency to offset the initial device cost.

Disclosures

The authors have no financial relationships relevant to this article to disclose. The authors have no conflicts of interest relevant to this article to disclose.