Implementation of nasal high flow therapy for infants with bronchiolitis: An integrative review

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Objective: Identify factors relevant to the implementation of nasal high flow for infants with bronchiolitis in rural and remote contexts. Background: Healthcare services in rural and remote Australia must be resilient in responding to paediatric respiratory illness and provide equitable access of care to the tertiary contexts. Retrievals cannot be the only option to provide equitable care, particularly in examples of cyclones reducing aeromedical retrieval services. Nasal high flow (NHF) therapy is available for use in tertiary contexts for treating infants with respiratory illness. However, its use in rural and remote services is inconsistent and implementations to support routine implementation into this context are unknown. Study Design and methods: An integrative review was completed using an adapted implementation science framework. The COM-B (Capability, Opportunity, Motivation - Behaviour) framework was used to structure and analyse the results in alignment with translatable clinical care setting implementations. Seven databases were searched using specified search terms such as nasal high flow therapy, bronchiolitis, and implementation. Results: The original search terms ‘rural’ and/or ‘remote’ yielded zero results and were therefore removed from the search criteria. Sixteen publications were included in the final analysis that yielded 73 implementation factors. Eight related to capability, 61 were opportunity factors and four were motivation factors. Many of the factors were relating to the local context level, such as using observation regimes. One study (two publications) explicitly reported using an implementation framework where context was considered as an important component in identifying implementation strategies. Discussion: Implementation strategies included staff training (capability). The opportunity for staff to use NHF was the most common factor with using guidelines. The least represented motivation strategies focused on the clinician’s confidence to use NHF therapy. Conclusion: The lack of reported NHF studies in rural and remote hospitals highlights a knowledge gap. Implementation science is recommended for use in contexts such as the rural/remote setting where the context is unique and requires targeted implementation strategies. Implications for research, policy, and practice: Research exploring the use of NHF therapy should consider the unique rural and remote context using appropriate implementation strategies. Implementation science has shown that factors such as local champions, guidelines, use of observational data, and having locally tailored training and supportive approaches does improve the implementation of NHF therapy. The authors recommend these strategies be applied in rural and remote contexts to inform future research, policies, procedures, and practices that will promote and support clinicians’ confidence and ability to implement NHF therapy. What is already known on the subject NHF therapy is used for infants with bronchiolitis within the tertiary environment. NHF is used outside of paediatric intensive care units. Implementation science frameworks hasten evidence-based clinical practice routine uptake. What this paper adds Identifies a gap in the literature reporting implementation factors relevant for NHF therapy. Identifies no published literature reporting NHF use in rural and remote contexts. Describes, using an implementation framework, relevant factors for the use of NHF therapy in rural and remote hospitals.