Feasibility and acceptability of implementing a practice guideline for the use of high flow nasal cannula in critically ill patients who have hypoxemia: a multi-centre study in Nepal

Background: Practice guidelines have the potential to improve processes and outcomes of care if strategies to facilitate implementation include attention to feasibility and acceptability in the local setting. The purpose of this study was to evaluate the feasibility and acceptability of a guideline for using a high-flow nasal cannula (HFNC) in intensive care units (ICUs) that was introduced in Nepal. Methods: We measured the proportion of eligible patients in seven ICUs who received HFNC between September 14, 2020, and December 9, 2021. We compared measures of oxygenation between patients who successfully survived HFNC and those who did not. We used an electronic survey of healthcare workers to measure the guideline's acceptability, appropriateness, and feasibility. Results: Out of the total (7,121) patients admitted to ICUs during the study period, 4,099 (57%) were eligible and 584 (14%) of the eligible patients received HFNC during the first three days (12% before and 14% after the introduction of the guideline). The median ROX time index (integral of ROX index (PaO2/FiO2 x respiratory rate) over time) of patients who were successfully treated with HFNC (n=146) was greater than that of patients who failed HFNC (n= 42; 0.8 vs. 0.04; p=0.001). Respondents rated the HFNC guideline highly for acceptability, appropriateness, and feasibility. Conclusions: Introduction of the guideline was associated with a small increase in the use of HFNC, but the guideline was feasible, acceptable, and appropriate for use in clinical practice.