Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis
OBJECTIVE: Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms.
METHODS: This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach.
RESULTS: Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice.
CONCLUSION: We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children’s hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.
© 2021 Society of Hospital Medicine
Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis is associated with increased rates of hospital admission, longer lengths of stay, more frequent treatment with supplemental oxygen, alarm fatigue, and higher hospital cost. There is no evidence that it improves clinical outcomes.1-7 The safety of reducing cSpO2 for stable bronchiolitis patients (ie, those who are clinically well and not requiring supplemental oxygen) has been assessed in quality improvement initiatives8-10 and a randomized controlled trial.2 These studies showed no increase in intensive care unit transfers, codes, or readmissions associated with reduced cSpO2. Current national guidelines from the American Academy of Pediatrics5 and the Society of Hospital Medicine Choosing Wisely in Pediatric Hospital Medicine workgroup4 support limiting monitoring of children with bronchiolitis. Despite this, the practice of cSpO2 in stable bronchiolitis patients off supplemental oxygen remains widespread.11,12
Deimplementation, defined as reducing or stopping low-value or ineffective healthcare practices,13,14 is a discrete focus area within implementation science. Deimplementation research involves the reduction of unnecessary and overused services for which there is potential for harm or no benefit.15,16 In pediatrics, there are a number of potential targets for deimplementation,4,17-20 including cSpO2 for stable infants with bronchiolitis, but efforts to reduce low-value practices have met limited success to date. 21,22
Implementation science offers rigorous methods for advancing the development and evaluation of strategies for deimplementation.23 In particular, implementation science frameworks can facilitate our understanding of relevant contextual factors that may hinder or help efforts to deimplement low-value practices. To develop broadly applicable strategies to reduce monitoring overuse, it is important to understand the barriers, facilitators, and contextual factors (eg, clinical, political, interpersonal) that contribute to guideline-discordant cSpO2 in hospitalized bronchiolitis patients. Further, the process by which one can develop a rigorous understanding of these factors and how they may impact deimplementation efforts could generalize to other scenarios in pediatrics where overuse remains an issue.
The goal of this study was to use semistructured interviews, informed by an established implementation science framework, specifically the Consolidated Framework for Implementation Research (CFIR),24 to (1) identify barriers and facilitators to deimplementing unnecessary cSpO2, and (2) develop strategies to deimplement cSpO2 in a multicenter cohort of hospital-based clinician and administrative stakeholders.
METHODS
Study Setting
This multicenter qualitative study using semistructured interviews took place within the Eliminating Monitor Overuse (EMO) SpO2 study. The EMO SpO2 study established rates of cSpO2 in bronchiolitis patients not receiving supplemental oxygen or not receiving room air flow at 56 hospitals across the United States and in Canada from December 1, 2018, through March 31, 2019.12 The study identified hospital-level risk-adjusted cSpO2 rates ranging from 6% to 82%. A description of the EMO SpO2 study methods25 and its findings12 have been published elsewhere.
Participants
We approached EMO study site principal investigators at 12 hospitals: the two highest- and two lowest-use hospitals within three hospital types (ie, freestanding children’s hospitals, children’s hospitals within large general hospitals, and community hospitals). We collaborated with the participating site principal investigators (n = 12), who were primarily hospitalist physicians in leadership roles, to recruit a purposive sample of additional stakeholders including bedside nurses (n = 12), hospitalist physicians (n = 15), respiratory therapists (n = 9), and hospital administrators (n = 8) to participate in semistructured interviews. Interviews were conducted until we achieved thematic saturation within each stakeholder group and within the high and low performing strata (total 56 interviews). Participants were asked to self-report basic demographic information (see Appendix, interview guide) as required by the study funder and to allow us to comment on the representativeness of the participant group.
