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.
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.
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.
The interview guide was informed by the CFIR, a comprehensive framework detailing contextual factors that require consideration when planning for the implementation of a health service intervention. Table 1 details the CFIR domains with study-related examples. The interview guide (Appendix) provided limited clinical context apart from the age, diagnosis, and oxygen requirement for the population of interest to promote a broad array of responses and to avoid anchoring on specific clinical scenarios. Interviews were conducted by master’s degree or doctoral-level research coordinators with qualitative interviewing experience and supervised by a medical anthropologist and qualitative methods expert (F.K.B.). Prior to engaging in audio recorded phone interviews, the interviewer explained the risks and benefits of participating. Participants were compensated $50. Audio recordings were transcribed, deidentified, and uploaded to NVivo 12 Plus (QSR International) for data management.
The Institutional Review Boards of Children’s Hospital of Philadelphia, Pennsylvania, and the University of Pennsylvania in Philadelphia determined that the study met eligibility criteria for IRB exemption.
Using an integrated approach to codebook development,26 a priori codes were developed using constructs from the CFIR. Additional codes were added by the research team following a close reading of the first five transcripts.27,28 Each code was defined, including decision rules for its application. Two research coordinators independently coded each transcript. Using the intercoder reliability function within NVivo, the coders established strong interrater reliability accordance scores (k > .8) by double coding 20% of the transcripts. Data were stratified by sites with low and high use of cSpO2 to examine differences in barriers and facilitators to deimplementation. Each code was subcoded, summarized, and examined for patterns within and across participating disciplines, which yielded themes related to barriers and facilitators. We conducted member checking and reviewed our conclusions with a multidisciplinary group of clinical stakeholders (n = 13) to validate our analyses.
Barriers and facilitators to deimplementation were identified in multiple domains of the CFIR: outer setting, inner setting, characteristics of the individuals, and intervention characteristics (Table 1). Participants also suggested strategies to facilitate deimplementation in response to some identified barriers. See Table 2 for participant demographics and Table 3 for illustrative participant quotations.
Outer Setting: Clinician Perceptions of Parental Discomfort With Discontinuing Monitoring
Participants mentioned parental preferences as a barrier to discontinuing cSpO2, noting that parents seem to take comfort in watching the numbers on the monitor screen and are reluctant to have it withdrawn. Clinicians noted that parents sometimes put the monitor back on their child after a clinician removed it or have expressed concern that their unmonitored child was not receiving the same level of care as other patients who were being monitored. In these scenarios, clinicians reported they have found it helpful to educate caregivers about when cSpO2 is and is not appropriate.
Inner Setting: Unclear or Nonexistent Guideline to Discontinue cSpO2
Guidelines to discontinue cSpO2 reportedly did not exist at all institutions. If a guideline did exist, lack of clarity or conflicting guidelines about when to use oxygen presented a barrier. Participants suggested that a clear guideline or additional oversight to ensure all clinicians are informed of the procedure for discontinuing cSpO2 may help prevent miscommunication. Participants noted that their electronic health record (EHR) order sets commonly included cSpO2 orders and that removing that option would facilitate deimplementation.
Inner Setting: Difficulty Educating All Staff
Participants noted difficulty with incorporating education about discontinuing cSpO2 to all clinicians, particularly to those who are nightshift only or to rotating staff or trainees. This created barriers for frequent re-education because these staff are not familiar with the policies and procedures of the unit, which is crucial to developing a culture that supports the deimplementation of cSpO2. Participants suggested that recurring education about procedures for discontinuing cSpO2 should target trainees, new nurses, and overnight nurses. This would help to ensure that the guideline is uniformly followed.
Inner Setting: Culture of High cSpO2 Use
Participants from high-use sites discussed a culture driven by readily available monitoring features or an expectation that monitoring indicates higher-quality care. Participants from low-use sites discussed increased cSpO2 driven by clinicians who were accustomed to caring for higher-acuity patients, for whom continuous monitoring is likely appropriate, and were simultaneously caring for stable bronchiolitis patients.
Some suggested that visual cues would be useful to clinicians to sustain awareness about a cSpO2 deimplementation guideline. It was also suggested that audit and feedback techniques like posting unit deimplementation statistics and creating a competition among units by posting unit performance could facilitate deimplementation. Additionally, some noted that visual aids in common spaces would be useful to remind clinicians and to engage caregivers about discontinuing cSpO2.
Characteristics of Individuals: Clinician Discomfort Discontinuing cSpO2
One frequently cited barrier across participants is that cSpO2 provides “peace of mind” to alert clinicians to patients with low oxygen saturations that might otherwise be missed. Participants identified that clinician discomfort with reducing cSpO2 may be driven by inexperienced clinicians less familiar with the bronchiolitis disease process, such as trainees, new nurses, or rotating clinicians unaccustomed to pediatric care. Trainees and new nurses were perceived as being more likely to work at night when there are fewer clinicians to provide patient care. Additionally, participants perceived that night shift clinicians favored cSpO2 because they could measure vital signs without waking patients and families.
Clinicians discussed that discontinuing cSpO2 would require alternative methods for assessing patient status, particularly for night shift nurses. Participants suggested strategies including changes to pulse oximetry assessment procedures to include more frequent “spot checks,” incorporation of assessments during sleep events (eg, naps) to ensure the patient does not experience desaturations during sleep, and training nurses to become more comfortable with suctioning patients. Suggestions also included education on the typical features of transient oxygen desaturations in otherwise stable patients with bronchiolitis2 to bolster clinical confidence for clinicians unfamiliar with caring for bronchiolitis patients. Participants perceived that education about appropriate vs inappropriate use may help to empower clinicians to employ cSpO2 appropriately.
Outer Setting: Standards and Evidence From Research, Professional Organizations, and Leaders in the Field
Many participants expressed the importance of consistent guidelines that are advocated by thought leaders in the field, supported by robust evidence, and consistent with approaches at peer hospitals. The more authoritative support a guideline has, the more comfortable people are adopting it and taking it seriously. Additionally, consistent education about guidelines was desired. Participants noted that all clinicians should be receiving education related to the American Academy of Pediatrics (AAP) Bronchiolitis and Choosing Wisely® guidelines, ranging from a one-time update to annually. Continual updates and re-education sessions for clinicians who shared evidence about how cSpO2 deimplementation could improve the quality of patient care by shortening hospital length of stay and lowering cost were suggested strategies.
Inner Setting: Leadership
Participants noted that successful deimplementation depends upon the presence of a champion or educator who will be able to lead the institutional charge in making practice change. This is typically an individual who is trusted at the institution, experienced in their field, or already doing implementation work. This could be either a single individual (champion) or a team. The most commonly noted clinician roles to engage in a leadership role or team were physicians and nurses.
Participants noted that a change in related clinical care pathways or EHR order sets would require cooperation from multiple clinical disciplines, administrators, and information technology leaders and explained that messaging and education about the value of the change would facilitate buy-in from those clinicians.
Inner Setting: EHR Support for Guidelines
Participants often endorsed the use of an order set within the EHR that supports guidelines and includes reminders to decrease cSpO2. These reminders could come up when supplemental oxygen is discontinued or occur regularly throughout the patient’s stay to prompt the clinician to consider discontinuing cSpO2.
Intervention Characteristics/Inner Setting: Clear Bronchiolitis Guidelines
The presence of a well-articulated hospital policy that delineates the appropriate and inappropriate use of cSpO2 in bronchiolitis was mentioned as another facilitator of deimplementation.
Results of this qualitative study of stakeholders across hospitals with high and low cSpO2 use illustrated the complexities involved with deimplementation of cSpO2 in pediatric patients hospitalized with bronchiolitis. We identified numerous barriers spanning the CFIR constructs, including unclear or absent guidelines for stopping cSpO2, clinician knowledge and comfort with bronchiolitis disease features, and unit culture. This suggests that multicomponent strategies that target various domains and a variety of stakeholders are needed to deimplement cSpO2 use for stable bronchiolitis patients. Participants also identified facilitators, including clear cSpO2 guidelines, supportive leaders and champions, and EHR modifications, that provide insight into strategies that may help sites reduce their use of cSpO2. Additionally, participants also provided concrete, actionable suggestions for ways to reduce unnecessary monitoring that will be useful in informing promising deimplementation strategies for subsequent trials.
The importance of having specific and well-known guidelines from trusted sources, such as the AAP, about cSpO2 and bronchiolitis treatment that are thoughtfully integrated in the EHR came through in multiple themes of our analysis. Prior studies on the effect of guidelines on clinical practice have suggested that rigorously designed guidelines can positively impact practice.29 Participants also noted that cSpO2 guidelines should be authoritative and that knowledge of guideline adoption by peer institutions was a facilitator of adoption. Usability issues negatively impact clinicians’ ability to follow guidelines.30 Further, prior studies have demonstrated that EHR integration of guidelines can change practice.31-33 Based on our findings, incorporating clear guidelines into commonly used formats, such as EHR order sets, could be an important deimplementation tool for cSpO2 in stable bronchiolitis patients.
Education about and awareness of cSpO2 guidelines was described as an important facilitator for appropriate cSpO2 use and was suggested as a potential deimplementation strategy. Participants noted that educational need may vary by stakeholder group. For example, education may facilitate obtaining buy-in from hospital leaders, which is necessary to support changes to the EHR. Education incorporating information on the typical features of bronchiolitis and examples of appropriate and inappropriate cSpO2 use was suggested for clinical team members. The limitations of education as a stand-alone deimplementation strategy were also noted, and participants highlighted challenges such as time needed for education and the need for ongoing education for rotating trainees. Inner and outer setting barriers, such as a perceived “culture of high pulse oximetryuse” and patient and family expectations, could also make education less effective as a stand-alone strategy. That—coupled with evidence that education and training alone are generally insufficient for producing reliable, sustained behavior change34,35—suggests that a multifaceted approach will be important.
Our respondents consider parental perceptions and preference in their practice, which provides nuance to recent studies suggesting that parents prefer continuous monitors when their child is hospitalized with bronchiolitis. Chi et al described the impact of a brief educational intervention on parental preferences for monitoring children hospitalized for bronchiolitis.36 This work suggests that educational interventions aimed at families should be considered in future (de)implementation studies because they may indirectly impact clinician behavior. Future studies should directly assess parental discomfort with discontinuing monitoring. Participants highlighted the link between knowledge and confidence in caring for typical bronchiolitis patients and monitoring practice, perceiving that less experienced clinicians are more likely to rely on cSpO2. Participants at high-use sites emphasized the expectation that monitoring should occur during hospitalizations. This reflection is particularly pertinent for bronchiolitis, a disease characterized by frequent, self-resolving desaturations even after hospital discharge.3 This may reinforce a perceived need to capture and react to these desaturation events even though they are expected in bronchiolitis and can occur in healthy infants.37 Some participants suggested that continuous monitoring be replaced with “nap tests” (ie, assessment for desaturations during a nap prior to discharge); however, like cSpO2 in stable infants with bronchiolitis, this is another low-value practice. Otherwise healthy infants with mild to moderate disease are unlikely to subsequently worsen after showing signs of clinical improvement.38 Nap tests are likely to lead to infants who are clinically improving being placed unnecessarily back on oxygen in reaction to the transient desaturations. Participants’ perception about the importance of cSpO2 in bronchiolitis management, despite evidence suggesting it is a low-value practice, underscores the importance of not simply telling clinicians to stop cSpO2. Employing strategies that replace continuous monitoring with another acceptable and feasible alternative (eg, regular clinician assessments including intermittent pulse oximetry checks) should be considered when planning for deimplementation.39
Previous studies indicate that continuous monitoring can affect clinician decision-making, independent of other factors,6,40 despite limited evidence that continuous monitors improve patient outcomes.1-7 Studies have demonstrated noticeable increase in admissions based purely on pulse oximetry values,40 with no evidence that this type of admission changes outcomes for bronchiolitis patients.6 One previous, single-center study identified inexperience as a potential driver for monitor use,41 and studies in adult populations have suggested that clinicians overestimate the value that continuous monitoring contributes to patient care,42,43 which promotes guideline-discordant use. Our study provides novel insight into the issue of monitoring in bronchiolitis. Our results suggest that there is a need to shift organizational cultures around monitoring (which likely vary based on a range of factors) and that educational strategies addressing typical disease course, especially desaturations, in bronchiolitis will be an essential component in any deimplementation effort.
This study is strengthened by its sample of diverse stakeholder groups from multiple US health systems. Additionally, we interviewed individuals at sites with high cSpO2 rates and at sites with low rates, as well as from community hospitals, children’s hospitals within general hospitals, and freestanding children’s hospitals, which allows us to understand barriers high-use sites encounter and facilitators of lower cSpO2 rates at low-use sites. We also employed an interview approach informed by an established implementation science framework. Nonetheless, several limitations exist. First, participants at low-use sites did not necessarily have direct experience with a previous deimplementation effort to reduce cSpO2. Additionally, participants were predominantly White and female; more diverse perspectives would strengthen confidence in the generalizability of our findings. While thematic saturation was achieved within each stakeholder group and within the high- and low-use strata, we interviewed fewer administrators and respiratory therapists relative to other stakeholder groups. Nevertheless, our conclusions were validated by our interdisciplinary stakeholder panel. As noted by participants, family preferences may influence clinician practice, and parents were not interviewed for this study. The information gleaned from the present study will inform the development of strategies to deimplement unnecessary cSpO2 in pediatric hospitals, which we aim to rigorously evaluate in a future trial.
We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children’s hospitals with high and low utilization of cSpO2. These themes map to multiple CFIR domains and, along with participant-suggested strategies, can directly inform an approach to cSpO2 deimplementation in a range of inpatient settings. Based on these data, future deimplementation efforts should focus on clear protocols for use and discontinuation of cSpO2, EHR changes, and regular bronchiolitis education for hospital staff that emphasizes reducing unnecessary cSpO2 utilization.
We acknowledge the NHLBI scientists who contributed their expertise to this project as part of the U01 Cooperative Agreement funding mechanism as federal employees conducting their official job duties: Lora Reineck, MD, MS, Karen Bienstock, MS, and Cheryl Boyce, PhD. We thank the Executive Council of the Pediatric Research in Inpatient Settings (PRIS) Network for their contributions to the early scientific development of this project. The Network assessed a Collaborative Support Fee for access to the hospitals and support of this project. We thank the PRIS Network collaborators for their major contributions to data collection measuring utilization to identify the hospitals we subsequently chose for this project. We thank Claire Bocage and the Mixed Methods Research Lab for major help in data management and data analysis.
Dr Schondelmeyer discloses additional grant funding from the Agency for Healthcare Research and Quality (AHRQ) and from the Association for the Advancement of Medical Instrumentation. Dr Brady discloses additional grant funding from the AHRQ. Dr Bettencourt discloses additional funding from the National Heart, Lung, and Blood Institute (NHLBI) and the National Clinician Scholars Program. Dr Bonafide discloses additional grant funding from the NHLBI, AHRQ, and the National Science Foundation for research related to physiologic monitoring. Dr Beidas receives royalties from Oxford University Press and has provided consultation to Merck and the Camden Coalition of Healthcare Providers. The other authors have no conflicts of interest to disclose.
Research reported in this publication was supported by a Cooperative Agreement from the NHLBI of the National Institutes of Health (NIH) under award number U01HL143475 (Bonafide, PI). As a Cooperative Agreement, NIH scientists participated in study conference calls and provided ongoing feedback on the conduct and findings of the study. Dr Schondelmeyer’s effort contributing to this manuscript was in part funded by the AHRQ under award number K08HS026763. Dr Brady’s effort contributing to this manuscript was in part funded by the AHRQ under award number K08HS23827. The funding organizations had no role in the design of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or AHRQ.