Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis

Abstract

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. Journal of Hospital Medicine 2020;15:XXX-XXX. © 2020 Society of Hospital Medicine

De‐implementing low‐value continuous pulse oximetry practice in infants hospitalized with bronchiolitis: A multicentre qualitative study

“…Wolk and colleagues conducted a multicentre qualitative study of clinicians at United States hospitals with low and high continuous pulse oximetry use in bronchiolitis care 24 . This study found numerous barriers to de‐implementing continuous monitoring, including unclear or absent guidelines for stopping continuous monitoring, clinician knowledge, unit culture, and clinician expertise in bronchiolitis management.…”

Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis

“…The primary outcomes were acceptability, appropriateness, and feasibility of the deimplementation strategies. 21 We also measured perceived safety of intermittently spot-checking oxygen saturation instead of using cSp o 2 . To estimate penetration 24 of guideline-concordant care 2 , 3 , 4 of patients with bronchiolitis not receiving supplemental oxygen, we assessed the change in cSp o 2 use between the baseline 10 and intervention periods.…”

“…The primary outcomes were acceptability, appropriateness, and feasibility of the deimplementation strategies . We also measured perceived safety of intermittently spot-checking oxygen saturation instead of using cSp o 2 .…”

“…20 The intervention consisted of 2 deimplementation strategies: educational outreach and audit and feedback (Figure 1). These strategies were chosen based on barriers and facilitators identified in prior qualitative research 21 and were then mapped to deimplementation strategies during 2 stakeholder strategy development panels. The education and audit and feedback interventions were delivered in person to physicians, nurses, and respiratory therapists.…”

Deimplementation: Discontinuing Low-Value, Potentially Harmful Hospital Care

“…2 In this issue, Wolk et al describe barriers and facilitators in deimplementing non-guideline adherent use of continuous pulse oximetry (CPO) in pediatric patients with bronchiolitis not requiring supplemental oxygen. 3 Unnecessary CPO use for these patients is associated with increased hospitalization rates, length of stay, alarm fatigue, and costs, without evidence of improved clinical outcomes. Despite these data, many hospitals participating in the multicenter Eliminating Monitor Overuse study struggled to decrease CPO usage.…”