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
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.
Facilitators
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.
