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

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 change^34,35—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.