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
CONCLUSION
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.
ACKNOWLEDGMENTS
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.
