Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial.

2022

72

10/2022

1748-5908

BACKGROUND: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown.

METHODS: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems).

DISCUSSION: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease.

TRIAL REGISTRATION: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

10.1186/s13012-022-01246-z

Implement Sci

36271399

EHR-Integrated Monitor Data to Measure Pulse Oximetry Use in Bronchiolitis.

2021

2021 Sep 28

2154-1671

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Continuous pulse oximetry (oxygen saturation [Spo]) monitoring in hospitalized children with bronchiolitis not requiring supplemental oxygen is discouraged by national guidelines, but determining monitoring status accurately requires in-person observation. Our objective was to determine if electronic health record (EHR) data can accurately estimate the extent of actual Spo monitoring use in bronchiolitis.</p>

<p><strong>METHODS: </strong>This repeated cross-sectional study included infants aged 8 weeks through 23 months hospitalized with bronchiolitis. In the validation phase at 3 children's hospitals, we calculated the test characteristics of the Spo monitor data streamed into the EHR each minute when monitoring was active compared with in-person observation of Spo monitoring use. In the application phase at 1 children's hospital, we identified periods when supplemental oxygen was administered using EHR flowsheet documentation and calculated the duration of Spo monitoring that occurred in the absence of supplemental oxygen.</p>

<p><strong>RESULTS: </strong>Among 668 infants at 3 hospitals (validation phase), EHR-integrated Spo data from the same minute as in-person observation had a sensitivity of 90%, specificity of 98%, positive predictive value of 88%, and negative predictive value of 98% for actual Spo monitoring use. Using EHR-integrated data in a sample of 317 infants at 1 hospital (application phase), infants were monitored in the absence of oxygen supplementation for a median 4.1 hours (interquartile range 1.4-9.4 hours). Those who received supplemental oxygen experienced a median 5.6 hours (interquartile range 3.0-10.6 hours) of monitoring after oxygen was stopped.</p>

<p><strong>CONCLUSIONS: </strong>EHR-integrated monitor data are a valid measure of actual Spo monitoring use that may help hospitals more efficiently identify opportunities to deimplement guideline-inconsistent use.</p>

10.1542/hpeds.2021-005894

Hosp Pediatr

34583959

Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial.

2021

e2122826

2021 Sep 01

2574-3805

<p><strong>Importance: </strong>National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high.</p>

<p><strong>Objectives: </strong>To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen.</p>

<p><strong>Design, Setting, and Participants: </strong>A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen.</p>

<p><strong>Interventions: </strong>Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits.</p>

<p><strong>Main Outcomes and Measures: </strong>Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen.</p>

<p><strong>Results: </strong>A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P &lt; .001) during the intervention period. There were no adverse events attributable to reduced monitoring.</p>

<p><strong>Conclusions and Relevance: </strong>In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step.</p>

<p><strong>Trial Registration: </strong>ClinicalTrials.gov Identifier: NCT04178941.</p>

10.1001/jamanetworkopen.2021.22826

JAMA Netw Open

34473258

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

2021

e2117816

2021 Jul 01

2574-3805

<p><strong>Importance: </strong>Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.</p>

<p><strong>Objectives: </strong>To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals.</p>

<p><strong>Design, Setting, and Participants: </strong>This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021.</p>

<p><strong>Main Outcomes and Measures: </strong>The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient.</p>

<p><strong>Results: </strong>There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18).</p>

<p><strong>Conclusions and Relevance: </strong>This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.</p>

10.1001/jamanetworkopen.2021.17816

JAMA Netw Open

34309667

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

2021

23-30

2021 Jan

1553-5606

<p><strong>OBJECTIVE: </strong>Continuous pulse oximetry monitoring (cSpO) 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 cSpO overuse in order to reduce overuse and its associated harms.</p>

<p><strong>METHODS: </strong>This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO study, a cross-sectional study to establish rates of cSpO 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 cSpO use rates to identify barriers and facilitators to addressing cSpO overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach.</p>

<p><strong>RESULTS: </strong>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 SpO use incorporated into electronic order sets, regular education about cSpO in bronchiolitis, and visual reminders may be needed to reduce cSpO utilization. Parental perceptions and individual clinician comfort affect cSpO practice.</p>

<p><strong>CONCLUSION: </strong>We identified barriers and facilitators to deimplementation of cSpO for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO.</p>

10.12788/jhm.3535

J Hosp Med

33357326

Variation in tonsillectomy cost and revisit rates: analysis of administrative and billing data from US children's hospitals.

2020

2020 Jun 30

2044-5423

<p><strong>BACKGROUND: </strong>Tonsillectomy is one of the most common and cumulatively expensive surgical procedures in children. We determined if substantial variation in resource use, as measured by standardised costs, exists across hospitals for performing tonsillectomy and if higher resource use is associated with better quality of care, as measured by revisits to hospital.</p>

<p><strong>METHODS: </strong>We conducted a retrospective analysis of children undergoing routine outpatient tonsillectomy between 2011 to 2017 across US children's hospitals using an administrative and billing data source. The primary outcome measures were the hospital tonsillectomy standardised cost and the 30-day revisit rate to hospital. We analysed the interhospital variation in standardised cost by determining the number of outlier hospitals in standardised cost and the intraclass correlation coefficient.</p>

<p><strong>RESULTS: </strong>131 814 children (median age 6 years, IQR: 4,9; female sex 52.5%) underwent tonsillectomy for airway obstruction (62.9%) and infection (23.9%) across 28 hospitals. The median adjusted hospital standardised cost for tonsillectomy was $2392 (IQR: $1827, $2793; range: $1166 to $4222). There was substantial interhospital variation in costs as 11 (40%) hospitals were cost outliers, and the intraclass correlation coefficient was 0.62, suggesting that 62% of the variation in cost was attributable to variation between hospitals. The median hospital revisit rate was 9.5% (IQR: 7.8, 12.1) and higher hospital costs did not correlate with lower revisit rates ( =0.03, 95% CI -0.36 to 0.41; p=0.87).</p>

<p><strong>CONCLUSIONS: </strong>There is substantial variation in hospital resource use and standardised costs for routine outpatient tonsillectomy across US children's hospitals. Higher resource use is not associated with lower revisit rates. Further study is needed to understand the practices of lower resource use hospitals who deliver high quality of care.</p>

10.1136/bmjqs-2019-010730

BMJ Qual Saf

32606211

Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen.

2020

1467-1477

2020 Apr 21

1538-3598

<p><strong>Importance: </strong>US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.</p>

<p><strong>Objective: </strong>Measure continuous pulse oximetry use in children with bronchiolitis.</p>

<p><strong>Design, Setting, and Participants: </strong>A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.</p>

<p><strong>Exposures: </strong>Hospitalization with bronchiolitis without active supplemental oxygen administration.</p>

<p><strong>Main Outcomes and Measures: </strong>The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.</p>

<p><strong>Results: </strong>The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.</p>

<p><strong>Conclusions and Relevance: </strong>In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.</p>

10.1001/jama.2020.2998

JAMA

32315058

Pediatric Respiratory Illness Measurement System (PRIMES) Scores and Outcomes.

2019

2019 Jul 26

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>The Pediatric Respiratory Illness Measurement System (PRIMES) generates condition-specific composite quality scores for asthma, bronchiolitis, croup, and pneumonia in hospital-based settings. We sought to determine if higher PRIMES composite scores are associated with improved health-related quality of life, decreased length of stay (LOS), and decreased reuse.</p>

<p><strong>METHODS: </strong>We conducted a prospective cohort study of 2334 children in 5 children's hospitals between July 2014 and June 2016. Surveys administered on admission and 2 to 6 weeks postdischarge assessed the Pediatric Quality of Life Inventory (PedsQL). Using medical records data, 3 PRIMES scores were calculated (0-100 scale; higher scores = improved adherence) for each condition: an overall composite (including all quality indicators for the condition), an overuse composite (including only indicators for care that should not be provided [eg, chest radiographs for bronchiolitis]), and an underuse composite (including only indicators for care that should be provided [eg, dexamethasone for croup]). Multivariable models assessed relationships between PRIMES composite scores and (1) PedsQL improvement, (2) LOS, and (3) 30-day reuse.</p>

<p><strong>RESULTS: </strong>For every 10-point increase in PRIMES overuse composite scores, LOS decreased by 8.8 hours (95% confidence interval [CI] -11.6 to -6.1) for bronchiolitis, 3.1 hours (95% CI -5.5 to -1.0) for asthma, and 2.0 hours (95% CI -3.9 to -0.1) for croup. Bronchiolitis overall composite scores were also associated with shorter LOS. PRIMES composites were not associated with PedsQL improvement or reuse.</p>

<p><strong>CONCLUSIONS: </strong>Better performance on some PRIMES condition-specific composite measures is associated with decreased LOS, with scores on overuse quality indicators being a primary driver of this relationship.</p>

10.1542/peds.2019-0242

Pediatrics

31350359

Measuring overuse of continuous pulse oximetry in bronchiolitis and developing strategies for large-scale deimplementation: study protocol for a feasibility trial.

2019

68

2019

2055-5784

<p><strong>Background: </strong>Deimplementation, the systematic elimination of low-value practices, has emerged as an important focus within implementation science. Bronchiolitis is the leading cause of infant hospitalization. Among stable inpatients with bronchiolitis who do not require supplemental oxygen, continuous pulse oximetry monitoring is recognized as an overused, low-value practice in pediatric hospital medicine. There is strong scientific evidence and practice guideline support for limiting pulse oximetry monitoring of stable children with bronchiolitis who do not require supplemental oxygen, yet the practice remains common. This study aims to (1) characterize the extent of this overuse in hospitals located in the USA and Canada, (2) identify barriers and facilitators of successful deimplementation of continuous pulse oximetry monitoring in bronchiolitis, and (3) develop consensus strategies for large-scale deimplementation. In addition to identifying feasible strategies for deimplementation, this study will test the feasibility of data collection approaches to be employed in a large-scale deimplementation trial.</p>

<p><strong>Methods: </strong>This multicenter study will be performed in approximately 38 hospitals in the Pediatric Research in Inpatient Settings Network. In Aim 1, we will determine the rate of overuse within each hospital by performing repeated cross-sectional observational sampling of continuous pulse oximetry monitoring of stable bronchiolitis patients age 8 weeks through 23 months who do not require supplemental oxygen. In Aim 2, we will use the Consolidated Framework for Implementation Research (CFIR) as a framework for semi-structured interviews with key stakeholders (physician, nurse, respiratory therapist, administrator, and parent) at the highest- and lowest-overuse hospitals to understand barriers and facilitators of continuous pulse oximetry monitoring deimplementation. In Aim 3, we will use a theory-based causal model to match the identified barriers and facilitators to potential strategies for deimplementation. Candidate strategies will be discussed with a panel of stakeholders from hospitals with high rates of overuse to assess feasibility and acceptability. A questionnaire ranking strategies based on feasibility, acceptability, and impact will be administered to a broader group of stakeholders to arrive at consensus about promising strategies for large-scale deimplementation to be tested in a subsequent trial.</p>

<p><strong>Discussion: </strong>Effective strategies for deimplementing continuous pulse oximetry monitoring of stable patients with bronchiolitis have not been well characterized. The findings of this study will provide further understanding of factors that facilitate deimplementation in pediatric hospital settings and provide pilot and feasibility data to inform a trial of large-scale deimplementation of this overused practice.</p>

<p><strong>Trial registration: </strong>Not applicable. This study does not meet the World Health Organization definition of a clinical trial.</p>

10.1186/s40814-019-0453-2

Pilot Feasibility Stud

31123593

Association of Weekend Admission and Weekend Discharge with Length of Stay and 30-Day Readmission in Children's Hospitals.

2018

2018 10 31

1553-5606

<p><strong>BACKGROUND: </strong>Worse outcomes among adults presenting for/receiving care on weekends (ie, "the weekend effect") have been observed for many diseases. However, little is known about the overall impact of the weekend effect in hospitalized children.</p>

<p><strong>OBJECTIVE: T</strong>o determine the association between weekend admission and length of stay (LOS) and between weekend discharge and 30-day all-cause readmission.</p>

<p><strong>METHODS: </strong>We conducted a retrospective, cross-sectional study of children hospitalized between October 1, 2014 and September 30, 2015 using the Pediatric Health Information System. Birth hospitalizations and planned procedures were excluded. We used generalized linear mixed modeling to assess the independent association between weekend admission and LOS and weekend discharge and readmission risk.</p>

<p><strong>RESULTS: </strong>Among 390,745 hospitalizations across 43 hospitals, the median LOS was 41 hours (interquartile range [IQR] 24-71) and the 30-day readmission rate was 8.2% (IQR 7.2-9.4). We observed no association between weekend admission and LOS (adjusted LOS [95% CI: weekend 63.70 [61.01-66.52] hours vs weekday 63.40 [60.73-66.19] hours, P = .112). Weekend discharge was associated with slightly increased odds of readmission compared with weekday discharge (adjusted probability of readmission [95% CI]: weekend 0.13 [0.12-0.13] versus weekday 0.11 [0.11-0.12], P &lt; .001) but was variable among individual hospitals. Patient characteristics (ie, number of chronic conditions) were more strongly associated with LOS and readmission risk than weekend admission or discharge.</p>

<p><strong>CONCLUSIONS: </strong>Patient-level factors (ie, clinical and demographic characteristics) are more indicative of longer LOS and readmission risk than weekend admissions or discharges. The overall impact of the weekend effect across children's hospitals was minimal.</p>

10.12788/jhm.3085

J Hosp Med

30379138