First name
Halley
Last name
Ruppel

Title

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.

Year of Publication

2022

Number of Pages

72

Date Published

10/2022

ISSN Number

1748-5908

Abstract

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.

DOI

10.1186/s13012-022-01246-z

Alternate Title

Implement Sci

PMID

36271399

Title

Parental Insights into Improving Home Pulse Oximetry Monitoring in Infants.

Year of Publication

2022

Number of Pages

e538

Date Published

2022 Mar-Apr

ISSN Number

2472-0054

Abstract

<p>Home pulse oximeters prescribed for infants with cardiorespiratory conditions generate many false alarms, which create caregiver stress and sleep disturbance and can lead to unsafe practices. Additionally, relationships among oximeters, alarms, and everyday living demands are not well understood. Therefore, we aimed to gather parent perspectives on home pulse oximetry monitoring during the problem analysis phase of a quality improvement (QI) initiative.</p>

<p><strong>Methods: </strong>We purposively sampled and interviewed parents of infants prescribed home pulse oximeters and receiving local home care company services. We based questions on systems engineering frameworks previously used in healthcare. Data were coded iteratively and analyzed deductively (theoretical frameworks) and inductively (emerging themes).</p>

<p><strong>Results: </strong>Generally, themes aligned with theoretical frameworks. Parents expressed dissatisfaction with the number of false alarms home pulse oximeters generate, which parents primarily attributed to poor probe adhesiveness and the inability of oximeters to account for infant movement. Interviews highlighted the burden associated with poor device tones and portability. Device-related issues had negative repercussions for the entire family related to sleep quality, mobility, and social interactions. Universally, parents developed workarounds, including cessation of monitoring.</p>

<p><strong>Conclusions: </strong>Parents of infants monitored at home using pulse oximetry face many challenges, resulting in compromises in safety. Continuing to instruct parents to comply with prescribed monitoring recommendations may be unrealistic. Instead, we suggest re-engineering the home monitoring system with the needs and goals of children and their families at the center. Our description of adapting qualitative research and systems engineering methods may benefit others developing QI work.</p>

DOI

10.1097/pq9.0000000000000538

Alternate Title

Pediatr Qual Saf

PMID

35369408

Title

Development and Validation of an Obstetric Comorbidity Risk Score for Clinical Use.

Year of Publication

2021

Number of Pages

507-515

Date Published

2021

ISSN Number

2688-4844

Abstract

<p><em><strong>Background: </strong></em>A comorbidity summary score may support early and systematic identification of women at high risk for adverse obstetric outcomes. The objective of this study was to conduct the initial development and validation of an obstetrics comorbidity risk score for automated implementation in the electronic health record (EHR) for clinical use. <em><strong>Methods: </strong></em>The score was developed and validated using EHR data for a retrospective cohort of pregnancies with delivery between 2010 and 2018 at Kaiser Permanente Northern California, an integrated health care system. The outcome used for model development consisted of adverse obstetric events from delivery hospitalization (<em>e.g.</em>, eclampsia, hemorrhage, death). Candidate predictors included maternal age, parity, multiple gestation, and any maternal diagnoses assigned in health care encounters in the 12 months before admission for delivery. We used penalized regression for variable selection, logistic regression to fit the model, and internal validation for model evaluation. We also evaluated prenatal model performance at 18 weeks of pregnancy. <em><strong>Results:</strong></em> The development cohort ( = 227,405 pregnancies) had an outcome rate of 3.8% and the validation cohort ( = 41,683) had an outcome rate of 2.9%. Of 276 candidate predictors, 37 were included in the final model. The final model had a validation c-statistic of 0.72 (95% confidence interval [CI] 0.70-0.73). When evaluated at 18 weeks of pregnancy, discrimination was modestly diminished (c-statistic 0.68 [95% CI 0.67-0.70]). <em><strong>Conclusions:</strong></em> The obstetric comorbidity score demonstrated good discrimination for adverse obstetric outcomes. After additional appropriate validation, the score can be automated in the EHR to support early identification of high-risk women and assist efforts to ensure risk-appropriate maternal care.</p>

DOI

10.1089/whr.2021.0046

Alternate Title

Womens Health Rep (New Rochelle)

PMID

34841397

Title

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

Year of Publication

2021

Date Published

2021 Sep 28

ISSN Number

2154-1671

Abstract

<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>

DOI

10.1542/hpeds.2021-005894

Alternate Title

Hosp Pediatr

PMID

34583959

Title

Physiologic Monitor Alarm Burden and Nurses' Subjective Workload in a Children's Hospital.

Year of Publication

2021

Date Published

2021 Jun 01

ISSN Number

2154-1671

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Physiologic monitor alarms occur at high rates in children's hospitals; ≤1% are actionable. The burden of alarms has implications for patient safety and is challenging to measure directly. Nurse workload, measured by using a version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX) validated among nurses, is a useful indicator of work burden that has been associated with patient outcomes. A recent study revealed that 5-point increases in the NASA-TLX score were associated with a 22% increased risk in missed nursing care. Our objective was to measure the relationship between alarm count and nurse workload by using the NASA-TLX.</p>

<p><strong>METHODS: </strong>We conducted a repeated cross-sectional study of pediatric nurses in a tertiary care children's hospital to measure the association between NASA-TLX workload evaluations (using the nurse-validated scale) and alarm count in the 2 hours preceding NASA-TLX administration. Using a multivariable mixed-effects regression accounting for nurse-level clustering, we modeled the adjusted association of alarm count with workload.</p>

<p><strong>RESULTS: </strong>The NASA-TLX score was assessed in 26 nurses during 394 nursing shifts over a 2-month period. In adjusted regression models, experiencing &gt;40 alarms in the preceding 2 hours was associated with a 5.5 point increase (95% confidence interval 5.2 to 5.7; &lt; .001) in subjective workload.</p>

<p><strong>CONCLUSION: </strong>Alarm count in the preceding 2 hours is associated with a significant increase in subjective nurse workload that exceeds the threshold associated with increased risk of missed nursing care and potential patient harm.</p>

DOI

10.1542/hpeds.2020-003509

Alternate Title

Hosp Pediatr

PMID

34074710

Title

Monitor-Watcher Use, Nurses' Knowledge of Electrocardiographic Monitoring, and Arrhythmia Detection.

Year of Publication

2021

Number of Pages

38-44

Date Published

2021 Jan 01

ISSN Number

1937-710X

Abstract

<p><strong>BACKGROUND: </strong>Electrocardiographic telemetry monitors are ubiquitous in hospitals. Dedicated monitor watchers, either on the unit or in a centralized location, are often responsible for observing telemetry monitors and responding to their alarms. The impact of use of monitor watchers is not known.</p>

<p><strong>OBJECTIVES: </strong>To evaluate the association of monitor-watcher use with (1) nurses' knowledge of electrocardiographic (ECG) monitoring and (2) accuracy of arrhythmia detection.</p>

<p><strong>METHODS: </strong>Baseline data from 37 non-intensive care unit cardiac patient care areas in 17 hospitals in the Practical Use of the Latest Standards for Electrocardiography trial were analyzed. Nurses' knowledge (n = 1136 nurses) was measured using a validated, 20-item online test. Accuracy of arrhythmia detection (n = 1189 patients) was assessed for 5 consecutive days by comparing arrhythmias stored in the monitor with nurses' documentation. Multiple regression was used to evaluate the association of use of monitor watchers with scores on the ECG-monitoring knowledge test. The association of monitor-watcher use with accuracy of arrhythmia detection was examined by χ2 analysis.</p>

<p><strong>RESULTS: </strong>Of the 37 units, 13 (35%) had monitor watchers. Use of monitor watchers was not independently associated with ECG-monitoring knowledge (P = .08). The presence of monitor watchers also was not significantly associated with the accuracy of arrhythmia detection (P = .94).</p>

<p><strong>CONCLUSION: </strong>Although the use of monitor watchers was not associated with diminished nurses' knowledge of ECG monitoring, it also was not associated with more accurate arrhythmia detection. If implementing a monitor-watcher program, critical safety points, such as ensuring closed-loop communication, must be considered.</p>

DOI

10.4037/ajcc2021122

Alternate Title

Am J Crit Care

PMID

33385199

Title

Analysis: Protocol for a New Method to Measure Physiologic Monitor Alarm Responsiveness.

Year of Publication

2020

Number of Pages

389-396

Date Published

2020 Nov 01

ISSN Number

0899-8205

Abstract

<p>Evaluating the clinical impacts of healthcare alarm management systems plays a critical role in assessing newly implemented monitoring technology, exposing latent threats to patient safety, and identifying opportunities for system improvement. We describe a novel, accurate, rapidly implementable, and readily reproducible in situ simulation approach to measure alarm response times and rates without the challenges and expense of video analysis. An interprofessional team consisting of biomedical engineers, human factors engineers, information technology specialists, nurses, physicians, facilitators from the hospital's simulation center, clinical informaticians, and hospital administrative leadership worked with three units at a pediatric hospital to design and conduct the simulations. Existing hospital technology was used to transmit a simulated, unambiguously critical alarm that appeared to originate from an actual patient to the nurse's mobile device, and discreet observers measured responses. Simulation observational data can be used to design and evaluate quality improvement efforts to address alarm responsiveness and to benchmark performance of different alarm communication systems.</p>

DOI

10.2345/0899-8205-54.6.389

Alternate Title

Biomed Instrum Technol

PMID

33339028

Title

Measurement of Physiological Monitor Alarm Accuracy and Clinical Relevance in Intensive Care Units.

Year of Publication

2018

Number of Pages

11-21

Date Published

2018 01

ISSN Number

1937-710X

Abstract

<p><strong>BACKGROUND: </strong>Alarm fatigue threatens patient safety by delaying or reducing clinician response to alarms, which can lead to missed critical events. Interventions to reduce alarms without jeopardizing patient safety target either inaccurate or clinically irrelevant alarms, so assessment of alarm accuracy and clinical relevance may enhance the rigor of alarm intervention studies done in clinical units.</p>

<p><strong>OBJECTIVES: </strong>To (1) examine approaches used to measure accuracy and/or clinical relevance of physiological monitor alarms in intensive care units and (2) compare the proportions of inaccurate and clinically irrelevant alarms.</p>

<p><strong>METHODS: </strong>An integrative review was used to systematically search the literature and synthesize resulting articles.</p>

<p><strong>RESULTS: </strong>Twelve studies explicitly measuring alarm accuracy and/or clinical relevance on a clinical unit were identified. In the most rigorous studies, alarms were annotated retrospectively by obtaining alarm data and parameter waveforms rather than being annotated in real time. More than half of arrhythmia alarms in recent studies were inaccurate. However, contextual data were needed to determine alarms' clinical relevance. Proportions of clinically irrelevant alarms were high, but definitions of clinically irrelevant alarms often included inaccurate alarms.</p>

<p><strong>CONCLUSIONS: </strong>Future studies testing interventions on clinical units should include alarm accuracy and/or clinical relevance as outcome measures. Arrhythmia alarm accuracy should improve with advances in technology. Clinical interventions should focus on reducing clinically irrelevant alarms, with careful consideration of how clinical relevance is defined and measured.</p>

DOI

10.4037/ajcc2018385

Alternate Title

Am J Crit Care

PMID

29292271

Title

Attitudes and Practices Related to Clinical Alarms: A Follow-up Survey.

Year of Publication

2018

Number of Pages

114-123

Date Published

2018 03

ISSN Number

1937-710X

Abstract

<p><strong>BACKGROUND: </strong>Alarm fatigue is a widely acknowledged patient safety concern in hospitals. In 2013, The Joint Commission issued a National Patient Safety Goal on Alarm Management, making addressing alarm management a priority. To capture changes in attitudes and practices related to alarms, the Healthcare Technology Foundation conducted and reported findings from national online surveys in 2006 and 2011 and completed a third survey in 2016.</p>

<p><strong>OBJECTIVES: </strong>The goal of the 2016 survey was to identify how hospital practices and clinicians' perceptions of alarms have changed since 2006.</p>

<p><strong>METHODS: </strong>The online survey was distributed via national health care organizations during a 2-month period. Results of the 2016 survey (N = 1241) were compared with results of the 2006 and 2011 surveys by using χ and Kruskal-Wallis analyses.</p>

<p><strong>RESULTS: </strong>Responses were significantly different for almost all items across the 3 surveys. Respondents in 2016 were more likely to agree that nuisance alarms occur frequently and disrupt patient care and were less likely to agree that clinical staff responds quickly to alarms. Compared with respondents in 2011, those in 2016 were almost twice as likely to report that their hospitals had experienced adverse events related to alarms in the past 2 years. However, in 2016 a much higher proportion of respondents indicated that their hospitals had implemented alarm improvement initiatives.</p>

<p><strong>CONCLUSIONS: </strong>Although survey findings show disappointing trends in the past 10 years, including worsening perceptions of nuisance alarms and more alarm-related adverse events, the increase in alarm improvement initiatives is encouraging.</p>

DOI

10.4037/ajcc2018185

Alternate Title

Am J Crit Care

PMID

29496767

Title

Nurse-Technology Interactions and Patient Safety.

Year of Publication

2018

Number of Pages

203-213

Date Published

2018 Jun

ISSN Number

1558-3481

Abstract

<p>Nurses are the end-users of most technology in intensive care units, and the ways in which they interact with technology affect quality of care and patient safety. Nurses' interactions include the processes of ensuring proper input of data into the technology as well as extracting and interpreting the output (clinical data, technical data, alarms). Current challenges in nurse-technology interactions for physiologic monitoring include issues regarding alarm management, workflow interruptions, and monitor surveillance. Patient safety concepts, like high reliability organizations and human factors, can advance efforts to enhance nurse-technology interactions.</p>

DOI

10.1016/j.cnc.2018.02.003

Alternate Title

Crit Care Nurs Clin North Am

PMID

29724439

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