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

Background 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. Methods 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. Discussion 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. Trial registration Not applicable. This study does not meet the World Health Organization definition of a clinical trial. Electronic supplementary material The online version of this article (10.1186/s40814-019-0453-2) contains supplementary material, which is available to authorized users.


Introduction
Today I'd like to discuss the role of pulse oximetry monitoring in patients with bronchiolitis with you. Our research team is in the process of developing an intervention aimed at promoting the use of intermittent pulse oximetry measurement instead of continuous pulse oximetry monitoring in patients with bronchiolitis who are stable on room air, not requiring any supplemental oxygen. When I use the term "intervention" during our interview, that is what I am referring to.
The goal of today's interview is to discuss how clinicians at your hospital approach pulse oximetry use in bronchiolitis. We will discuss barriers and facilitators to reducing the use of continuous pulse oximetry at your hospital in patients who are stable on room air. It's important for you to know that there are NO right or wrong answers. I'm most interested in your perspective.
Section 1: Understanding the process and exploring general barriers/facilitators Q (Role of oximetry): First, I'd like to hear your general thoughts about the role that continuous monitoring plays in caring for infants with bronchiolitis at your hospital. This includes pulse oximetry monitoring as well as monitoring heart rhythm, heart rate, and respiratory rate with electrocardiographic leads.

Q (Reaction to data):
This past winter, we measured how often your hospital used continuous pulse oximetry in patients with bronchiolitis when they were not requiring supplemental oxygen. We found that the overuse rate was ___%, meaning that ___% of patients age 0-23 months who had a diagnosis of bronchiolitis and were breathing room air were being continuously monitored with pulse oximetry. Can you tell me if that percentage seems to make sense based on what you experience in your role at the hospital, or if it is surprising, and why? Q (Prior experience): Have you or your hospital had any prior experience implementing interventions aimed at reducing unnecessary pulse oximetry monitoring in bronchiolitis? If so, can you tell me about them, and how they went?

Q (Initiation process):
Tell me about the process of initiating continuous pulse oximetry in bronchiolitis patients at your hospital. I'm interested in the steps that need to occur to start a patient on continuous monitoring, and who is responsible for each step. I'm interested in all roles, including physicians, nurses, technicians, respiratory therapists, et cetera.

Q (Process failures):
Can you give me some examples of when the above processes don't work well, and patients end up being monitored unnecessarily even though they are not requiring supplemental oxygen?
Q (General barriers): I'd like to hear your thoughts about any barriers you have experienced to intermittently measuring the pulse oximetry value instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen. By barriers, I mean anything that has gotten in the way of launching, implementing or sustaining this practice in your setting.

Q (General facilitators):
Next, I'd like to hear your thoughts about any facilitators you have experienced to intermittently measuring the pulse oximetry value instead of continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen. By facilitators, I mean anything that has made it easier to launch, implement, or maintain this practice in your setting.

Q (External policies & incentives):
What hospital or departmental policies would either help or hinder launching and sustaining an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen?

Q (External policies & incentives):
What hospital protocols or care pathways for bronchiolitis would either help or hinder launching and sustaining an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen?

Q (External policies & incentives):
Are there any other external pressures that would influence launching and sustaining an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen? Q (Implementation climate): What do you expect would be the general level of receptivity in your organization to implementing an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen?
 Probe: Do you anticipate that units making improvements in reducing unnecessary pulse oximetry monitoring would be acknowledged or rewarded?
 Probe: Who in your organization would be most likely to resist this change, and why?

Q (Tension for change):
Is there a perceived need to stop using continuous pulse oximetry monitoring in bronchiolitis patients who are stable on room air at your hospital? Why or why not?

Q (Available resources):
What resources or support would be needed to effectively implement an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen at your hospital?

Q (Knowledge & beliefs):
Do you think an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen would be effective at your hospital? Why or why not?

Q (Knowledge & beliefs):
What is most uncomfortable to you about reducing the amount of continuous pulse oximetry monitoring that is occurring at your hospital?

Q (Knowledge & beliefs):
How do you think reducing the amount of continuous pulse oximetry monitoring that is occurring at your hospital could improve patient outcomes?
 Probe: How do you balance your fears with these potential benefits? Q (Self-efficacy): How confident are you that you will be able to successfully stop using continuous pulse oximetry monitoring in all bronchiolitis patients who are not requiring supplemental oxygen at your hospital?
 Probe: What else could be done to make that process easier?

Section 3: Intervention Mapping (Step 5) questions
In this final section, I will be asking you about the people who would be responsible for launching, implementing, and maintaining an intervention to promote use of intermittent pulse oximetry measurement instead of using continuous pulse oximetry in bronchiolitis patients.

Q (Role):
Tell me about what role you'd have if this intervention were implemented in your setting.
 Probe: Do you anticipate that you would be involved in the decision to implement it, in actually implementing the intervention, and/or in helping ensure it is implemented correctly and consistently over time?

Q (Adopters):
Who, specifically, in your health system would need to make the decision to use intermittent pulse oximetry measurement instead of using continuous pulse oximetry in bronchiolitis patients (e.g., hospital or department leadership, nursing department, chief quality officer)?
 Probe: What specific behaviors would indicate adoption of the practice? Q (Implementers): Who, specifically, in your health system would actually be involved in the implementation of intermittent pulse oximetry measurement instead of continuous pulse oximetry in all bronchiolitis patients not requiring supplemental oxygen? Let's start by listing all of the potential people (doctors, nurses, medical assistants) who might be involved in the tasks necessary to avoid continuous monitoring and instead use intermittent oximetry measurement. Who would be best suited for which task? What training initiatives do you think would be necessary or helpful?
 Explore how the practice might oversee quality of intervention delivery; communication between different clinicians; how this could be documented in the medical record.

Q (Maintenance):
Who would be responsible for ensuring that the intervention to promote use of intermittent pulse oximetry measurement instead of continuous pulse oximetry monitoring in bronchiolitis patients who are not requiring supplemental oxygen is implemented correctly and consistently over time? How would you know that the intervention has been maintained? In other words, what behavior would the key people responsible for maintenance engage in that would suggest the decision to sustain has been made (e.g., policies updated, clinical pathways, responsibilities clearly delineated)?

End
Thank you very much for taking part in this interview. We greatly appreciate the opportunity to learn from your perspectives.