Christopher P Landrigan, MD, MPH

Continuous pulse oximetry monitoring (cSpO₂) in children with bronchiolitis is associated with increased rates of hospital admission, longer lengths of stay, more frequent treatment with supplemental oxygen, alarm fatigue, and higher hospital cost. There is no evidence that it improves clinical outcomes.^1-7 The safety of reducing cSpO₂ for stable bronchiolitis patients (ie, those who are clinically well and not requiring supplemental oxygen) has been assessed in quality improvement initiatives^8-10 and a randomized controlled trial.² These studies showed no increase in intensive care unit transfers, codes, or readmissions associated with reduced cSpO₂. Current national guidelines from the American Academy of Pediatrics⁵ and the Society of Hospital Medicine Choosing Wisely in Pediatric Hospital Medicine workgroup⁴ support limiting monitoring of children with bronchiolitis. Despite this, the practice of cSpO₂ in stable bronchiolitis patients off supplemental oxygen remains widespread.^11,12

Deimplementation, defined as reducing or stopping low-value or ineffective healthcare practices,^13,14 is a discrete focus area within implementation science. Deimplementation research involves the reduction of unnecessary and overused services for which there is potential for harm or no benefit.^15,16 In pediatrics, there are a number of potential targets for deimplementation,^4,17-20 including cSpO₂ for stable infants with bronchiolitis, but efforts to reduce low-value practices have met limited success to date. ^21,22

Implementation science offers rigorous methods for advancing the development and evaluation of strategies for deimplementation.²³ In particular, implementation science frameworks can facilitate our understanding of relevant contextual factors that may hinder or help efforts to deimplement low-value practices. To develop broadly applicable strategies to reduce monitoring overuse, it is important to understand the barriers, facilitators, and contextual factors (eg, clinical, political, interpersonal) that contribute to guideline-discordant cSpO₂ in hospitalized bronchiolitis patients. Further, the process by which one can develop a rigorous understanding of these factors and how they may impact deimplementation efforts could generalize to other scenarios in pediatrics where overuse remains an issue.

The goal of this study was to use semistructured interviews, informed by an established implementation science framework, specifically the Consolidated Framework for Implementation Research (CFIR),²⁴ to (1) identify barriers and facilitators to deimplementing unnecessary cSpO₂, and (2) develop strategies to deimplement cSpO₂ in a multicenter cohort of hospital-based clinician and administrative stakeholders.

Study Setting

This multicenter qualitative study using semistructured interviews took place within the Eliminating Monitor Overuse (EMO) SpO₂ study. The EMO SpO₂ study established rates of cSpO₂ in bronchiolitis patients not receiving supplemental oxygen or not receiving room air flow at 56 hospitals across the United States and in Canada from December 1, 2018, through March 31, 2019.¹² The study identified hospital-level risk-adjusted cSpO₂ rates ranging from 6% to 82%. A description of the EMO SpO₂ study methods²⁵ and its findings¹² have been published elsewhere.

Participants

We approached EMO study site principal investigators at 12 hospitals: the two highest- and two lowest-use hospitals within three hospital types (ie, freestanding children’s hospitals, children’s hospitals within large general hospitals, and community hospitals). We collaborated with the participating site principal investigators (n = 12), who were primarily hospitalist physicians in leadership roles, to recruit a purposive sample of additional stakeholders including bedside nurses (n = 12), hospitalist physicians (n = 15), respiratory therapists (n = 9), and hospital administrators (n = 8) to participate in semistructured interviews. Interviews were conducted until we achieved thematic saturation within each stakeholder group and within the high and low performing strata (total 56 interviews). Participants were asked to self-report basic demographic information (see Appendix, interview guide) as required by the study funder and to allow us to comment on the representativeness of the participant group.

Procedure

The interview guide was informed by the CFIR, a comprehensive framework detailing contextual factors that require consideration when planning for the implementation of a health service intervention. Table 1 details the CFIR domains with study-related examples. The interview guide (Appendix) provided limited clinical context apart from the age, diagnosis, and oxygen requirement for the population of interest to promote a broad array of responses and to avoid anchoring on specific clinical scenarios. Interviews were conducted by master’s degree or doctoral-level research coordinators with qualitative interviewing experience and supervised by a medical anthropologist and qualitative methods expert (F.K.B.). Prior to engaging in audio recorded phone interviews, the interviewer explained the risks and benefits of participating. Participants were compensated $50. Audio recordings were transcribed, deidentified, and uploaded to NVivo 12 Plus (QSR International) for data management.

schondelmeyer06121223e_t1.jpg

The Institutional Review Boards of Children’s Hospital of Philadelphia, Pennsylvania, and the University of Pennsylvania in Philadelphia determined that the study met eligibility criteria for IRB exemption.

Data Analysis

Using an integrated approach to codebook development,²⁶ a priori codes were developed using constructs from the CFIR. Additional codes were added by the research team following a close reading of the first five transcripts.^27,28 Each code was defined, including decision rules for its application. Two research coordinators independently coded each transcript. Using the intercoder reliability function within NVivo, the coders established strong interrater reliability accordance scores (k > .8) by double coding 20% of the transcripts. Data were stratified by sites with low and high use of cSpO₂ to examine differences in barriers and facilitators to deimplementation. Each code was subcoded, summarized, and examined for patterns within and across participating disciplines, which yielded themes related to barriers and facilitators. We conducted member checking and reviewed our conclusions with a multidisciplinary group of clinical stakeholders (n = 13) to validate our analyses.

Barriers and facilitators to deimplementation were identified in multiple domains of the CFIR: outer setting, inner setting, characteristics of the individuals, and intervention characteristics (Table 1). Participants also suggested strategies to facilitate deimplementation in response to some identified barriers. See Table 2 for participant demographics and Table 3 for illustrative participant quotations.

schondelmeyer06121223e_t2.jpg

schondelmeyer06121223e_t3.jpg

Barriers

Outer Setting: Clinician Perceptions of Parental Discomfort With Discontinuing Monitoring

Participants mentioned parental preferences as a barrier to discontinuing cSpO₂, noting that parents seem to take comfort in watching the numbers on the monitor screen and are reluctant to have it withdrawn. Clinicians noted that parents sometimes put the monitor back on their child after a clinician removed it or have expressed concern that their unmonitored child was not receiving the same level of care as other patients who were being monitored. In these scenarios, clinicians reported they have found it helpful to educate caregivers about when cSpO₂ is and is not appropriate.

Inner Setting: Unclear or Nonexistent Guideline to Discontinue cSpO₂

Guidelines to discontinue cSpO₂ reportedly did not exist at all institutions. If a guideline did exist, lack of clarity or conflicting guidelines about when to use oxygen presented a barrier. Participants suggested that a clear guideline or additional oversight to ensure all clinicians are informed of the procedure for discontinuing cSpO₂ may help prevent miscommunication. Participants noted that their electronic health record (EHR) order sets commonly included cSpO₂ orders and that removing that option would facilitate deimplementation.

Inner Setting: Difficulty Educating All Staff

Participants noted difficulty with incorporating education about discontinuing cSpO₂ to all clinicians, particularly to those who are nightshift only or to rotating staff or trainees. This created barriers for frequent re-education because these staff are not familiar with the policies and procedures of the unit, which is crucial to developing a culture that supports the deimplementation of cSpO₂. Participants suggested that recurring education about procedures for discontinuing cSpO₂ should target trainees, new nurses, and overnight nurses. This would help to ensure that the guideline is uniformly followed.

Inner Setting: Culture of High cSpO₂ Use

Participants from high-use sites discussed a culture driven by readily available monitoring features or an expectation that monitoring indicates higher-quality care. Participants from low-use sites discussed increased cSpO₂ driven by clinicians who were accustomed to caring for higher-acuity patients, for whom continuous monitoring is likely appropriate, and were simultaneously caring for stable bronchiolitis patients.

Some suggested that visual cues would be useful to clinicians to sustain awareness about a cSpO₂ deimplementation guideline. It was also suggested that audit and feedback techniques like posting unit deimplementation statistics and creating a competition among units by posting unit performance could facilitate deimplementation. Additionally, some noted that visual aids in common spaces would be useful to remind clinicians and to engage caregivers about discontinuing cSpO₂.

Characteristics of Individuals: Clinician Discomfort Discontinuing cSpO₂

One frequently cited barrier across participants is that cSpO₂ provides “peace of mind” to alert clinicians to patients with low oxygen saturations that might otherwise be missed. Participants identified that clinician discomfort with reducing cSpO₂ may be driven by inexperienced clinicians less familiar with the bronchiolitis disease process, such as trainees, new nurses, or rotating clinicians unaccustomed to pediatric care. Trainees and new nurses were perceived as being more likely to work at night when there are fewer clinicians to provide patient care. Additionally, participants perceived that night shift clinicians favored cSpO₂ because they could measure vital signs without waking patients and families.

Clinicians discussed that discontinuing cSpO₂ would require alternative methods for assessing patient status, particularly for night shift nurses. Participants suggested strategies including changes to pulse oximetry assessment procedures to include more frequent “spot checks,” incorporation of assessments during sleep events (eg, naps) to ensure the patient does not experience desaturations during sleep, and training nurses to become more comfortable with suctioning patients. Suggestions also included education on the typical features of transient oxygen desaturations in otherwise stable patients with bronchiolitis² to bolster clinical confidence for clinicians unfamiliar with caring for bronchiolitis patients. Participants perceived that education about appropriate vs inappropriate use may help to empower clinicians to employ cSpO₂ appropriately.

Facilitators

Outer Setting: Standards and Evidence From Research, Professional Organizations, and Leaders in the Field

Many participants expressed the importance of consistent guidelines that are advocated by thought leaders in the field, supported by robust evidence, and consistent with approaches at peer hospitals. The more authoritative support a guideline has, the more comfortable people are adopting it and taking it seriously. Additionally, consistent education about guidelines was desired. Participants noted that all clinicians should be receiving education related to the American Academy of Pediatrics (AAP) Bronchiolitis and Choosing Wisely^® guidelines, ranging from a one-time update to annually. Continual updates and re-education sessions for clinicians who shared evidence about how cSpO₂ deimplementation could improve the quality of patient care by shortening hospital length of stay and lowering cost were suggested strategies.

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.

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.

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.

Continuous pulse oximetry monitoring (cSpO₂) in children with bronchiolitis is associated with increased rates of hospital admission, longer lengths of stay, more frequent treatment with supplemental oxygen, alarm fatigue, and higher hospital cost. There is no evidence that it improves clinical outcomes.^1-7 The safety of reducing cSpO₂ for stable bronchiolitis patients (ie, those who are clinically well and not requiring supplemental oxygen) has been assessed in quality improvement initiatives^8-10 and a randomized controlled trial.² These studies showed no increase in intensive care unit transfers, codes, or readmissions associated with reduced cSpO₂. Current national guidelines from the American Academy of Pediatrics⁵ and the Society of Hospital Medicine Choosing Wisely in Pediatric Hospital Medicine workgroup⁴ support limiting monitoring of children with bronchiolitis. Despite this, the practice of cSpO₂ in stable bronchiolitis patients off supplemental oxygen remains widespread.^11,12

Deimplementation, defined as reducing or stopping low-value or ineffective healthcare practices,^13,14 is a discrete focus area within implementation science. Deimplementation research involves the reduction of unnecessary and overused services for which there is potential for harm or no benefit.^15,16 In pediatrics, there are a number of potential targets for deimplementation,^4,17-20 including cSpO₂ for stable infants with bronchiolitis, but efforts to reduce low-value practices have met limited success to date. ^21,22

Implementation science offers rigorous methods for advancing the development and evaluation of strategies for deimplementation.²³ In particular, implementation science frameworks can facilitate our understanding of relevant contextual factors that may hinder or help efforts to deimplement low-value practices. To develop broadly applicable strategies to reduce monitoring overuse, it is important to understand the barriers, facilitators, and contextual factors (eg, clinical, political, interpersonal) that contribute to guideline-discordant cSpO₂ in hospitalized bronchiolitis patients. Further, the process by which one can develop a rigorous understanding of these factors and how they may impact deimplementation efforts could generalize to other scenarios in pediatrics where overuse remains an issue.

The goal of this study was to use semistructured interviews, informed by an established implementation science framework, specifically the Consolidated Framework for Implementation Research (CFIR),²⁴ to (1) identify barriers and facilitators to deimplementing unnecessary cSpO₂, and (2) develop strategies to deimplement cSpO₂ in a multicenter cohort of hospital-based clinician and administrative stakeholders.

Study Setting

This multicenter qualitative study using semistructured interviews took place within the Eliminating Monitor Overuse (EMO) SpO₂ study. The EMO SpO₂ study established rates of cSpO₂ in bronchiolitis patients not receiving supplemental oxygen or not receiving room air flow at 56 hospitals across the United States and in Canada from December 1, 2018, through March 31, 2019.¹² The study identified hospital-level risk-adjusted cSpO₂ rates ranging from 6% to 82%. A description of the EMO SpO₂ study methods²⁵ and its findings¹² have been published elsewhere.

Participants

We approached EMO study site principal investigators at 12 hospitals: the two highest- and two lowest-use hospitals within three hospital types (ie, freestanding children’s hospitals, children’s hospitals within large general hospitals, and community hospitals). We collaborated with the participating site principal investigators (n = 12), who were primarily hospitalist physicians in leadership roles, to recruit a purposive sample of additional stakeholders including bedside nurses (n = 12), hospitalist physicians (n = 15), respiratory therapists (n = 9), and hospital administrators (n = 8) to participate in semistructured interviews. Interviews were conducted until we achieved thematic saturation within each stakeholder group and within the high and low performing strata (total 56 interviews). Participants were asked to self-report basic demographic information (see Appendix, interview guide) as required by the study funder and to allow us to comment on the representativeness of the participant group.

Procedure

The interview guide was informed by the CFIR, a comprehensive framework detailing contextual factors that require consideration when planning for the implementation of a health service intervention. Table 1 details the CFIR domains with study-related examples. The interview guide (Appendix) provided limited clinical context apart from the age, diagnosis, and oxygen requirement for the population of interest to promote a broad array of responses and to avoid anchoring on specific clinical scenarios. Interviews were conducted by master’s degree or doctoral-level research coordinators with qualitative interviewing experience and supervised by a medical anthropologist and qualitative methods expert (F.K.B.). Prior to engaging in audio recorded phone interviews, the interviewer explained the risks and benefits of participating. Participants were compensated $50. Audio recordings were transcribed, deidentified, and uploaded to NVivo 12 Plus (QSR International) for data management.

schondelmeyer06121223e_t1.jpg

The Institutional Review Boards of Children’s Hospital of Philadelphia, Pennsylvania, and the University of Pennsylvania in Philadelphia determined that the study met eligibility criteria for IRB exemption.

Data Analysis

Using an integrated approach to codebook development,²⁶ a priori codes were developed using constructs from the CFIR. Additional codes were added by the research team following a close reading of the first five transcripts.^27,28 Each code was defined, including decision rules for its application. Two research coordinators independently coded each transcript. Using the intercoder reliability function within NVivo, the coders established strong interrater reliability accordance scores (k > .8) by double coding 20% of the transcripts. Data were stratified by sites with low and high use of cSpO₂ to examine differences in barriers and facilitators to deimplementation. Each code was subcoded, summarized, and examined for patterns within and across participating disciplines, which yielded themes related to barriers and facilitators. We conducted member checking and reviewed our conclusions with a multidisciplinary group of clinical stakeholders (n = 13) to validate our analyses.

Barriers and facilitators to deimplementation were identified in multiple domains of the CFIR: outer setting, inner setting, characteristics of the individuals, and intervention characteristics (Table 1). Participants also suggested strategies to facilitate deimplementation in response to some identified barriers. See Table 2 for participant demographics and Table 3 for illustrative participant quotations.

schondelmeyer06121223e_t2.jpg

schondelmeyer06121223e_t3.jpg

Barriers

Outer Setting: Clinician Perceptions of Parental Discomfort With Discontinuing Monitoring

Participants mentioned parental preferences as a barrier to discontinuing cSpO₂, noting that parents seem to take comfort in watching the numbers on the monitor screen and are reluctant to have it withdrawn. Clinicians noted that parents sometimes put the monitor back on their child after a clinician removed it or have expressed concern that their unmonitored child was not receiving the same level of care as other patients who were being monitored. In these scenarios, clinicians reported they have found it helpful to educate caregivers about when cSpO₂ is and is not appropriate.

Inner Setting: Unclear or Nonexistent Guideline to Discontinue cSpO₂

Guidelines to discontinue cSpO₂ reportedly did not exist at all institutions. If a guideline did exist, lack of clarity or conflicting guidelines about when to use oxygen presented a barrier. Participants suggested that a clear guideline or additional oversight to ensure all clinicians are informed of the procedure for discontinuing cSpO₂ may help prevent miscommunication. Participants noted that their electronic health record (EHR) order sets commonly included cSpO₂ orders and that removing that option would facilitate deimplementation.

Inner Setting: Difficulty Educating All Staff

Participants noted difficulty with incorporating education about discontinuing cSpO₂ to all clinicians, particularly to those who are nightshift only or to rotating staff or trainees. This created barriers for frequent re-education because these staff are not familiar with the policies and procedures of the unit, which is crucial to developing a culture that supports the deimplementation of cSpO₂. Participants suggested that recurring education about procedures for discontinuing cSpO₂ should target trainees, new nurses, and overnight nurses. This would help to ensure that the guideline is uniformly followed.

Inner Setting: Culture of High cSpO₂ Use

Participants from high-use sites discussed a culture driven by readily available monitoring features or an expectation that monitoring indicates higher-quality care. Participants from low-use sites discussed increased cSpO₂ driven by clinicians who were accustomed to caring for higher-acuity patients, for whom continuous monitoring is likely appropriate, and were simultaneously caring for stable bronchiolitis patients.

Some suggested that visual cues would be useful to clinicians to sustain awareness about a cSpO₂ deimplementation guideline. It was also suggested that audit and feedback techniques like posting unit deimplementation statistics and creating a competition among units by posting unit performance could facilitate deimplementation. Additionally, some noted that visual aids in common spaces would be useful to remind clinicians and to engage caregivers about discontinuing cSpO₂.

Characteristics of Individuals: Clinician Discomfort Discontinuing cSpO₂

One frequently cited barrier across participants is that cSpO₂ provides “peace of mind” to alert clinicians to patients with low oxygen saturations that might otherwise be missed. Participants identified that clinician discomfort with reducing cSpO₂ may be driven by inexperienced clinicians less familiar with the bronchiolitis disease process, such as trainees, new nurses, or rotating clinicians unaccustomed to pediatric care. Trainees and new nurses were perceived as being more likely to work at night when there are fewer clinicians to provide patient care. Additionally, participants perceived that night shift clinicians favored cSpO₂ because they could measure vital signs without waking patients and families.

Clinicians discussed that discontinuing cSpO₂ would require alternative methods for assessing patient status, particularly for night shift nurses. Participants suggested strategies including changes to pulse oximetry assessment procedures to include more frequent “spot checks,” incorporation of assessments during sleep events (eg, naps) to ensure the patient does not experience desaturations during sleep, and training nurses to become more comfortable with suctioning patients. Suggestions also included education on the typical features of transient oxygen desaturations in otherwise stable patients with bronchiolitis² to bolster clinical confidence for clinicians unfamiliar with caring for bronchiolitis patients. Participants perceived that education about appropriate vs inappropriate use may help to empower clinicians to employ cSpO₂ appropriately.

Facilitators

Outer Setting: Standards and Evidence From Research, Professional Organizations, and Leaders in the Field

Many participants expressed the importance of consistent guidelines that are advocated by thought leaders in the field, supported by robust evidence, and consistent with approaches at peer hospitals. The more authoritative support a guideline has, the more comfortable people are adopting it and taking it seriously. Additionally, consistent education about guidelines was desired. Participants noted that all clinicians should be receiving education related to the American Academy of Pediatrics (AAP) Bronchiolitis and Choosing Wisely^® guidelines, ranging from a one-time update to annually. Continual updates and re-education sessions for clinicians who shared evidence about how cSpO₂ deimplementation could improve the quality of patient care by shortening hospital length of stay and lowering cost were suggested strategies.

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.

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.

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.

Continuous pulse oximetry monitoring (cSpO₂) in children with bronchiolitis is associated with increased rates of hospital admission, longer lengths of stay, more frequent treatment with supplemental oxygen, alarm fatigue, and higher hospital cost. There is no evidence that it improves clinical outcomes.^1-7 The safety of reducing cSpO₂ for stable bronchiolitis patients (ie, those who are clinically well and not requiring supplemental oxygen) has been assessed in quality improvement initiatives^8-10 and a randomized controlled trial.² These studies showed no increase in intensive care unit transfers, codes, or readmissions associated with reduced cSpO₂. Current national guidelines from the American Academy of Pediatrics⁵ and the Society of Hospital Medicine Choosing Wisely in Pediatric Hospital Medicine workgroup⁴ support limiting monitoring of children with bronchiolitis. Despite this, the practice of cSpO₂ in stable bronchiolitis patients off supplemental oxygen remains widespread.^11,12

Deimplementation, defined as reducing or stopping low-value or ineffective healthcare practices,^13,14 is a discrete focus area within implementation science. Deimplementation research involves the reduction of unnecessary and overused services for which there is potential for harm or no benefit.^15,16 In pediatrics, there are a number of potential targets for deimplementation,^4,17-20 including cSpO₂ for stable infants with bronchiolitis, but efforts to reduce low-value practices have met limited success to date. ^21,22

Implementation science offers rigorous methods for advancing the development and evaluation of strategies for deimplementation.²³ In particular, implementation science frameworks can facilitate our understanding of relevant contextual factors that may hinder or help efforts to deimplement low-value practices. To develop broadly applicable strategies to reduce monitoring overuse, it is important to understand the barriers, facilitators, and contextual factors (eg, clinical, political, interpersonal) that contribute to guideline-discordant cSpO₂ in hospitalized bronchiolitis patients. Further, the process by which one can develop a rigorous understanding of these factors and how they may impact deimplementation efforts could generalize to other scenarios in pediatrics where overuse remains an issue.

The goal of this study was to use semistructured interviews, informed by an established implementation science framework, specifically the Consolidated Framework for Implementation Research (CFIR),²⁴ to (1) identify barriers and facilitators to deimplementing unnecessary cSpO₂, and (2) develop strategies to deimplement cSpO₂ in a multicenter cohort of hospital-based clinician and administrative stakeholders.

Study Setting

This multicenter qualitative study using semistructured interviews took place within the Eliminating Monitor Overuse (EMO) SpO₂ study. The EMO SpO₂ study established rates of cSpO₂ in bronchiolitis patients not receiving supplemental oxygen or not receiving room air flow at 56 hospitals across the United States and in Canada from December 1, 2018, through March 31, 2019.¹² The study identified hospital-level risk-adjusted cSpO₂ rates ranging from 6% to 82%. A description of the EMO SpO₂ study methods²⁵ and its findings¹² have been published elsewhere.

Participants

We approached EMO study site principal investigators at 12 hospitals: the two highest- and two lowest-use hospitals within three hospital types (ie, freestanding children’s hospitals, children’s hospitals within large general hospitals, and community hospitals). We collaborated with the participating site principal investigators (n = 12), who were primarily hospitalist physicians in leadership roles, to recruit a purposive sample of additional stakeholders including bedside nurses (n = 12), hospitalist physicians (n = 15), respiratory therapists (n = 9), and hospital administrators (n = 8) to participate in semistructured interviews. Interviews were conducted until we achieved thematic saturation within each stakeholder group and within the high and low performing strata (total 56 interviews). Participants were asked to self-report basic demographic information (see Appendix, interview guide) as required by the study funder and to allow us to comment on the representativeness of the participant group.

Procedure

The interview guide was informed by the CFIR, a comprehensive framework detailing contextual factors that require consideration when planning for the implementation of a health service intervention. Table 1 details the CFIR domains with study-related examples. The interview guide (Appendix) provided limited clinical context apart from the age, diagnosis, and oxygen requirement for the population of interest to promote a broad array of responses and to avoid anchoring on specific clinical scenarios. Interviews were conducted by master’s degree or doctoral-level research coordinators with qualitative interviewing experience and supervised by a medical anthropologist and qualitative methods expert (F.K.B.). Prior to engaging in audio recorded phone interviews, the interviewer explained the risks and benefits of participating. Participants were compensated $50. Audio recordings were transcribed, deidentified, and uploaded to NVivo 12 Plus (QSR International) for data management.

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The Institutional Review Boards of Children’s Hospital of Philadelphia, Pennsylvania, and the University of Pennsylvania in Philadelphia determined that the study met eligibility criteria for IRB exemption.

Data Analysis

Using an integrated approach to codebook development,²⁶ a priori codes were developed using constructs from the CFIR. Additional codes were added by the research team following a close reading of the first five transcripts.^27,28 Each code was defined, including decision rules for its application. Two research coordinators independently coded each transcript. Using the intercoder reliability function within NVivo, the coders established strong interrater reliability accordance scores (k > .8) by double coding 20% of the transcripts. Data were stratified by sites with low and high use of cSpO₂ to examine differences in barriers and facilitators to deimplementation. Each code was subcoded, summarized, and examined for patterns within and across participating disciplines, which yielded themes related to barriers and facilitators. We conducted member checking and reviewed our conclusions with a multidisciplinary group of clinical stakeholders (n = 13) to validate our analyses.

Barriers and facilitators to deimplementation were identified in multiple domains of the CFIR: outer setting, inner setting, characteristics of the individuals, and intervention characteristics (Table 1). Participants also suggested strategies to facilitate deimplementation in response to some identified barriers. See Table 2 for participant demographics and Table 3 for illustrative participant quotations.

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Barriers

Outer Setting: Clinician Perceptions of Parental Discomfort With Discontinuing Monitoring

Participants mentioned parental preferences as a barrier to discontinuing cSpO₂, noting that parents seem to take comfort in watching the numbers on the monitor screen and are reluctant to have it withdrawn. Clinicians noted that parents sometimes put the monitor back on their child after a clinician removed it or have expressed concern that their unmonitored child was not receiving the same level of care as other patients who were being monitored. In these scenarios, clinicians reported they have found it helpful to educate caregivers about when cSpO₂ is and is not appropriate.

Inner Setting: Unclear or Nonexistent Guideline to Discontinue cSpO₂

Guidelines to discontinue cSpO₂ reportedly did not exist at all institutions. If a guideline did exist, lack of clarity or conflicting guidelines about when to use oxygen presented a barrier. Participants suggested that a clear guideline or additional oversight to ensure all clinicians are informed of the procedure for discontinuing cSpO₂ may help prevent miscommunication. Participants noted that their electronic health record (EHR) order sets commonly included cSpO₂ orders and that removing that option would facilitate deimplementation.

Inner Setting: Difficulty Educating All Staff

Participants noted difficulty with incorporating education about discontinuing cSpO₂ to all clinicians, particularly to those who are nightshift only or to rotating staff or trainees. This created barriers for frequent re-education because these staff are not familiar with the policies and procedures of the unit, which is crucial to developing a culture that supports the deimplementation of cSpO₂. Participants suggested that recurring education about procedures for discontinuing cSpO₂ should target trainees, new nurses, and overnight nurses. This would help to ensure that the guideline is uniformly followed.

Inner Setting: Culture of High cSpO₂ Use

Participants from high-use sites discussed a culture driven by readily available monitoring features or an expectation that monitoring indicates higher-quality care. Participants from low-use sites discussed increased cSpO₂ driven by clinicians who were accustomed to caring for higher-acuity patients, for whom continuous monitoring is likely appropriate, and were simultaneously caring for stable bronchiolitis patients.

Some suggested that visual cues would be useful to clinicians to sustain awareness about a cSpO₂ deimplementation guideline. It was also suggested that audit and feedback techniques like posting unit deimplementation statistics and creating a competition among units by posting unit performance could facilitate deimplementation. Additionally, some noted that visual aids in common spaces would be useful to remind clinicians and to engage caregivers about discontinuing cSpO₂.

Characteristics of Individuals: Clinician Discomfort Discontinuing cSpO₂

One frequently cited barrier across participants is that cSpO₂ provides “peace of mind” to alert clinicians to patients with low oxygen saturations that might otherwise be missed. Participants identified that clinician discomfort with reducing cSpO₂ may be driven by inexperienced clinicians less familiar with the bronchiolitis disease process, such as trainees, new nurses, or rotating clinicians unaccustomed to pediatric care. Trainees and new nurses were perceived as being more likely to work at night when there are fewer clinicians to provide patient care. Additionally, participants perceived that night shift clinicians favored cSpO₂ because they could measure vital signs without waking patients and families.

Clinicians discussed that discontinuing cSpO₂ would require alternative methods for assessing patient status, particularly for night shift nurses. Participants suggested strategies including changes to pulse oximetry assessment procedures to include more frequent “spot checks,” incorporation of assessments during sleep events (eg, naps) to ensure the patient does not experience desaturations during sleep, and training nurses to become more comfortable with suctioning patients. Suggestions also included education on the typical features of transient oxygen desaturations in otherwise stable patients with bronchiolitis² to bolster clinical confidence for clinicians unfamiliar with caring for bronchiolitis patients. Participants perceived that education about appropriate vs inappropriate use may help to empower clinicians to employ cSpO₂ appropriately.

Facilitators

Outer Setting: Standards and Evidence From Research, Professional Organizations, and Leaders in the Field

Many participants expressed the importance of consistent guidelines that are advocated by thought leaders in the field, supported by robust evidence, and consistent with approaches at peer hospitals. The more authoritative support a guideline has, the more comfortable people are adopting it and taking it seriously. Additionally, consistent education about guidelines was desired. Participants noted that all clinicians should be receiving education related to the American Academy of Pediatrics (AAP) Bronchiolitis and Choosing Wisely^® guidelines, ranging from a one-time update to annually. Continual updates and re-education sessions for clinicians who shared evidence about how cSpO₂ deimplementation could improve the quality of patient care by shortening hospital length of stay and lowering cost were suggested strategies.

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.

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.

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.

Continuous pulse oximetry monitoring in children with bronchiolitis who don’t require supplemental oxygen is discouraged by practice guidelines and is recognized as a form of medical overuse.^1-3 This practice can be associated with negative outcomes, including prolonged length of stay,^4-6 increased cost of hospitalization,⁷ and alarm fatigue among nurses.⁸ Despite initiatives to reduce continuous pulse oximetry monitoring in stable patients with bronchiolitis,^1,2 wide practice variation exists between hospitals.^9,10 Previous studies have shown that higher prevalence of inpatient bronchiolitis admissions is associated with decreased utilization of unnecessary interventions.¹¹ However, the relationship between pulse oximetry use and bronchiolitis prevalence has not been studied. The objective of this study is to test the hypothesis that hospital units with lower proportions of patients admitted for bronchiolitis and those with fewer general pediatrics patients relative to subspecialty patients would have higher rates of pulse oximetry overuse.

Study Design

We conducted a substudy of the Pediatric Research in Inpatient Settings (PRIS) Network’s Eliminating Monitoring Overuse (EMO) pulse oximetry study,^10,12 a 56-hospital cross-sectional study that used direct observation to measure the prevalence of continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who did not require supplemental oxygen between December 1, 2018, through March 31, 2019. This substudy was not included as part of the original aims of the project and was proposed as a separate analysis during data collection. For US sites, the Institutional Review Board (IRB) at Children’s Hospital of Philadelphia approved the study and served as the central IRB. The Research Ethics Board at University of Calgary also approved the study.

Site Selection

Hospitals with at least 60 observations were eligible for inclusion. Of the 32 hospitals that conducted the minimum observations, 25 agreed to participate (21 free-standing children’s hospitals, 3 children’s hospitals within general hospitals, and 1 community hospital).

Patient Population

The parent study included patients aged 8 weeks through 23 months with a primary diagnosis of bronchiolitis. Patients were included only if they were not receiving supplemental oxygen or nasal cannula flow at the time of data collection. The inclusion and exclusion criteria were for both the parent study and the substudy. Further inclusion and exclusion criteria have been described previously.^10,12

Data Collection

In order to ascertain continuous pulse oximetry monitoring status, staff at each hospital performed observational rounds by walking to the bedside of each patient who met inclusion criteria. Additional methodology for the parent study has been published elsewhere.^10,12

Bronchiolitis Admission Volume by Unit

Collaborators at each hospital gathered bronchiolitis census data from each unit that admitted patients with bronchiolitis. Units were identified prior to data collection and were characterized at the institution level based on previous local definitions. Each site was responsible for using institution-specific data collection methods for determining bronchiolitis and total admissions on each unit (eg, departmental reports or directly querying admissions data using International Classification of Diseases, Tenth Revision, diagnosis codes for bronchiolitis) over the same period as the parent study. Following data analysis, bronchiolitis admission burden was classified into five categories, based on less than 10%, 10% to less than 20%, 20% to less than 30%, 30% to less than 40%, or 40% or more of total admissions having a primary discharge diagnosis of bronchiolitis during the study period. This categorization allowed investigators to determine whether there was a dose-dependent response among categories.

Unit Composition

Site investigators also completed a survey identifying which patients were admitted to each unit (eg, general pediatrics only, medical subspecialty, surgical). Based on these results, units were further classified into seven types (Appendix Table). For the final analysis, units caring exclusively for general pediatrics patients were compared to all other unit types.

Analysis

Bronchiolitis admission burden and unit composition data were combined with observations of pulse oximetry monitoring use of patients not requiring supplemental oxygen from the parent study. We determined unadjusted observed monitoring proportions for each unit’s bronchiolitis admission burden category across all 25 hospitals. This was calculated as a simple proportion of the total number of observations during which patients were continuously monitored divided by the total number of observations performed within each unit’s admission category. We then calculated unadjusted odds ratios using the 40% and higher bronchiolitis admission burden category as a reference. We calculated similar proportions and odds ratios for the dichotomous unit composition variable. Next, we used mixed-effects logistic regression with a random intercept for each hospital to allow for differences in baseline monitoring rates, which varied widely between hospitals (2% to 92%),¹⁰ to calculate adjusted odds ratios for the unit’s admission category and unit’s composition. We also adjusted for the same covariates used in the primary study’s analysis (Table).¹⁰

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We analyzed 2,366 observations of bronchiolitis patients from 25 hospitals. Most observations were concentrated in freestanding children’s hospitals (89%), and 50% were from hospitals with more than 250 pediatric beds. Observations were well distributed among the five categories of admit burden (Table).

In unadjusted regression, the relationship between admission burden and rate of pulse oximetry use did not appear to be dose-dependent, and 95% CIs were wide. We then analyzed the data accounting for baseline differences in hospital monitoring rates and adjusted for the covariates significantly associated with continuous pulse oximetry monitoring in the primary study’s analysis with use of a mixed-effects model. As shown in the Table, low-burden units in which bronchiolitis constituted less than 10% of total admissions had a 2.16-fold increased odds of unnecessary pulse oximetry monitoring compared to high-burden units in which bronchiolitis constituted 40% or more of total admissions (95% CI, 1.27-3.69; P = .01).

In examining the subspecialty unit composition, 596 observations (25.2%) were conducted on units exclusively caring for general pediatrics patients. In the mixed-effects model adjusted for bronchiolitis admission burden and the covariates used in the study’s primary analysis, units exclusively caring for general pediatrics patients did not have significantly different independent odds of pulse oximetry monitoring use compared to units with a mixed patient population (OR 1.01; 95% CI, 0.71-1.45; P = .95) (Appendix Table).

In this multicenter observational study of children hospitalized with bronchiolitis not concurrently receiving supplemental oxygen, units that only occasionally cared for bronchiolitis patients appeared to be more likely to overuse continuous pulse oximetry during bronchiolitis hospitalizations.

This finding was not immediately apparent when examining the raw data because of wide hospital-level variation in continuous pulse oximetry monitoring use. However, when the high degree of hospital-level variation in baseline overuse was accounted for with use of a random intercept for each hospital in the mixed-effects model, units that cared for higher proportions of bronchiolitis patients had significantly lower odds of continuous pulse oximetry monitoring use compared to units that cared for these infants infrequently.

As many institutions have subspecialized units to cultivate nursing expertise for care of certain diseases and patient populations, we hypothesized that units caring primarily for children on general pediatrics units would also have lower rates of monitoring overuse compared to mixed units. Interestingly, these units did not perform better, likely because potential cultural factors that might contribute to differences in monitoring are accounted for by bronchiolitis admission burden.

Our findings build on prior literature by demonstrating that unit-level, as well as hospital-level, factors appear to drive overuse in healthcare. A prior single-site retrospective cohort study demonstrated an association between higher prevalence of inpatient bronchiolitis and decreased use of unnecessary interventions such as laboratory and radiographic testing, as well as steroid and antibiotic administration.¹¹ Although study of the relationship between volume and quality is not new to healthcare, to our knowledge, this study is the first to examine the relationship between pulse oximetry overuse in bronchiolitis and unit-level factors like admission burden and subspecialty composition.

There are several limitations. First, because the study population included only children not receiving supplemental oxygen, both the parent study and this substudy assumed that all observed use of pulse oximetry monitoring was overuse. In some cases, however, there may have been other compelling clinical reasons, institutional policies, or differences in pulse oximetry availability that were not captured during data collection or in our adjusted model. Second, hospitals used convenience sampling. It is possible this resulted in samples that were not representative of each unit’s underlying patient population or monitoring practice. In addition, not all of the 32 eligible sites were able to provide data related to hospital admissions at the unit level and thus are not included in our analysis. This remains a potential source of hospital-level selection bias.

These findings demonstrate that high bronchiolitis admission burden correlates with lower rates of unnecessary pulse oximetry monitoring in bronchiolitis. We speculate that these outcomes might reflect differing degrees of nursing comfort, expertise, and unit-level norms in caring for bronchiolitis patients, although our study was not designed to establish underlying causes. Identification of operating principles that underpin low pulse oximetry monitoring on high-burden units will provide guidance for decreasing unnecessary monitoring and will inform future studies seeking ways to discourage continuous pulse oximetry monitoring in low-risk infants. Given the institutional variation in monitoring rates, future studies examining both institution-wide and unit-level interventions will be necessary to decrease unnecessary pulse oximetry monitoring in bronchiolitis. Furthermore, these findings may be relevant to studying care quality in other disease processes, with bronchiolitis serving as a model illness for overuse.

The authors acknowledge the National Heart, Lung, and Blood Institute of the National Institutes of Health 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. The authors thank the executive council of the Pediatric Research in Inpatient Settings 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.

The authors thank the PRIS Network collaborators for their major contributions to data collection (see Appendix).

Continuous pulse oximetry monitoring in children with bronchiolitis who don’t require supplemental oxygen is discouraged by practice guidelines and is recognized as a form of medical overuse.^1-3 This practice can be associated with negative outcomes, including prolonged length of stay,^4-6 increased cost of hospitalization,⁷ and alarm fatigue among nurses.⁸ Despite initiatives to reduce continuous pulse oximetry monitoring in stable patients with bronchiolitis,^1,2 wide practice variation exists between hospitals.^9,10 Previous studies have shown that higher prevalence of inpatient bronchiolitis admissions is associated with decreased utilization of unnecessary interventions.¹¹ However, the relationship between pulse oximetry use and bronchiolitis prevalence has not been studied. The objective of this study is to test the hypothesis that hospital units with lower proportions of patients admitted for bronchiolitis and those with fewer general pediatrics patients relative to subspecialty patients would have higher rates of pulse oximetry overuse.

Study Design

We conducted a substudy of the Pediatric Research in Inpatient Settings (PRIS) Network’s Eliminating Monitoring Overuse (EMO) pulse oximetry study,^10,12 a 56-hospital cross-sectional study that used direct observation to measure the prevalence of continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who did not require supplemental oxygen between December 1, 2018, through March 31, 2019. This substudy was not included as part of the original aims of the project and was proposed as a separate analysis during data collection. For US sites, the Institutional Review Board (IRB) at Children’s Hospital of Philadelphia approved the study and served as the central IRB. The Research Ethics Board at University of Calgary also approved the study.

Site Selection

Hospitals with at least 60 observations were eligible for inclusion. Of the 32 hospitals that conducted the minimum observations, 25 agreed to participate (21 free-standing children’s hospitals, 3 children’s hospitals within general hospitals, and 1 community hospital).

Patient Population

The parent study included patients aged 8 weeks through 23 months with a primary diagnosis of bronchiolitis. Patients were included only if they were not receiving supplemental oxygen or nasal cannula flow at the time of data collection. The inclusion and exclusion criteria were for both the parent study and the substudy. Further inclusion and exclusion criteria have been described previously.^10,12

Data Collection

In order to ascertain continuous pulse oximetry monitoring status, staff at each hospital performed observational rounds by walking to the bedside of each patient who met inclusion criteria. Additional methodology for the parent study has been published elsewhere.^10,12

Bronchiolitis Admission Volume by Unit

Collaborators at each hospital gathered bronchiolitis census data from each unit that admitted patients with bronchiolitis. Units were identified prior to data collection and were characterized at the institution level based on previous local definitions. Each site was responsible for using institution-specific data collection methods for determining bronchiolitis and total admissions on each unit (eg, departmental reports or directly querying admissions data using International Classification of Diseases, Tenth Revision, diagnosis codes for bronchiolitis) over the same period as the parent study. Following data analysis, bronchiolitis admission burden was classified into five categories, based on less than 10%, 10% to less than 20%, 20% to less than 30%, 30% to less than 40%, or 40% or more of total admissions having a primary discharge diagnosis of bronchiolitis during the study period. This categorization allowed investigators to determine whether there was a dose-dependent response among categories.

Unit Composition

Site investigators also completed a survey identifying which patients were admitted to each unit (eg, general pediatrics only, medical subspecialty, surgical). Based on these results, units were further classified into seven types (Appendix Table). For the final analysis, units caring exclusively for general pediatrics patients were compared to all other unit types.

Analysis

Bronchiolitis admission burden and unit composition data were combined with observations of pulse oximetry monitoring use of patients not requiring supplemental oxygen from the parent study. We determined unadjusted observed monitoring proportions for each unit’s bronchiolitis admission burden category across all 25 hospitals. This was calculated as a simple proportion of the total number of observations during which patients were continuously monitored divided by the total number of observations performed within each unit’s admission category. We then calculated unadjusted odds ratios using the 40% and higher bronchiolitis admission burden category as a reference. We calculated similar proportions and odds ratios for the dichotomous unit composition variable. Next, we used mixed-effects logistic regression with a random intercept for each hospital to allow for differences in baseline monitoring rates, which varied widely between hospitals (2% to 92%),¹⁰ to calculate adjusted odds ratios for the unit’s admission category and unit’s composition. We also adjusted for the same covariates used in the primary study’s analysis (Table).¹⁰

stoeck03351021e_t1.jpg

We analyzed 2,366 observations of bronchiolitis patients from 25 hospitals. Most observations were concentrated in freestanding children’s hospitals (89%), and 50% were from hospitals with more than 250 pediatric beds. Observations were well distributed among the five categories of admit burden (Table).

In unadjusted regression, the relationship between admission burden and rate of pulse oximetry use did not appear to be dose-dependent, and 95% CIs were wide. We then analyzed the data accounting for baseline differences in hospital monitoring rates and adjusted for the covariates significantly associated with continuous pulse oximetry monitoring in the primary study’s analysis with use of a mixed-effects model. As shown in the Table, low-burden units in which bronchiolitis constituted less than 10% of total admissions had a 2.16-fold increased odds of unnecessary pulse oximetry monitoring compared to high-burden units in which bronchiolitis constituted 40% or more of total admissions (95% CI, 1.27-3.69; P = .01).

In examining the subspecialty unit composition, 596 observations (25.2%) were conducted on units exclusively caring for general pediatrics patients. In the mixed-effects model adjusted for bronchiolitis admission burden and the covariates used in the study’s primary analysis, units exclusively caring for general pediatrics patients did not have significantly different independent odds of pulse oximetry monitoring use compared to units with a mixed patient population (OR 1.01; 95% CI, 0.71-1.45; P = .95) (Appendix Table).

In this multicenter observational study of children hospitalized with bronchiolitis not concurrently receiving supplemental oxygen, units that only occasionally cared for bronchiolitis patients appeared to be more likely to overuse continuous pulse oximetry during bronchiolitis hospitalizations.

This finding was not immediately apparent when examining the raw data because of wide hospital-level variation in continuous pulse oximetry monitoring use. However, when the high degree of hospital-level variation in baseline overuse was accounted for with use of a random intercept for each hospital in the mixed-effects model, units that cared for higher proportions of bronchiolitis patients had significantly lower odds of continuous pulse oximetry monitoring use compared to units that cared for these infants infrequently.

As many institutions have subspecialized units to cultivate nursing expertise for care of certain diseases and patient populations, we hypothesized that units caring primarily for children on general pediatrics units would also have lower rates of monitoring overuse compared to mixed units. Interestingly, these units did not perform better, likely because potential cultural factors that might contribute to differences in monitoring are accounted for by bronchiolitis admission burden.

Our findings build on prior literature by demonstrating that unit-level, as well as hospital-level, factors appear to drive overuse in healthcare. A prior single-site retrospective cohort study demonstrated an association between higher prevalence of inpatient bronchiolitis and decreased use of unnecessary interventions such as laboratory and radiographic testing, as well as steroid and antibiotic administration.¹¹ Although study of the relationship between volume and quality is not new to healthcare, to our knowledge, this study is the first to examine the relationship between pulse oximetry overuse in bronchiolitis and unit-level factors like admission burden and subspecialty composition.

There are several limitations. First, because the study population included only children not receiving supplemental oxygen, both the parent study and this substudy assumed that all observed use of pulse oximetry monitoring was overuse. In some cases, however, there may have been other compelling clinical reasons, institutional policies, or differences in pulse oximetry availability that were not captured during data collection or in our adjusted model. Second, hospitals used convenience sampling. It is possible this resulted in samples that were not representative of each unit’s underlying patient population or monitoring practice. In addition, not all of the 32 eligible sites were able to provide data related to hospital admissions at the unit level and thus are not included in our analysis. This remains a potential source of hospital-level selection bias.

These findings demonstrate that high bronchiolitis admission burden correlates with lower rates of unnecessary pulse oximetry monitoring in bronchiolitis. We speculate that these outcomes might reflect differing degrees of nursing comfort, expertise, and unit-level norms in caring for bronchiolitis patients, although our study was not designed to establish underlying causes. Identification of operating principles that underpin low pulse oximetry monitoring on high-burden units will provide guidance for decreasing unnecessary monitoring and will inform future studies seeking ways to discourage continuous pulse oximetry monitoring in low-risk infants. Given the institutional variation in monitoring rates, future studies examining both institution-wide and unit-level interventions will be necessary to decrease unnecessary pulse oximetry monitoring in bronchiolitis. Furthermore, these findings may be relevant to studying care quality in other disease processes, with bronchiolitis serving as a model illness for overuse.

The authors acknowledge the National Heart, Lung, and Blood Institute of the National Institutes of Health 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. The authors thank the executive council of the Pediatric Research in Inpatient Settings 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.

The authors thank the PRIS Network collaborators for their major contributions to data collection (see Appendix).

Continuous pulse oximetry monitoring in children with bronchiolitis who don’t require supplemental oxygen is discouraged by practice guidelines and is recognized as a form of medical overuse.^1-3 This practice can be associated with negative outcomes, including prolonged length of stay,^4-6 increased cost of hospitalization,⁷ and alarm fatigue among nurses.⁸ Despite initiatives to reduce continuous pulse oximetry monitoring in stable patients with bronchiolitis,^1,2 wide practice variation exists between hospitals.^9,10 Previous studies have shown that higher prevalence of inpatient bronchiolitis admissions is associated with decreased utilization of unnecessary interventions.¹¹ However, the relationship between pulse oximetry use and bronchiolitis prevalence has not been studied. The objective of this study is to test the hypothesis that hospital units with lower proportions of patients admitted for bronchiolitis and those with fewer general pediatrics patients relative to subspecialty patients would have higher rates of pulse oximetry overuse.

Study Design

We conducted a substudy of the Pediatric Research in Inpatient Settings (PRIS) Network’s Eliminating Monitoring Overuse (EMO) pulse oximetry study,^10,12 a 56-hospital cross-sectional study that used direct observation to measure the prevalence of continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who did not require supplemental oxygen between December 1, 2018, through March 31, 2019. This substudy was not included as part of the original aims of the project and was proposed as a separate analysis during data collection. For US sites, the Institutional Review Board (IRB) at Children’s Hospital of Philadelphia approved the study and served as the central IRB. The Research Ethics Board at University of Calgary also approved the study.

Site Selection

Hospitals with at least 60 observations were eligible for inclusion. Of the 32 hospitals that conducted the minimum observations, 25 agreed to participate (21 free-standing children’s hospitals, 3 children’s hospitals within general hospitals, and 1 community hospital).

Patient Population

The parent study included patients aged 8 weeks through 23 months with a primary diagnosis of bronchiolitis. Patients were included only if they were not receiving supplemental oxygen or nasal cannula flow at the time of data collection. The inclusion and exclusion criteria were for both the parent study and the substudy. Further inclusion and exclusion criteria have been described previously.^10,12

Data Collection

In order to ascertain continuous pulse oximetry monitoring status, staff at each hospital performed observational rounds by walking to the bedside of each patient who met inclusion criteria. Additional methodology for the parent study has been published elsewhere.^10,12

Bronchiolitis Admission Volume by Unit

Collaborators at each hospital gathered bronchiolitis census data from each unit that admitted patients with bronchiolitis. Units were identified prior to data collection and were characterized at the institution level based on previous local definitions. Each site was responsible for using institution-specific data collection methods for determining bronchiolitis and total admissions on each unit (eg, departmental reports or directly querying admissions data using International Classification of Diseases, Tenth Revision, diagnosis codes for bronchiolitis) over the same period as the parent study. Following data analysis, bronchiolitis admission burden was classified into five categories, based on less than 10%, 10% to less than 20%, 20% to less than 30%, 30% to less than 40%, or 40% or more of total admissions having a primary discharge diagnosis of bronchiolitis during the study period. This categorization allowed investigators to determine whether there was a dose-dependent response among categories.

Unit Composition

Site investigators also completed a survey identifying which patients were admitted to each unit (eg, general pediatrics only, medical subspecialty, surgical). Based on these results, units were further classified into seven types (Appendix Table). For the final analysis, units caring exclusively for general pediatrics patients were compared to all other unit types.

Analysis

Bronchiolitis admission burden and unit composition data were combined with observations of pulse oximetry monitoring use of patients not requiring supplemental oxygen from the parent study. We determined unadjusted observed monitoring proportions for each unit’s bronchiolitis admission burden category across all 25 hospitals. This was calculated as a simple proportion of the total number of observations during which patients were continuously monitored divided by the total number of observations performed within each unit’s admission category. We then calculated unadjusted odds ratios using the 40% and higher bronchiolitis admission burden category as a reference. We calculated similar proportions and odds ratios for the dichotomous unit composition variable. Next, we used mixed-effects logistic regression with a random intercept for each hospital to allow for differences in baseline monitoring rates, which varied widely between hospitals (2% to 92%),¹⁰ to calculate adjusted odds ratios for the unit’s admission category and unit’s composition. We also adjusted for the same covariates used in the primary study’s analysis (Table).¹⁰

stoeck03351021e_t1.jpg

We analyzed 2,366 observations of bronchiolitis patients from 25 hospitals. Most observations were concentrated in freestanding children’s hospitals (89%), and 50% were from hospitals with more than 250 pediatric beds. Observations were well distributed among the five categories of admit burden (Table).

In unadjusted regression, the relationship between admission burden and rate of pulse oximetry use did not appear to be dose-dependent, and 95% CIs were wide. We then analyzed the data accounting for baseline differences in hospital monitoring rates and adjusted for the covariates significantly associated with continuous pulse oximetry monitoring in the primary study’s analysis with use of a mixed-effects model. As shown in the Table, low-burden units in which bronchiolitis constituted less than 10% of total admissions had a 2.16-fold increased odds of unnecessary pulse oximetry monitoring compared to high-burden units in which bronchiolitis constituted 40% or more of total admissions (95% CI, 1.27-3.69; P = .01).

In examining the subspecialty unit composition, 596 observations (25.2%) were conducted on units exclusively caring for general pediatrics patients. In the mixed-effects model adjusted for bronchiolitis admission burden and the covariates used in the study’s primary analysis, units exclusively caring for general pediatrics patients did not have significantly different independent odds of pulse oximetry monitoring use compared to units with a mixed patient population (OR 1.01; 95% CI, 0.71-1.45; P = .95) (Appendix Table).

In this multicenter observational study of children hospitalized with bronchiolitis not concurrently receiving supplemental oxygen, units that only occasionally cared for bronchiolitis patients appeared to be more likely to overuse continuous pulse oximetry during bronchiolitis hospitalizations.

This finding was not immediately apparent when examining the raw data because of wide hospital-level variation in continuous pulse oximetry monitoring use. However, when the high degree of hospital-level variation in baseline overuse was accounted for with use of a random intercept for each hospital in the mixed-effects model, units that cared for higher proportions of bronchiolitis patients had significantly lower odds of continuous pulse oximetry monitoring use compared to units that cared for these infants infrequently.

As many institutions have subspecialized units to cultivate nursing expertise for care of certain diseases and patient populations, we hypothesized that units caring primarily for children on general pediatrics units would also have lower rates of monitoring overuse compared to mixed units. Interestingly, these units did not perform better, likely because potential cultural factors that might contribute to differences in monitoring are accounted for by bronchiolitis admission burden.

Our findings build on prior literature by demonstrating that unit-level, as well as hospital-level, factors appear to drive overuse in healthcare. A prior single-site retrospective cohort study demonstrated an association between higher prevalence of inpatient bronchiolitis and decreased use of unnecessary interventions such as laboratory and radiographic testing, as well as steroid and antibiotic administration.¹¹ Although study of the relationship between volume and quality is not new to healthcare, to our knowledge, this study is the first to examine the relationship between pulse oximetry overuse in bronchiolitis and unit-level factors like admission burden and subspecialty composition.

There are several limitations. First, because the study population included only children not receiving supplemental oxygen, both the parent study and this substudy assumed that all observed use of pulse oximetry monitoring was overuse. In some cases, however, there may have been other compelling clinical reasons, institutional policies, or differences in pulse oximetry availability that were not captured during data collection or in our adjusted model. Second, hospitals used convenience sampling. It is possible this resulted in samples that were not representative of each unit’s underlying patient population or monitoring practice. In addition, not all of the 32 eligible sites were able to provide data related to hospital admissions at the unit level and thus are not included in our analysis. This remains a potential source of hospital-level selection bias.

These findings demonstrate that high bronchiolitis admission burden correlates with lower rates of unnecessary pulse oximetry monitoring in bronchiolitis. We speculate that these outcomes might reflect differing degrees of nursing comfort, expertise, and unit-level norms in caring for bronchiolitis patients, although our study was not designed to establish underlying causes. Identification of operating principles that underpin low pulse oximetry monitoring on high-burden units will provide guidance for decreasing unnecessary monitoring and will inform future studies seeking ways to discourage continuous pulse oximetry monitoring in low-risk infants. Given the institutional variation in monitoring rates, future studies examining both institution-wide and unit-level interventions will be necessary to decrease unnecessary pulse oximetry monitoring in bronchiolitis. Furthermore, these findings may be relevant to studying care quality in other disease processes, with bronchiolitis serving as a model illness for overuse.

The authors acknowledge the National Heart, Lung, and Blood Institute of the National Institutes of Health 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. The authors thank the executive council of the Pediatric Research in Inpatient Settings 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.

The authors thank the PRIS Network collaborators for their major contributions to data collection (see Appendix).

As part of improvement collaboratives that aimed to reduce overuse of continuous pulse oximetry in children hospitalized with bronchiolitis, researchers used the presence of an active order for it as a proxy for the actual use of such monitoring.^1,2 With use of this proxy, investigators on a national study documented a high burden of continuous oximetry overuse (86.5% before quality improvement interventions and 45.5% after),¹ but the validity of orders in representing actual monitoring practice is unknown. If the presence of an active pulse oximetry order accurately identifies infants on monitors, electronic health record data could inform epidemiologic estimates of monitoring overuse and measure the success of quality improvement and deimplementation interventions. Alternatively, if nurses commonly begin and/or discontinue pulse oximetry without updated orders, a pulse oximetry order would not be an accurate proxy, and additional data capture methods (eg, bedside observation or data capture from bedside monitors) would be needed.

Understanding the validity of orders for detection of actual use is critical because continuous pulse oximetry monitoring is considered an overused practice in pediatric acute viral bronchiolitis,³ and national guidelines recommend against its use in low-risk hospitalized children.^4,5 Continuous monitoring may identify trivial, self-resolving oxygen desaturation and its use is not associated with improved outcomes.^6-9 When self-resolving desaturations are treated with additional supplemental oxygen, hospital stays may be unnecessarily prolonged.¹⁰ In order to reduce unnecessary continuous pulse oximetry use, measurement of the extent of the overused practice is necessary. In this 56-hospital study,¹¹ we aimed to determine the validity of using active continuous pulse oximetry orders instead of bedside observation of actual monitor use.

Design

In this multicenter, repeated cross-sectional study, investigators used direct bedside observation to determine continuous pulse oximetry monitor use and then assessed whether an active continuous monitoring order was present in the electronic health record. The study took place during one bronchiolitis season, December 1, 2018, through March 31, 2019.

Setting and Patients

Investigators at 56 freestanding children’s hospitals, children’s hospitals within general hospitals, and community hospitals in the Pediatric Research in Inpatient Settings (PRIS) Network collected data on infants aged 8 weeks to 23 months who were hospitalized with bronchiolitis. As this work was a substudy of the larger Eliminating Monitor Overuse study, only infants not currently receiving supplemental oxygen were included.¹¹ Investigators observed eligible infants outside of the intensive care unit on general hospital medicine units. We excluded infants born premature (documented prematurity of <28 weeks’ gestation or documented “premature” without a gestational age listed), as well as those with a home oxygen requirement, cyanotic congenital heart disease, pulmonary hypertension, tracheostomy, primary neuromuscular disease, immunodeficiency, or cancer.

Data Collection

Investigators used the electronic health record to identify eligible infants. Investigators entered patient rooms to confirm the infant was not on supplemental oxygen (hence confirming eligibility for the study) and determine if continuous pulse oximetry was actively in use by examining the monitor display for a pulse oximetry waveform. Investigators then confirmed if active orders for pulse oximetry were present in the patient’s chart. Per study design, site investigators aimed to observe approximately half of eligible infants during the day (10 am to 5 pm) and the other half during the night (11 pm to 7 am).

Analysis

We excluded patients with conditional orders (eg, monitored only when certain conditions exist, such as when asleep) because of the time-varying and wide range of conditions that could be specified. Furthermore, conditional orders would not be useful as proxies to measure oximetry use because investigators would still need additional data (eg, bedside observation) to determine current monitoring status.

We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of active orders using the reference standard of direct bedside observation, as well as corresponding 95% CIs that accounted for within-hospital clustering. We calculated these test characteristics overall and as stratified across four age groups: 8 weeks to 5 months, 6 months to 11 months, 12 months to 17 months, and 18 months to 23 months. We also calculated the test characteristics for each hospital. We decided a priori that a PPV and NPV of 80% would represent a reasonable threshold to use active orders as a proxy in multicenter research. For hospital-level analyses we included only hospitals with 60 or more total observations and more than 15 observations with active orders for PPV and more than 15 observations without active orders for NPV. We used Stata (StataCorp LLC, College Station, Texas) version 15.1 for analysis.

For US sites, the Institutional Review Board (IRB) at Children’s Hospital of Philadelphia approved the study as the single reviewing IRB, and the remaining US sites established reliance agreements with the reviewing IRB. Research Ethics Boards at the Canadian sites (University of Calgary and The Hospital for Sick Children) also reviewed and approved the study. All sites granted waivers of consent, assent, parental permission, and HIPAA authorization.

Investigators completed 3,612 observations in 56 hospitals. This included 33 freestanding children’s hospitals, 14 hospitals within large general hospitals, and 9 community hospitals. Of 3,612 completed observations, on 631 occasions (17%) patients had conditional orders (eg, continuous monitoring only when sleeping) and were excluded from further analysis.

Most pulse oximetry–monitored infants did not have an active monitoring order (670 out of 1,309; sensitivity of 49%). Test characteristics, stratified by age group, are presented in the Table. Across all observations, the overall PPV was 77% (95% CI, 72-82), and the overall NPV was 69% (95% CI, 61-77). Variation of all test characteristics across age group was small (eg, the sensitivity ranged from 43% to 51%).

brady08281021e_t1.jpg

With inclusion of only those hospitals with sufficient observations, hospital-level variation in the PPV and NPV of using active orders was substantial (PPV range of 48% to 96% and NPV range of 30% to 98%). Only two hospitals had both a PPV and NPV for using monitor orders that exceeded the 80% threshold.

Active continuous pulse oximetry orders did not accurately represent actual monitoring status in this study. Monitoring orders alone frequently misrepresent true monitoring status and, as such, should be interpreted with caution in research or quality improvement activities. If more valid estimates of monitoring use and overuse are needed, potential measurement options include direct observation, as used in our study, as well as the use of more complex data streams such as the output of monitoring devices or pulse oximetry data in the electronic health record. In only two of the hospitals, using active continuous monitoring orders was a reasonable proxy for detecting actual monitor use. Monitoring orders could potentially be validly used for deimplementation efforts at those centers; other hospitals could consider targeted improvement efforts (eg, morning huddles examining the discordance between monitoring orders and monitoring status) to improve the accuracy of using continuous pulse oximetry orders.

We acknowledge several limitations of this study. Site investigators employed a convenience sampling approach, so it is possible that some investigators observed sicker or less sick infants. Although the PRIS network includes a geographically diverse group of North American hospitals, community hospitals were underrepresented in this study. Our results hence generalize more precisely to freestanding children’s hospitals than to community hospitals. We did not observe infants currently on supplemental oxygen, so we do not know to what degree using orders is valid in that context. We did not collect data on why actual monitoring status differed from monitoring orders and hence cannot quantify to what extent different factors (eg, nurse belief that monitors are a safety net or infants inadvertently left on monitors after a spot check pulse oximetry reading) contributed to this discordance. Finally, our study only examined one electronic health record variable—the presence of an active order. It may be that other variables in the health record (eg, minute-by-minute pulse oximetry values in a vital sign flowsheet) are much better proxies of actual continuous monitor use.

Using an active order for continuous pulse oximetry has poor sensitivity, PPV, and NPV for detecting true monitoring status at the bedside. Teams intending to measure the actual use of pulse oximetry should be aware of the limitations of using active orders alone as an accurate measure of pulse oximetry monitoring.

We thank the NHLBI scientists who contributed to this project as part of the U01 Cooperative Agreement funding mechanism: Lora Reineck, MD, MS, Karen Bienstock, MS, and Cheryl Boyce, PhD.

We thank the Executive Council of the PRIS Network for their contributions to the early scientific development of this project. We thank the PRIS site investigators for their major contributions to the Eliminating Monitor Overuse (EMO) Study data collection. Each listed collaborator is a group author for the PRIS Network in this manuscript. Their names can be found in the online supplemental information.

As part of improvement collaboratives that aimed to reduce overuse of continuous pulse oximetry in children hospitalized with bronchiolitis, researchers used the presence of an active order for it as a proxy for the actual use of such monitoring.^1,2 With use of this proxy, investigators on a national study documented a high burden of continuous oximetry overuse (86.5% before quality improvement interventions and 45.5% after),¹ but the validity of orders in representing actual monitoring practice is unknown. If the presence of an active pulse oximetry order accurately identifies infants on monitors, electronic health record data could inform epidemiologic estimates of monitoring overuse and measure the success of quality improvement and deimplementation interventions. Alternatively, if nurses commonly begin and/or discontinue pulse oximetry without updated orders, a pulse oximetry order would not be an accurate proxy, and additional data capture methods (eg, bedside observation or data capture from bedside monitors) would be needed.

Understanding the validity of orders for detection of actual use is critical because continuous pulse oximetry monitoring is considered an overused practice in pediatric acute viral bronchiolitis,³ and national guidelines recommend against its use in low-risk hospitalized children.^4,5 Continuous monitoring may identify trivial, self-resolving oxygen desaturation and its use is not associated with improved outcomes.^6-9 When self-resolving desaturations are treated with additional supplemental oxygen, hospital stays may be unnecessarily prolonged.¹⁰ In order to reduce unnecessary continuous pulse oximetry use, measurement of the extent of the overused practice is necessary. In this 56-hospital study,¹¹ we aimed to determine the validity of using active continuous pulse oximetry orders instead of bedside observation of actual monitor use.

Design

In this multicenter, repeated cross-sectional study, investigators used direct bedside observation to determine continuous pulse oximetry monitor use and then assessed whether an active continuous monitoring order was present in the electronic health record. The study took place during one bronchiolitis season, December 1, 2018, through March 31, 2019.

Setting and Patients

Investigators at 56 freestanding children’s hospitals, children’s hospitals within general hospitals, and community hospitals in the Pediatric Research in Inpatient Settings (PRIS) Network collected data on infants aged 8 weeks to 23 months who were hospitalized with bronchiolitis. As this work was a substudy of the larger Eliminating Monitor Overuse study, only infants not currently receiving supplemental oxygen were included.¹¹ Investigators observed eligible infants outside of the intensive care unit on general hospital medicine units. We excluded infants born premature (documented prematurity of <28 weeks’ gestation or documented “premature” without a gestational age listed), as well as those with a home oxygen requirement, cyanotic congenital heart disease, pulmonary hypertension, tracheostomy, primary neuromuscular disease, immunodeficiency, or cancer.

Data Collection

Investigators used the electronic health record to identify eligible infants. Investigators entered patient rooms to confirm the infant was not on supplemental oxygen (hence confirming eligibility for the study) and determine if continuous pulse oximetry was actively in use by examining the monitor display for a pulse oximetry waveform. Investigators then confirmed if active orders for pulse oximetry were present in the patient’s chart. Per study design, site investigators aimed to observe approximately half of eligible infants during the day (10 am to 5 pm) and the other half during the night (11 pm to 7 am).

Analysis

We excluded patients with conditional orders (eg, monitored only when certain conditions exist, such as when asleep) because of the time-varying and wide range of conditions that could be specified. Furthermore, conditional orders would not be useful as proxies to measure oximetry use because investigators would still need additional data (eg, bedside observation) to determine current monitoring status.

We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of active orders using the reference standard of direct bedside observation, as well as corresponding 95% CIs that accounted for within-hospital clustering. We calculated these test characteristics overall and as stratified across four age groups: 8 weeks to 5 months, 6 months to 11 months, 12 months to 17 months, and 18 months to 23 months. We also calculated the test characteristics for each hospital. We decided a priori that a PPV and NPV of 80% would represent a reasonable threshold to use active orders as a proxy in multicenter research. For hospital-level analyses we included only hospitals with 60 or more total observations and more than 15 observations with active orders for PPV and more than 15 observations without active orders for NPV. We used Stata (StataCorp LLC, College Station, Texas) version 15.1 for analysis.

For US sites, the Institutional Review Board (IRB) at Children’s Hospital of Philadelphia approved the study as the single reviewing IRB, and the remaining US sites established reliance agreements with the reviewing IRB. Research Ethics Boards at the Canadian sites (University of Calgary and The Hospital for Sick Children) also reviewed and approved the study. All sites granted waivers of consent, assent, parental permission, and HIPAA authorization.

Investigators completed 3,612 observations in 56 hospitals. This included 33 freestanding children’s hospitals, 14 hospitals within large general hospitals, and 9 community hospitals. Of 3,612 completed observations, on 631 occasions (17%) patients had conditional orders (eg, continuous monitoring only when sleeping) and were excluded from further analysis.

Most pulse oximetry–monitored infants did not have an active monitoring order (670 out of 1,309; sensitivity of 49%). Test characteristics, stratified by age group, are presented in the Table. Across all observations, the overall PPV was 77% (95% CI, 72-82), and the overall NPV was 69% (95% CI, 61-77). Variation of all test characteristics across age group was small (eg, the sensitivity ranged from 43% to 51%).

brady08281021e_t1.jpg

With inclusion of only those hospitals with sufficient observations, hospital-level variation in the PPV and NPV of using active orders was substantial (PPV range of 48% to 96% and NPV range of 30% to 98%). Only two hospitals had both a PPV and NPV for using monitor orders that exceeded the 80% threshold.

Active continuous pulse oximetry orders did not accurately represent actual monitoring status in this study. Monitoring orders alone frequently misrepresent true monitoring status and, as such, should be interpreted with caution in research or quality improvement activities. If more valid estimates of monitoring use and overuse are needed, potential measurement options include direct observation, as used in our study, as well as the use of more complex data streams such as the output of monitoring devices or pulse oximetry data in the electronic health record. In only two of the hospitals, using active continuous monitoring orders was a reasonable proxy for detecting actual monitor use. Monitoring orders could potentially be validly used for deimplementation efforts at those centers; other hospitals could consider targeted improvement efforts (eg, morning huddles examining the discordance between monitoring orders and monitoring status) to improve the accuracy of using continuous pulse oximetry orders.

We acknowledge several limitations of this study. Site investigators employed a convenience sampling approach, so it is possible that some investigators observed sicker or less sick infants. Although the PRIS network includes a geographically diverse group of North American hospitals, community hospitals were underrepresented in this study. Our results hence generalize more precisely to freestanding children’s hospitals than to community hospitals. We did not observe infants currently on supplemental oxygen, so we do not know to what degree using orders is valid in that context. We did not collect data on why actual monitoring status differed from monitoring orders and hence cannot quantify to what extent different factors (eg, nurse belief that monitors are a safety net or infants inadvertently left on monitors after a spot check pulse oximetry reading) contributed to this discordance. Finally, our study only examined one electronic health record variable—the presence of an active order. It may be that other variables in the health record (eg, minute-by-minute pulse oximetry values in a vital sign flowsheet) are much better proxies of actual continuous monitor use.

Using an active order for continuous pulse oximetry has poor sensitivity, PPV, and NPV for detecting true monitoring status at the bedside. Teams intending to measure the actual use of pulse oximetry should be aware of the limitations of using active orders alone as an accurate measure of pulse oximetry monitoring.

We thank the NHLBI scientists who contributed to this project as part of the U01 Cooperative Agreement funding mechanism: Lora Reineck, MD, MS, Karen Bienstock, MS, and Cheryl Boyce, PhD.

We thank the Executive Council of the PRIS Network for their contributions to the early scientific development of this project. We thank the PRIS site investigators for their major contributions to the Eliminating Monitor Overuse (EMO) Study data collection. Each listed collaborator is a group author for the PRIS Network in this manuscript. Their names can be found in the online supplemental information.

As part of improvement collaboratives that aimed to reduce overuse of continuous pulse oximetry in children hospitalized with bronchiolitis, researchers used the presence of an active order for it as a proxy for the actual use of such monitoring.^1,2 With use of this proxy, investigators on a national study documented a high burden of continuous oximetry overuse (86.5% before quality improvement interventions and 45.5% after),¹ but the validity of orders in representing actual monitoring practice is unknown. If the presence of an active pulse oximetry order accurately identifies infants on monitors, electronic health record data could inform epidemiologic estimates of monitoring overuse and measure the success of quality improvement and deimplementation interventions. Alternatively, if nurses commonly begin and/or discontinue pulse oximetry without updated orders, a pulse oximetry order would not be an accurate proxy, and additional data capture methods (eg, bedside observation or data capture from bedside monitors) would be needed.

Understanding the validity of orders for detection of actual use is critical because continuous pulse oximetry monitoring is considered an overused practice in pediatric acute viral bronchiolitis,³ and national guidelines recommend against its use in low-risk hospitalized children.^4,5 Continuous monitoring may identify trivial, self-resolving oxygen desaturation and its use is not associated with improved outcomes.^6-9 When self-resolving desaturations are treated with additional supplemental oxygen, hospital stays may be unnecessarily prolonged.¹⁰ In order to reduce unnecessary continuous pulse oximetry use, measurement of the extent of the overused practice is necessary. In this 56-hospital study,¹¹ we aimed to determine the validity of using active continuous pulse oximetry orders instead of bedside observation of actual monitor use.

Design

In this multicenter, repeated cross-sectional study, investigators used direct bedside observation to determine continuous pulse oximetry monitor use and then assessed whether an active continuous monitoring order was present in the electronic health record. The study took place during one bronchiolitis season, December 1, 2018, through March 31, 2019.

Setting and Patients

Investigators at 56 freestanding children’s hospitals, children’s hospitals within general hospitals, and community hospitals in the Pediatric Research in Inpatient Settings (PRIS) Network collected data on infants aged 8 weeks to 23 months who were hospitalized with bronchiolitis. As this work was a substudy of the larger Eliminating Monitor Overuse study, only infants not currently receiving supplemental oxygen were included.¹¹ Investigators observed eligible infants outside of the intensive care unit on general hospital medicine units. We excluded infants born premature (documented prematurity of <28 weeks’ gestation or documented “premature” without a gestational age listed), as well as those with a home oxygen requirement, cyanotic congenital heart disease, pulmonary hypertension, tracheostomy, primary neuromuscular disease, immunodeficiency, or cancer.

Data Collection

Investigators used the electronic health record to identify eligible infants. Investigators entered patient rooms to confirm the infant was not on supplemental oxygen (hence confirming eligibility for the study) and determine if continuous pulse oximetry was actively in use by examining the monitor display for a pulse oximetry waveform. Investigators then confirmed if active orders for pulse oximetry were present in the patient’s chart. Per study design, site investigators aimed to observe approximately half of eligible infants during the day (10 am to 5 pm) and the other half during the night (11 pm to 7 am).

Analysis

We excluded patients with conditional orders (eg, monitored only when certain conditions exist, such as when asleep) because of the time-varying and wide range of conditions that could be specified. Furthermore, conditional orders would not be useful as proxies to measure oximetry use because investigators would still need additional data (eg, bedside observation) to determine current monitoring status.

We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of active orders using the reference standard of direct bedside observation, as well as corresponding 95% CIs that accounted for within-hospital clustering. We calculated these test characteristics overall and as stratified across four age groups: 8 weeks to 5 months, 6 months to 11 months, 12 months to 17 months, and 18 months to 23 months. We also calculated the test characteristics for each hospital. We decided a priori that a PPV and NPV of 80% would represent a reasonable threshold to use active orders as a proxy in multicenter research. For hospital-level analyses we included only hospitals with 60 or more total observations and more than 15 observations with active orders for PPV and more than 15 observations without active orders for NPV. We used Stata (StataCorp LLC, College Station, Texas) version 15.1 for analysis.

For US sites, the Institutional Review Board (IRB) at Children’s Hospital of Philadelphia approved the study as the single reviewing IRB, and the remaining US sites established reliance agreements with the reviewing IRB. Research Ethics Boards at the Canadian sites (University of Calgary and The Hospital for Sick Children) also reviewed and approved the study. All sites granted waivers of consent, assent, parental permission, and HIPAA authorization.

Investigators completed 3,612 observations in 56 hospitals. This included 33 freestanding children’s hospitals, 14 hospitals within large general hospitals, and 9 community hospitals. Of 3,612 completed observations, on 631 occasions (17%) patients had conditional orders (eg, continuous monitoring only when sleeping) and were excluded from further analysis.

Most pulse oximetry–monitored infants did not have an active monitoring order (670 out of 1,309; sensitivity of 49%). Test characteristics, stratified by age group, are presented in the Table. Across all observations, the overall PPV was 77% (95% CI, 72-82), and the overall NPV was 69% (95% CI, 61-77). Variation of all test characteristics across age group was small (eg, the sensitivity ranged from 43% to 51%).

brady08281021e_t1.jpg

With inclusion of only those hospitals with sufficient observations, hospital-level variation in the PPV and NPV of using active orders was substantial (PPV range of 48% to 96% and NPV range of 30% to 98%). Only two hospitals had both a PPV and NPV for using monitor orders that exceeded the 80% threshold.

Active continuous pulse oximetry orders did not accurately represent actual monitoring status in this study. Monitoring orders alone frequently misrepresent true monitoring status and, as such, should be interpreted with caution in research or quality improvement activities. If more valid estimates of monitoring use and overuse are needed, potential measurement options include direct observation, as used in our study, as well as the use of more complex data streams such as the output of monitoring devices or pulse oximetry data in the electronic health record. In only two of the hospitals, using active continuous monitoring orders was a reasonable proxy for detecting actual monitor use. Monitoring orders could potentially be validly used for deimplementation efforts at those centers; other hospitals could consider targeted improvement efforts (eg, morning huddles examining the discordance between monitoring orders and monitoring status) to improve the accuracy of using continuous pulse oximetry orders.

We acknowledge several limitations of this study. Site investigators employed a convenience sampling approach, so it is possible that some investigators observed sicker or less sick infants. Although the PRIS network includes a geographically diverse group of North American hospitals, community hospitals were underrepresented in this study. Our results hence generalize more precisely to freestanding children’s hospitals than to community hospitals. We did not observe infants currently on supplemental oxygen, so we do not know to what degree using orders is valid in that context. We did not collect data on why actual monitoring status differed from monitoring orders and hence cannot quantify to what extent different factors (eg, nurse belief that monitors are a safety net or infants inadvertently left on monitors after a spot check pulse oximetry reading) contributed to this discordance. Finally, our study only examined one electronic health record variable—the presence of an active order. It may be that other variables in the health record (eg, minute-by-minute pulse oximetry values in a vital sign flowsheet) are much better proxies of actual continuous monitor use.

Using an active order for continuous pulse oximetry has poor sensitivity, PPV, and NPV for detecting true monitoring status at the bedside. Teams intending to measure the actual use of pulse oximetry should be aware of the limitations of using active orders alone as an accurate measure of pulse oximetry monitoring.

We thank the NHLBI scientists who contributed to this project as part of the U01 Cooperative Agreement funding mechanism: Lora Reineck, MD, MS, Karen Bienstock, MS, and Cheryl Boyce, PhD.

We thank the Executive Council of the PRIS Network for their contributions to the early scientific development of this project. We thank the PRIS site investigators for their major contributions to the Eliminating Monitor Overuse (EMO) Study data collection. Each listed collaborator is a group author for the PRIS Network in this manuscript. Their names can be found in the online supplemental information.

For parents of children with medical complexity (CMC), bringing a child to the hospital for needed expertise, equipment, and support is necessarily accompanied by a loss of power, freedom, and control. Two of our authors (K.L., P.M.) are parents of CMC—patients affectionately known as “frequent flyers” at their local hospitals. When health needs present, these experienced parents quickly identify what can be managed at home and what needs a higher level of care. The autonomy and security that accompany this parental expertise have been mitigated by, and in some cases even lost in, the COVID-19 pandemic. In particular, one of the most obvious changes to patients’ and families’ roles in inpatient care has been in communication practices, including changes to patient- and family-centered rounding that result from current isolation procedures and visitation policies. Over the past few months, we’ve learned a tremendous amount from providers and caregivers of hospitalized patients; in this article, we share some of what they’ve taught us.

Before we continue, we take a humble pause. The process of writing this piece spanned weeks during which certain areas of the world were overwhelmed. Our perspective has been informed by others who shared their experiences, and as a result, our health systems are more prepared. We offer this perspective recognizing the importance of learning from others and feeling a sense of gratitude to the providers and patients on the front lines.

As a group of parents, nurses, physicians, educators, and researchers who have spent the last 10 years studying how to communicate more effectively in the healthcare setting,^1,2 we find ourselves in uncharted territory. Even now, we are engaged in an ongoing mentored implementation program examining the effects of a communication bundle on patient- and family- centered rounds (PFCRs) at 21 teaching hospitals across North America (the SHM I-PASS SCORE Study).³ COVID-19 has put that study on hold, and we have taken a step back to reassess the most basic communication needs of patients and families under any circumstance.

Even among our study group, our family advisors have also been on the front lines as patients and caregivers. One author (P.M.), shared a recent experience that she and her son, John Michael had:

“My son [who has autoimmune hepatitis and associated conditions] began coughing and had an intense sinus headache. As his symptoms continued, our concern steadily grew: Could we push through at home or would we have to go in [to the hospital] to seek care? My mind raced. We faced this decision many times, but never with the overwhelming threat of COVID-19 in the equation. My son, who is able to recognize troublesome symptoms, was afraid his sinuses were infected and decided that we should go in. My heart sank.”

Now, amid the COVID-19 pandemic, we have heard that patients like John Michael, who are accustomed to the healthcare setting, are “terrified with this additional concern of just being safe in the hospital,” reported a member of our Family Advisory Council. One of our members added, “We recognize this extends to the providers as well, who maintain great care despite their own family and personal safety concerns.” Although families affirmed the necessity of the enhanced isolation procedures and strict visitation policies, they also highlighted the effects of these changes on usual communication practices, including PFCRs.

In response to these sentiments, we reached out to all of our family advisors, as well as other team members, for suggestions on how healthcare teams could help patients and families best manage their hospital experiences in the setting of COVID-19. Additionally, we asked our physician and nursing colleagues across health systems about current inpatient unit adaptations. Their suggestions and adaptations reinforced and directly aligned with some of the core values of family engagement and patient- and family-centered care,⁴ namely, (1) prioritizing communication, (2) maintaining active engagement with patients and families, and (3) enhancing communication with technology.

Prioritizing Communication

Timely and clear communication can help providers manage the expectations of patients and families, build patient and family feelings of confidence, and reduce their feelings of anxiety and vulnerability. Almost universally, families acknowledged the importance of infection control and physical distancing measures while fearing that decreased entry into rooms would lead to decreased communication. “Since COVID-19 is contagious, families will want to see every precaution taken … but in a way that doesn’t cut off communication and leave an already sick and scared child and their family feeling emotionally isolated in a scary situation,” an Advisory Council member recounted. Importantly, one parent shared that hearing about personal protective equipment conservation could amplify stress because of fear their child wouldn’t be protected. These perspectives remind us that families may be experiencing heightened sensitivity and vulnerability during this pandemic.

Maintaining Active Engagement With Patients and Families

PFCRs continue to be an ideal setting for providers, patients, and families to communicate and build shared understanding, as well as build rapport and connection through human interactions. Maintaining rounding structures, when possible, reinforces familiarity with roles and expectations, among both patients who have been hospitalized in the past and those hospitalized for the first time. Adapting rounds may be as simple as opening the door during walk-rounds to invite caregiver participation while being aware of distancing. With large rounding teams, more substantial workflow changes may be necessary.

Beyond PFCRs, patients and family members can be further engaged through tasks/responsibilities for the time in between rounding communication. Examples include recording patient symptoms (eg, work of breathing) or actions (eg, how much water their child drinks). By doing this, patients and caregivers who feel helpless and anxious may be given a greater sense of control while at the same time making helpful contributions to medical care.

Parents also expressed value in reinforcing the message that patients and families are experts about themselves/their loved ones. Healthcare teams can invite their insights, questions, and concerns to show respect for their expertise and value. This builds trust and leads to a feeling of togetherness and teamwork. Across the board, families stressed the value of family engagement and communication in ideal conditions, and even more so in this time of upheaval.

Enhancing Communication With Technology

Many hospitals are leveraging technology to promote communication by integrating workstations on wheels & tablets with video-conferencing software (eg, Zoom, Skype) and even by adding communication via email and phone. While fewer team members are entering rooms, rounding teams are still including the voices of pharmacists, nutritionists, social workers, primary care physicians, and caregivers who are unable to be at the bedside.

These alternative communication methods may actually provide patients with more comfortable avenues for participating in their own care even beyond the pandemic. Children, in particular, may have strong opinions about their care but may not be comfortable speaking up in front of providers whom they don’t know very well. Telehealth, whiteboards, email, and limiting the number of providers in the room might actually create a more approachable environment for these patients even under routine conditions.

Patients, families, nurses, physicians, and other team members all feel the current stress on our healthcare system. As we continue to change workflows, alignment with principles of family engagement and patient- and family-centered care⁴ remain a priority for all involved. Prioritizing effective communication, maintaining engagement with patients and families, and using technology in new ways will all help us maintain high standards of care in both typical and completely atypical settings, such as during this pandemic. Nothing captures the benefits of effective communication better than P.M.’s description of John Michael’s experience during his hospitalization:

“Although usually an expedited triage patient, we spent hours in the ER among other ill and anxious patients. Ultimately, John Michael tested positive for influenza A. We spent 5 days in the hospital on droplet protection.

“The staff was amazing! The doctors and nurses communicated with us every step of the way. They made us aware of extra precautions and explained limitations, like not being able to go in the nutrition room or only having the doctors come in once midday. Whenever they did use [personal protective equipment] and come in, the nurses and team kept a safe distance but made sure to connect with John Michael, talking about what was on TV, what his favorite teams are, asking about his sisters, and always asking if we needed anything or if there was anything they could do. I am grateful for the kind, compassionate, and professional people who continue to care for our children under the intense danger and overwhelming magnitude of COVID-19.”

Dr Landrigan has served as a paid consultant to the Midwest Lighting Institute to help study the effect of blue light on health care provider performance and safety. He has consulted with and holds equity in the I-PASS Institute, which seeks to train institutions in best handoff practices and aid in their implementation. Dr Landrigan has received consulting fees from the Missouri Hospital Association/Executive Speakers Bureau for consulting on I-PASS. In addition, he has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation. Drs Spector and Baird have also consulted with and hold equity in the I-PASS Institute. Dr Baird has consulted with the I-PASS Patient Safety Institute. Dr Patel holds equity/stock options in and has consulted for the I-PASS Patient Safety Institute. Dr Rosenbluth previously consulted with the I-PASS Patient Safety Institute, but not within the past 36 months. The other authors have no conflicts of interest or external support other than the existing PCORI funding for the Society of Hospital Medicine I-PASS SCORE study.

The I-PASS Patient Safety Institute did not provide support to any authors for this work.

For parents of children with medical complexity (CMC), bringing a child to the hospital for needed expertise, equipment, and support is necessarily accompanied by a loss of power, freedom, and control. Two of our authors (K.L., P.M.) are parents of CMC—patients affectionately known as “frequent flyers” at their local hospitals. When health needs present, these experienced parents quickly identify what can be managed at home and what needs a higher level of care. The autonomy and security that accompany this parental expertise have been mitigated by, and in some cases even lost in, the COVID-19 pandemic. In particular, one of the most obvious changes to patients’ and families’ roles in inpatient care has been in communication practices, including changes to patient- and family-centered rounding that result from current isolation procedures and visitation policies. Over the past few months, we’ve learned a tremendous amount from providers and caregivers of hospitalized patients; in this article, we share some of what they’ve taught us.

Before we continue, we take a humble pause. The process of writing this piece spanned weeks during which certain areas of the world were overwhelmed. Our perspective has been informed by others who shared their experiences, and as a result, our health systems are more prepared. We offer this perspective recognizing the importance of learning from others and feeling a sense of gratitude to the providers and patients on the front lines.

As a group of parents, nurses, physicians, educators, and researchers who have spent the last 10 years studying how to communicate more effectively in the healthcare setting,^1,2 we find ourselves in uncharted territory. Even now, we are engaged in an ongoing mentored implementation program examining the effects of a communication bundle on patient- and family- centered rounds (PFCRs) at 21 teaching hospitals across North America (the SHM I-PASS SCORE Study).³ COVID-19 has put that study on hold, and we have taken a step back to reassess the most basic communication needs of patients and families under any circumstance.

Even among our study group, our family advisors have also been on the front lines as patients and caregivers. One author (P.M.), shared a recent experience that she and her son, John Michael had:

“My son [who has autoimmune hepatitis and associated conditions] began coughing and had an intense sinus headache. As his symptoms continued, our concern steadily grew: Could we push through at home or would we have to go in [to the hospital] to seek care? My mind raced. We faced this decision many times, but never with the overwhelming threat of COVID-19 in the equation. My son, who is able to recognize troublesome symptoms, was afraid his sinuses were infected and decided that we should go in. My heart sank.”

Now, amid the COVID-19 pandemic, we have heard that patients like John Michael, who are accustomed to the healthcare setting, are “terrified with this additional concern of just being safe in the hospital,” reported a member of our Family Advisory Council. One of our members added, “We recognize this extends to the providers as well, who maintain great care despite their own family and personal safety concerns.” Although families affirmed the necessity of the enhanced isolation procedures and strict visitation policies, they also highlighted the effects of these changes on usual communication practices, including PFCRs.

In response to these sentiments, we reached out to all of our family advisors, as well as other team members, for suggestions on how healthcare teams could help patients and families best manage their hospital experiences in the setting of COVID-19. Additionally, we asked our physician and nursing colleagues across health systems about current inpatient unit adaptations. Their suggestions and adaptations reinforced and directly aligned with some of the core values of family engagement and patient- and family-centered care,⁴ namely, (1) prioritizing communication, (2) maintaining active engagement with patients and families, and (3) enhancing communication with technology.

Prioritizing Communication

Timely and clear communication can help providers manage the expectations of patients and families, build patient and family feelings of confidence, and reduce their feelings of anxiety and vulnerability. Almost universally, families acknowledged the importance of infection control and physical distancing measures while fearing that decreased entry into rooms would lead to decreased communication. “Since COVID-19 is contagious, families will want to see every precaution taken … but in a way that doesn’t cut off communication and leave an already sick and scared child and their family feeling emotionally isolated in a scary situation,” an Advisory Council member recounted. Importantly, one parent shared that hearing about personal protective equipment conservation could amplify stress because of fear their child wouldn’t be protected. These perspectives remind us that families may be experiencing heightened sensitivity and vulnerability during this pandemic.

Maintaining Active Engagement With Patients and Families

PFCRs continue to be an ideal setting for providers, patients, and families to communicate and build shared understanding, as well as build rapport and connection through human interactions. Maintaining rounding structures, when possible, reinforces familiarity with roles and expectations, among both patients who have been hospitalized in the past and those hospitalized for the first time. Adapting rounds may be as simple as opening the door during walk-rounds to invite caregiver participation while being aware of distancing. With large rounding teams, more substantial workflow changes may be necessary.

Beyond PFCRs, patients and family members can be further engaged through tasks/responsibilities for the time in between rounding communication. Examples include recording patient symptoms (eg, work of breathing) or actions (eg, how much water their child drinks). By doing this, patients and caregivers who feel helpless and anxious may be given a greater sense of control while at the same time making helpful contributions to medical care.

Parents also expressed value in reinforcing the message that patients and families are experts about themselves/their loved ones. Healthcare teams can invite their insights, questions, and concerns to show respect for their expertise and value. This builds trust and leads to a feeling of togetherness and teamwork. Across the board, families stressed the value of family engagement and communication in ideal conditions, and even more so in this time of upheaval.

Enhancing Communication With Technology

Many hospitals are leveraging technology to promote communication by integrating workstations on wheels & tablets with video-conferencing software (eg, Zoom, Skype) and even by adding communication via email and phone. While fewer team members are entering rooms, rounding teams are still including the voices of pharmacists, nutritionists, social workers, primary care physicians, and caregivers who are unable to be at the bedside.

These alternative communication methods may actually provide patients with more comfortable avenues for participating in their own care even beyond the pandemic. Children, in particular, may have strong opinions about their care but may not be comfortable speaking up in front of providers whom they don’t know very well. Telehealth, whiteboards, email, and limiting the number of providers in the room might actually create a more approachable environment for these patients even under routine conditions.

Patients, families, nurses, physicians, and other team members all feel the current stress on our healthcare system. As we continue to change workflows, alignment with principles of family engagement and patient- and family-centered care⁴ remain a priority for all involved. Prioritizing effective communication, maintaining engagement with patients and families, and using technology in new ways will all help us maintain high standards of care in both typical and completely atypical settings, such as during this pandemic. Nothing captures the benefits of effective communication better than P.M.’s description of John Michael’s experience during his hospitalization:

“Although usually an expedited triage patient, we spent hours in the ER among other ill and anxious patients. Ultimately, John Michael tested positive for influenza A. We spent 5 days in the hospital on droplet protection.

“The staff was amazing! The doctors and nurses communicated with us every step of the way. They made us aware of extra precautions and explained limitations, like not being able to go in the nutrition room or only having the doctors come in once midday. Whenever they did use [personal protective equipment] and come in, the nurses and team kept a safe distance but made sure to connect with John Michael, talking about what was on TV, what his favorite teams are, asking about his sisters, and always asking if we needed anything or if there was anything they could do. I am grateful for the kind, compassionate, and professional people who continue to care for our children under the intense danger and overwhelming magnitude of COVID-19.”

Dr Landrigan has served as a paid consultant to the Midwest Lighting Institute to help study the effect of blue light on health care provider performance and safety. He has consulted with and holds equity in the I-PASS Institute, which seeks to train institutions in best handoff practices and aid in their implementation. Dr Landrigan has received consulting fees from the Missouri Hospital Association/Executive Speakers Bureau for consulting on I-PASS. In addition, he has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation. Drs Spector and Baird have also consulted with and hold equity in the I-PASS Institute. Dr Baird has consulted with the I-PASS Patient Safety Institute. Dr Patel holds equity/stock options in and has consulted for the I-PASS Patient Safety Institute. Dr Rosenbluth previously consulted with the I-PASS Patient Safety Institute, but not within the past 36 months. The other authors have no conflicts of interest or external support other than the existing PCORI funding for the Society of Hospital Medicine I-PASS SCORE study.

The I-PASS Patient Safety Institute did not provide support to any authors for this work.

For parents of children with medical complexity (CMC), bringing a child to the hospital for needed expertise, equipment, and support is necessarily accompanied by a loss of power, freedom, and control. Two of our authors (K.L., P.M.) are parents of CMC—patients affectionately known as “frequent flyers” at their local hospitals. When health needs present, these experienced parents quickly identify what can be managed at home and what needs a higher level of care. The autonomy and security that accompany this parental expertise have been mitigated by, and in some cases even lost in, the COVID-19 pandemic. In particular, one of the most obvious changes to patients’ and families’ roles in inpatient care has been in communication practices, including changes to patient- and family-centered rounding that result from current isolation procedures and visitation policies. Over the past few months, we’ve learned a tremendous amount from providers and caregivers of hospitalized patients; in this article, we share some of what they’ve taught us.

Before we continue, we take a humble pause. The process of writing this piece spanned weeks during which certain areas of the world were overwhelmed. Our perspective has been informed by others who shared their experiences, and as a result, our health systems are more prepared. We offer this perspective recognizing the importance of learning from others and feeling a sense of gratitude to the providers and patients on the front lines.

As a group of parents, nurses, physicians, educators, and researchers who have spent the last 10 years studying how to communicate more effectively in the healthcare setting,^1,2 we find ourselves in uncharted territory. Even now, we are engaged in an ongoing mentored implementation program examining the effects of a communication bundle on patient- and family- centered rounds (PFCRs) at 21 teaching hospitals across North America (the SHM I-PASS SCORE Study).³ COVID-19 has put that study on hold, and we have taken a step back to reassess the most basic communication needs of patients and families under any circumstance.

Even among our study group, our family advisors have also been on the front lines as patients and caregivers. One author (P.M.), shared a recent experience that she and her son, John Michael had:

“My son [who has autoimmune hepatitis and associated conditions] began coughing and had an intense sinus headache. As his symptoms continued, our concern steadily grew: Could we push through at home or would we have to go in [to the hospital] to seek care? My mind raced. We faced this decision many times, but never with the overwhelming threat of COVID-19 in the equation. My son, who is able to recognize troublesome symptoms, was afraid his sinuses were infected and decided that we should go in. My heart sank.”

Now, amid the COVID-19 pandemic, we have heard that patients like John Michael, who are accustomed to the healthcare setting, are “terrified with this additional concern of just being safe in the hospital,” reported a member of our Family Advisory Council. One of our members added, “We recognize this extends to the providers as well, who maintain great care despite their own family and personal safety concerns.” Although families affirmed the necessity of the enhanced isolation procedures and strict visitation policies, they also highlighted the effects of these changes on usual communication practices, including PFCRs.

In response to these sentiments, we reached out to all of our family advisors, as well as other team members, for suggestions on how healthcare teams could help patients and families best manage their hospital experiences in the setting of COVID-19. Additionally, we asked our physician and nursing colleagues across health systems about current inpatient unit adaptations. Their suggestions and adaptations reinforced and directly aligned with some of the core values of family engagement and patient- and family-centered care,⁴ namely, (1) prioritizing communication, (2) maintaining active engagement with patients and families, and (3) enhancing communication with technology.

Prioritizing Communication

Timely and clear communication can help providers manage the expectations of patients and families, build patient and family feelings of confidence, and reduce their feelings of anxiety and vulnerability. Almost universally, families acknowledged the importance of infection control and physical distancing measures while fearing that decreased entry into rooms would lead to decreased communication. “Since COVID-19 is contagious, families will want to see every precaution taken … but in a way that doesn’t cut off communication and leave an already sick and scared child and their family feeling emotionally isolated in a scary situation,” an Advisory Council member recounted. Importantly, one parent shared that hearing about personal protective equipment conservation could amplify stress because of fear their child wouldn’t be protected. These perspectives remind us that families may be experiencing heightened sensitivity and vulnerability during this pandemic.

Maintaining Active Engagement With Patients and Families

PFCRs continue to be an ideal setting for providers, patients, and families to communicate and build shared understanding, as well as build rapport and connection through human interactions. Maintaining rounding structures, when possible, reinforces familiarity with roles and expectations, among both patients who have been hospitalized in the past and those hospitalized for the first time. Adapting rounds may be as simple as opening the door during walk-rounds to invite caregiver participation while being aware of distancing. With large rounding teams, more substantial workflow changes may be necessary.

Beyond PFCRs, patients and family members can be further engaged through tasks/responsibilities for the time in between rounding communication. Examples include recording patient symptoms (eg, work of breathing) or actions (eg, how much water their child drinks). By doing this, patients and caregivers who feel helpless and anxious may be given a greater sense of control while at the same time making helpful contributions to medical care.

Parents also expressed value in reinforcing the message that patients and families are experts about themselves/their loved ones. Healthcare teams can invite their insights, questions, and concerns to show respect for their expertise and value. This builds trust and leads to a feeling of togetherness and teamwork. Across the board, families stressed the value of family engagement and communication in ideal conditions, and even more so in this time of upheaval.

Enhancing Communication With Technology

Many hospitals are leveraging technology to promote communication by integrating workstations on wheels & tablets with video-conferencing software (eg, Zoom, Skype) and even by adding communication via email and phone. While fewer team members are entering rooms, rounding teams are still including the voices of pharmacists, nutritionists, social workers, primary care physicians, and caregivers who are unable to be at the bedside.

These alternative communication methods may actually provide patients with more comfortable avenues for participating in their own care even beyond the pandemic. Children, in particular, may have strong opinions about their care but may not be comfortable speaking up in front of providers whom they don’t know very well. Telehealth, whiteboards, email, and limiting the number of providers in the room might actually create a more approachable environment for these patients even under routine conditions.

Patients, families, nurses, physicians, and other team members all feel the current stress on our healthcare system. As we continue to change workflows, alignment with principles of family engagement and patient- and family-centered care⁴ remain a priority for all involved. Prioritizing effective communication, maintaining engagement with patients and families, and using technology in new ways will all help us maintain high standards of care in both typical and completely atypical settings, such as during this pandemic. Nothing captures the benefits of effective communication better than P.M.’s description of John Michael’s experience during his hospitalization:

“Although usually an expedited triage patient, we spent hours in the ER among other ill and anxious patients. Ultimately, John Michael tested positive for influenza A. We spent 5 days in the hospital on droplet protection.

“The staff was amazing! The doctors and nurses communicated with us every step of the way. They made us aware of extra precautions and explained limitations, like not being able to go in the nutrition room or only having the doctors come in once midday. Whenever they did use [personal protective equipment] and come in, the nurses and team kept a safe distance but made sure to connect with John Michael, talking about what was on TV, what his favorite teams are, asking about his sisters, and always asking if we needed anything or if there was anything they could do. I am grateful for the kind, compassionate, and professional people who continue to care for our children under the intense danger and overwhelming magnitude of COVID-19.”

Dr Landrigan has served as a paid consultant to the Midwest Lighting Institute to help study the effect of blue light on health care provider performance and safety. He has consulted with and holds equity in the I-PASS Institute, which seeks to train institutions in best handoff practices and aid in their implementation. Dr Landrigan has received consulting fees from the Missouri Hospital Association/Executive Speakers Bureau for consulting on I-PASS. In addition, he has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation. Drs Spector and Baird have also consulted with and hold equity in the I-PASS Institute. Dr Baird has consulted with the I-PASS Patient Safety Institute. Dr Patel holds equity/stock options in and has consulted for the I-PASS Patient Safety Institute. Dr Rosenbluth previously consulted with the I-PASS Patient Safety Institute, but not within the past 36 months. The other authors have no conflicts of interest or external support other than the existing PCORI funding for the Society of Hospital Medicine I-PASS SCORE study.

The I-PASS Patient Safety Institute did not provide support to any authors for this work.