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

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          Abstract

          Background

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

          Methods

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

          Discussion

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

          Trial registration

          Not applicable. This study does not meet the World Health Organization definition of a clinical trial.

          Electronic supplementary material

          The online version of this article (10.1186/s40814-019-0453-2) contains supplementary material, which is available to authorized users.

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          Most cited references 37

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          Trends in bronchiolitis hospitalizations in the United States, 2000-2009.

          To examine temporal trend in the national incidence of bronchiolitis hospitalizations, use of mechanical ventilation, and hospital charges between 2000 and 2009.
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            The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.

             M Chassin,  R Galvin (1998)
            To identify issues related to the quality of health care in the United States, including its measurement, assessment, and improvement, requiring action by health care professionals or other constituencies in the public or private sectors. The National Roundtable on Health Care Quality, convened by the Institute of Medicine, a component of the National Academy of Sciences, comprised 20 representatives of the private and public sectors, practicing medicine and nursing, representing academia, business, consumer advocacy, and the health media, and including the heads of federal health programs. The roundtable met 6 times between February 1996 and January 1998. It explored ongoing, rapid changes in health care and the implications of these changes for the quality of health and health care in the United States. Roundtable members held discussions with a wide variety of experts, convened conferences, commissioned papers, and drew on their individual professional experience. At the end of its deliberations, roundtable members reached consensus on the conclusions described in this article by a series of discussions at committee meetings and reviews of successive draft documents, the first of which was created by the listed authors and the Institute of Medicine project director. The drafts were revised following these discussions, and the final document was approved according to the formal report review procedures of the National Research Council of the National Academy of Sciences. The quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine. Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality.
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              An introduction to reading and appraising qualitative research.

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                Author and article information

                Contributors
                rasoolyi@email.chop.edu
                rbeidas@upenn.edu
                cbenja@upenn.edu
                fran.barg@uphs.upenn.edu
                clandrigan@partners.org
                amanda.schondelmeyer@cchmc.org
                patrick.brady@cchmc.org
                lisa.mcleod@icloud.com
                bonafide@email.chop.edu
                Journal
                Pilot Feasibility Stud
                Pilot Feasibility Stud
                Pilot and Feasibility Studies
                BioMed Central (London )
                2055-5784
                15 May 2019
                15 May 2019
                2019
                : 5
                Affiliations
                [1 ]ISNI 0000 0001 0680 8770, GRID grid.239552.a, Section of Hospital Medicine, , Children’s Hospital of Philadelphia, ; Buerger Center for Advanced Pediatric Care, 3500 Civic Center Blvd., 11th Floor, Philadelphia, PA USA
                [2 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Department of Psychiatry, Perelman School of Medicine, , University of Pennsylvania, ; 3535 Market Street, Suite 3015, Philadelphia, PA USA
                [3 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Department of Medical Ethics and Health Policy, Perelman School of Medicine, , University of Pennsylvania, ; Blockley Hall, 423 Guardian Drive, Philadelphia, PA USA
                [4 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Leonard Davis Institute of Health Economics, , University of Pennsylvania, ; 3535 Market Street, Suite 3006, Philadelphia, PA USA
                [5 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Department of Family Medicine and Community Health, , Perelman School of Medicine, University of Pennsylvania, ; Blockley Hall, 423 Guardian Drive, Philadelphia, PA USA
                [6 ]ISNI 0000 0004 0378 8438, GRID grid.2515.3, Division of General Pediatrics, Department of Pediatrics, , Boston Children’s Hospital, ; 300 Longwood Ave, Enders 1, Boston, MA USA
                [7 ]ISNI 0000 0004 0378 8294, GRID grid.62560.37, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, , Brigham and Women’s Hospital, ; 75 Francis Street, Boston, MA USA
                [8 ]ISNI 000000041936754X, GRID grid.38142.3c, Harvard Medical School, ; 25 Shattuck St., Boston, MA USA
                [9 ]ISNI 0000 0001 2179 9593, GRID grid.24827.3b, Department of Pediatrics, , University of Cincinnati College of Medicine, ; 3333 Burnet Ave., MLC 9016, Cincinnati, OH USA
                [10 ]ISNI 0000 0000 9025 8099, GRID grid.239573.9, Division of Hospital Medicine, , Cincinnati Children’s Hospital Medical Center, ; 3333 Burnet Ave., MLC 9016, Cincinnati, OH USA
                [11 ]ISNI 0000 0000 9025 8099, GRID grid.239573.9, James M. Anderson Center for Health Systems Excellence, , Cincinnati Children’s Hospital Medical Center, ; 3333 Burnet Ave., MLC 7014, Cincinnati, OH USA
                [12 ]ISNI 0000 0001 0690 7621, GRID grid.413957.d, Department of Pediatrics, Section of Hospital Medicine, , Children’s Hospital Colorado, ; 13123 E. 16th Street, Aurora, CO USA
                [13 ]ISNI 0000 0001 0703 675X, GRID grid.430503.1, Adult Child Consortium for Outcomes Research and Healthcare Delivery Sciences, , University of Colorado School of Medicine, ; 13001 East 17th Place, Aurora, CO USA
                [14 ]ISNI 0000 0001 0680 8770, GRID grid.239552.a, Center for Pediatric Clinical Effectiveness, , Children’s Hospital of Philadelphia, ; Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA USA
                Article
                453
                10.1186/s40814-019-0453-2
                6518681
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000050, National Heart, Lung, and Blood Institute;
                Award ID: 1U01HL143475-01
                Award ID: 5K23HL116427-04
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100009633, Eunice Kennedy Shriver National Institute of Child Health and Human Development;
                Award ID: 5T32HD060550-09
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: 5R25MH08091607
                Award Recipient :
                Categories
                Study Protocol
                Custom metadata
                © The Author(s) 2019

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