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Al-Beltagi M, Saeed NK, Bediwy AS, Elbeltagi R. Pulse oximetry in pediatric care: Balancing advantages and limitations. World J Clin Pediatr 2024; 13:96950. [DOI: 10.5409/wjcp.v13.i3.96950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 07/06/2024] [Accepted: 07/30/2024] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND Pulse oximetry has become a cornerstone technology in healthcare, providing non-invasive monitoring of oxygen saturation levels and pulse rate. Despite its widespread use, the technology has inherent limitations and challenges that must be addressed to ensure accurate and reliable patient care.
AIM To comprehensively evaluate the advantages, limitations, and challenges of pulse oximetry in clinical practice, as well as to propose recommendations for optimizing its use.
METHODS A systematic literature review was conducted to identify studies related to pulse oximetry and its applications in various clinical settings. Relevant articles were selected based on predefined inclusion and exclusion criteria, and data were synthesized to provide a comprehensive overview of the topic.
RESULTS Pulse oximetry offers numerous advantages, including non-invasiveness, real-time feedback, portability, and cost-effectiveness. However, several limitations and challenges were identified, including motion artifacts, poor peripheral perfusion, ambient light interference, and patient-specific factors such as skin pigmentation and hemoglobin variants. Recommendations for optimizing pulse oximetry use include technological advancements, education and training initiatives, quality assurance protocols, and interdisciplinary collaboration.
CONCLUSION Pulse oximetry is crucial in modern healthcare, offering invaluable insights into patients’ oxygenation status. Despite its limitations, pulse oximetry remains an indispensable tool for monitoring patients in diverse clinical settings. By implementing the recommendations outlined in this review, healthcare providers can enhance the effectiveness, accessibility, and safety of pulse oximetry monitoring, ultimately improving patient outcomes and quality of care.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatric, Faculty of Medicine, Tanta University, Tanta 31511, Alghrabia, Egypt
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama 26671, Manama, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 26671, Manama, Bahrain
- Medical Microbiology Section, Department of Pathology, Irish Royal College of Surgeon in Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Pulmonology, Faculty of Medicine, Tanta University, Tanta 31527, Alghrabia, Egypt
- Department of Pulmonology, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama 26671, Manama, Bahrain
| | - Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland-Bahrain, Busiateen 15503, Muharraq, Bahrain
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Ruppel H, Bonafide CP, Beidas RS, Albanowski K, Parlar-Chun R, Rajbhandari P, Kern-Goldberger AS, Stoeck PA, Snow K, House SA, Lucey KE, Brady PW, Schondelmeyer AC. Continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: A qualitative analysis of clinicians' justifications. J Hosp Med 2024. [PMID: 39120261 DOI: 10.1002/jhm.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024]
Abstract
Continuous pulse oximetry (cSpO2) monitoring use outside established guidelines is common in children hospitalized with bronchiolitis. We analyzed clinicians' real-time rationale for continuous monitoring in stable children with bronchiolitis not requiring supplemental oxygen. Data for this study were collected as part a multicenter deimplementation trial for cSpO2 in children hospitalized with bronchiolitis. We analyzed 371 clinician responses across 36 hospitals; 258 (70%) responses did not include a clinical reason for monitoring ("nonclinical"; e.g., respondent forgot to discontinue monitoring, did not know why the patient was monitored, or was following an order). The remaining 113 (30%) responses contained a clinical reason for monitoring ("clinical"; e.g., recently requiring oxygen, physical exam concerns, or concerns relating to patient condition or history). Strategies to reduce unnecessary monitoring should include changes in workflow to facilitate shared understanding of monitoring goals and timely discontinuation of monitoring.
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Affiliation(s)
- Halley Ruppel
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Clinical Futures, A Center of Emphasis Within the CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher P Bonafide
- Clinical Futures, A Center of Emphasis Within the CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center (PISCE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rinad S Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kimberly Albanowski
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Raymond Parlar-Chun
- Division of Hospital Medicine, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Prabi Rajbhandari
- Division of Hospital Medicine, Akron Children's Hospital, Akron, Ohio, USA
- Department of Pediatrics, Northeast Ohio Medical Unversity (NEOMED), Akron, Ohio, USA
- Rebecca D.Considine Research Institute, Akron Children's Hospital, Akron, Ohio, USA
| | - Andrew S Kern-Goldberger
- Division of Pediatric Hospital Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Patricia A Stoeck
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Snow
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samantha A House
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| | - Kate E Lucey
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Hospital Based Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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Clark NA, Kyler KE, Allen GL, Ausmus A, Berg K, Beyer J, Centanni R, Claeys C, Hall M, Miles A, Nyberg G, Malloy-Walton L. Variations in Alarm Burden, Source, and Cause Across Inpatient Units at a Children's Hospital. Hosp Pediatr 2024; 14:642-648. [PMID: 39011551 PMCID: PMC11287059 DOI: 10.1542/hpeds.2023-007604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/26/2024] [Accepted: 04/06/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND AND OBJECTIVES Alarms at hospitals are frequent and can lead to alarm fatigue posing patient safety risks. We aimed to describe alarm burden over a 1-year period and explored variations in alarm rates stratified by unit type, alarm source, and cause. METHODS A retrospective study of inpatient alarm and patient census data at 1 children's hospital from January 1, 2019, to December 31, 2019, including 8 inpatient units: 6 medical/surgical unit (MSU), 1 PICU, and 1 NICU. Rates of alarms per patient day (appd) were calculated overall and by unit type, alarm source, and cause. Poisson regression was used for comparisons. RESULTS There were 7 934 997 alarms over 84 077 patient days (94.4 appd). Significant differences in alarm rates existed across inpatient unit types (MSU 81.3 appd, PICU 90.7, NICU 117.5). Pulse oximetry (POx) probes were the alarm source with highest rate, followed by cardiorespiratory leads (54.4 appd versus 31). PICU had lowest rate of POx alarms (33.3 appd, MSU 37.6, NICU 92.6), whereas NICU had lowest rate of cardiorespiratory lead alarms (16.2 appd, MSU 40.1, PICU 31.4). Alarms stratified by cause displayed variation across unit types where "low oxygen saturation" had the highest overall rate, followed by "technical" alarms (43.4 appp versus 16.3). ICUs had higher rates of low oxygenation saturation alarms, but lower rates of technical alarms than MSUs. CONCLUSIONS Clinical alarms are frequent and vary across unit types, sources, and causes. Unit-level alarm rates and frequent alarm sources (eg, POx) should be considered when implementing alarm reduction strategies.
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Affiliation(s)
- Nicholas A. Clark
- Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Kathryn E. Kyler
- Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Geoffrey L. Allen
- Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Andrew Ausmus
- Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Kathleen Berg
- Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Jeremy Beyer
- Clackamas & Oregon Pediatrics, Southgate, Oregon
| | - Ryan Centanni
- Kansas City University College of Osteopathic Medicine, Kansas City, Missouri
| | | | - Matthew Hall
- Children’s Mercy Kansas City, Kansas City, Missouri
- Children’s Hospital Association, Lenexa, Kansas
| | - Andrea Miles
- Children’s Mercy Kansas City, Kansas City, Missouri
| | - Ginny Nyberg
- Children’s Mercy Kansas City, Kansas City, Missouri
| | - Lindsey Malloy-Walton
- Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Schondelmeyer AC, Sauers-Ford H, Touzinsky SM, Brady PW, Britto MT, Molloy MJ, Simmons JM, Cvach MM, Shah SS, Vaughn LM, Won J, Walsh KE. Clinician Perspectives on Continuous Monitor Use in a Children's Hospital: A Qualitative Study. Hosp Pediatr 2024; 14:649-657. [PMID: 39044720 PMCID: PMC11287064 DOI: 10.1542/hpeds.2023-007638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/03/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND AND OBJECTIVES Variation in continuous cardiopulmonary monitor (cCPM) use across children's hospitals suggests preference-based use. We sought to understand how clinical providers make decisions to use cCPMs. METHODS We conducted a qualitative study using semi-structed interviews with clinicians (nurses, respiratory therapists [RTs], and resident and attending physicians) from 2 hospital medicine units at a children's hospital. The interview guide employed patient cases and open-ended prompts to elicit information about workflows and decision-making related to cCPM, and we collected basic demographic information about participants. We used an inductive approach following thematic analysis to code transcripts and create themes. RESULTS We interviewed 5 nurses, 5 RTs, 7 residents, and 7 attending physicians. We discovered that clinicians perceive a low threshold for starting cCPM, and this often occurred as a default action at admission. Clinicians thought of cCPMs as helping them cope with uncertainty. Despite acknowledging considerable flaws in how cCPMs were used, they were perceived as a low-risk intervention. Although RNs and RTs were most aware of the patient's current condition and number of alarms, physicians decided when to discontinue monitors. No structured process for identifying when to discontinue monitors existed. CONCLUSIONS We concluded that nurses, physicians, and RTs often default to cCPM use and lack a standardized process for identifying when cCPM should be discontinued. Interventions aiming to reduce monitor use will need to account for or target these factors.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence
| | | | - Sara M. Touzinsky
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus Ohio
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence
| | - Maria T. Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence
| | - Matthew J. Molloy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
| | - Lisa M. Vaughn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus Ohio
- Educational and Community-Based Action Research PhD Program, University of Cincinnati College of Education, Criminal Justice & Human Services, Cincinnati, Ohio
| | - James Won
- Human Factors and System Design, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Medicine
- School of Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen E. Walsh
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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McDaniel LM, Kurtz A, Bryan MA. The next frontier of continuous pulse oximetry de-implementation: Overcoming competing priorities. J Hosp Med 2024. [PMID: 38922791 DOI: 10.1002/jhm.13441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Lauren M McDaniel
- Department of Pediatrics, Division of Hospital Medicine, University of Washington, Seattle, Washington, USA
| | - Amber Kurtz
- Department of Pediatrics, Division of Hospital Medicine, University of Washington, Seattle, Washington, USA
| | - Mersine A Bryan
- Department of Pediatrics, Division of Hospital Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
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Marlow JA, Kalburgi S, Gupta V, Shadman K, Webb NE, Chang PW, Ben Wang X, Frost PA, Flesher SL, Le MK, Shankar LG, Schroeder AR. Perspectives of Health Care Personnel on the Benefits of Bronchiolitis Interventions. Pediatrics 2023; 151:e2022059939. [PMID: 37183614 PMCID: PMC10233737 DOI: 10.1542/peds.2022-059939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Many interventions in bronchiolitis are low-value or poorly studied. Inpatient bronchiolitis management is multidisciplinary, with varying degrees of registered nurse (RN) and respiratory therapist (RT) autonomy. Understanding the perceived benefit of interventions for frontline health care personnel may facilitate deimplementation efforts. Our objective was to examine perceptions surrounding the benefit of common inpatient bronchiolitis interventions. METHODS We conducted a cross-sectional survey of inpatient pediatric RNs, RTs, and physicians/licensed practitioners (P/LPs) (eg, advanced-practice practitioners) from May to December of 2021 at 9 university-affiliated and 2 community hospitals. A clinical vignette preceded a series of inpatient bronchiolitis management questions. RESULTS A total of 331 surveys were analyzed with a completion rate of 71.9%: 76.5% for RNs, 57.4% for RTs, and 71.2% for P/LPs. Approximately 54% of RNs and 45% of RTs compared with 2% of P/LPs believe albuterol would be "extremely or somewhat likely" to improve work of breathing (P < .001). Similarly, 52% of RNs, 32% of RTs, and 23% of P/LPs thought initiating or escalating oxygen in the absence of hypoxemia was likely to improve work of breathing (P < .001). Similar differences in perceived benefit were observed for steroids, nebulized hypertonic saline, and deep suctioning, but not superficial nasal suctioning. Hospital type (community versus university-affiliated) did not impact the magnitude of these differences. CONCLUSIONS Variation exists in the perceived benefit of several low-value or poorly studied bronchiolitis interventions among health care personnel, with RNs/RTs generally perceiving higher benefit. Deimplementation, educational, and quality improvement efforts should be designed with an interprofessional framework.
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Affiliation(s)
- Julia A. Marlow
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford School of Medicine, Palo Alto, California
| | - Sonal Kalburgi
- Division of Hospital Medicine, Children’s National Hospital, the George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Vedant Gupta
- Division of Pediatric Hospital Medicine, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Kristin Shadman
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Nicole E. Webb
- Division of Hospital Medicine, Valley Children’s Healthcare, Madera, California
| | - Pearl W. Chang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Xiao Ben Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, UCLA Mattel Children’s Hospital, Los Angeles, California
| | - Patricia A. Frost
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Susan L. Flesher
- Department of Pediatrics, Joan C. Edwards Marshall University School of Medicine, Huntington, West Virginia
| | - Matthew K. Le
- Pediatric Hospital Medicine, Department of Pediatrics, Oklahoma Children’s Hospital, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lavanya G Shankar
- Division of Hospital Medicine Outreach, Ann & Robert Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Alan R. Schroeder
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford School of Medicine, Palo Alto, California
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Schondelmeyer AC, Harris CD, Bonafide CP. The Path to Large-Scale High-Flow Nasal Cannula Deimplementation in Bronchiolitis. Hosp Pediatr 2023; 13:e99-e101. [PMID: 36938615 PMCID: PMC10071425 DOI: 10.1542/hpeds.2023-007147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Clea D. Harris
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher P. Bonafide
- Section of Hospital Medicine
- Clinical Futures: a CHOP Research Institute Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania
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Parker G, Shahid N, Rappon T, Kastner M, Born K, Berta W. Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review. Implement Sci 2022; 17:6. [PMID: 35057832 PMCID: PMC8772067 DOI: 10.1186/s13012-021-01177-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. METHODS We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. RESULTS Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. CONCLUSIONS This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.
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Affiliation(s)
- Gillian Parker
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Nida Shahid
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Tim Rappon
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Monika Kastner
- Centre for Research and Innovation, North York General Hospital, 4001, Leslie Street, Toronto, Ontario M2K 1E1 Canada
| | - Karen Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
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Schondelmeyer AC, Jenkins AM, Vaughn LM, Brady PW. Family Perspectives on Continuous Monitor Use in a Children's Hospital: A Qualitative Study. Hosp Pediatr 2021; 11:hpeds.2021-005949. [PMID: 34808668 DOI: 10.1542/hpeds.2021-005949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Alarms from continuous cardiorespiratory and pulse oximetry monitors may contribute to parental anxiety and poor sleep during hospitalization, yet families also may find monitoring reassuring. Our objective was to understand how families perceive the utility, benefits, and harms of continuous monitoring. METHODS In this single-center qualitative study, we used semistructured interviews and direct observation. We enrolled families of patients of a variety of ages and clinical diagnoses. We extracted patient demographic information (age, diagnosis) from the health record. Semistructured interviews were recorded and transcribed. Detailed field notes were taken during observations. We used an inductive thematic approach to develop and refine codes that informed the development of themes. RESULTS We recruited 24 families and conducted 23 interviews and 9 observation sessions. Respiratory conditions (eg, bronchiolitis, asthma) were the most common reason for hospitalization. The hospitalized children covered a range of ages: <4 weeks (16%), 4 weeks to 6 months (20%), 7 months to 5 years (44%), and >5 years (20%); 55% had previously been hospitalized. Families expressed varying degrees of understanding the utility of monitors and often conducted their own assessments before notifying staff about alarms. Families expected monitoring, including negative effects like sleep disruption, as part of hospitalization. Families perceived the benefit of monitoring in context of previous hospital experiences, often seeing less benefit and worrying less about alarms in subsequent hospitalizations. CONCLUSIONS Family members continue to find reassurance from cardiorespiratory monitoring despite evidence that it offers limited benefit outside of the ICU setting. Parental perspectives should be addressed in future deimplementation efforts.
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Affiliation(s)
- Amanda C Schondelmeyer
- Departments of Pediatrics
- Divisions of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley M Jenkins
- Departments of Pediatrics
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Patrick W Brady
- Departments of Pediatrics
- Divisions of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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10
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Schondelmeyer AC, Bettencourt AP, Xiao R, Beidas RS, Wolk CB, Landrigan CP, Brady PW, Brent CR, Parthasarathy P, Kern-Goldberger AS, Sergay N, Lee V, Russell CJ, Prasto J, Zaman S, McQuistion K, Lucey K, Solomon C, Garcia M, Bonafide CP. Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial. JAMA Netw Open 2021; 4:e2122826. [PMID: 34473258 PMCID: PMC8414187 DOI: 10.1001/jamanetworkopen.2021.22826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high. OBJECTIVES To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen. INTERVENTIONS Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits. MAIN OUTCOMES AND MEASURES Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen. RESULTS A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring. CONCLUSIONS AND RELEVANCE In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04178941.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita R. Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Padmavathy Parthasarathy
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nathaniel Sergay
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vivian Lee
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Julianne Prasto
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Pediatrics, Children’s Hospital of Philadelphia Pediatric Care and Penn Medicine Princeton Medical Center, Philadelphia, Pennsylvania
| | - Sarah Zaman
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Kaitlyn McQuistion
- University of Washington Pediatric Residency Program, Department of Pediatrics, University of Washington, Seattle
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
- Division of Pediatric Hospital Medicine, Children’s Health Dallas, Texas
| | - Mayra Garcia
- Division of General and Thoracic Surgery, Children’s Health Dallas, Dallas, Texas
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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11
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Treasure JD, Parker MW, Shah SS. Deimplementation in Bronchiolitis: How Low Can We Go? Pediatrics 2021; 148:peds.2021-051697. [PMID: 34462341 DOI: 10.1542/peds.2021-051697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle W Parker
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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12
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Lipshaw MJ, Florin TA. "Don't Just Do Something, Stand There": Embracing Deimplementation of Bronchiolitis Therapeutics. Pediatrics 2021; 147:peds.2020-048645. [PMID: 33893228 DOI: 10.1542/peds.2020-048645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Todd A Florin
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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13
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Treasure JD, Hubbell B, Statile AM. Enough Is Enough: Quality Improvement to Deimplement High-Flow Nasal Cannula in Bronchiolitis. Hosp Pediatr 2021; 11:e54-e56. [PMID: 33753361 DOI: 10.1542/hpeds.2021-005849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Brittany Hubbell
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and.,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
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14
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Kulkarni SA, Leykum LK, Moriates C. Deimplementation: Discontinuing Low-Value, Potentially Harmful Hospital Care. J Hosp Med 2021; 16:63. [PMID: 33357335 PMCID: PMC7768917 DOI: 10.12788/jhm.3563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Shradha A Kulkarni
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
- Corresponding Author: Shradha A Kulkarni, MD; ; Telephone: 415-476-1742; Twitter: @shradhakulk
| | - Luci K Leykum
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas
- South Texas Veterans Health Care System, San Antonio, Texas
| | - Christopher Moriates
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas
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