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Clinical Trial
. 2021 Sep 1;4(9):e2122826.
doi: 10.1001/jamanetworkopen.2021.22826.

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

Amanda C Schondelmeyer  1   2   3 , Amanda P Bettencourt  1 , Rui Xiao  2 , Rinad S Beidas  3   4   5   6 , Courtney Benjamin Wolk  3   6 , Christopher P Landrigan  7   8   9   10 , Patrick W Brady  11   12   13 , Canita R Brent  14   15 , Padmavathy Parthasarathy  14   16 , Andrew S Kern-Goldberger  14 , Nathaniel Sergay  16   17 , Vivian Lee  18   19 , Christopher J Russell  18   19 , Julianne Prasto  16   20 , Sarah Zaman  21   22 , Kaitlyn McQuistion  23 , Kate Lucey  24   25 , Courtney Solomon  26   27 , Mayra Garcia  28 , Christopher P Bonafide  14   15   16 ; Pediatric Research in Inpatient Settings (PRIS) Network
Collaborators, Affiliations
Clinical Trial

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

Amanda C Schondelmeyer et al. JAMA Netw 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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Conflict of interest statement

Conflict of Interest Disclosures: Dr Schondelmeyer reported receiving grant funding from the Agency for Healthcare Research and Quality (AHRQ) and the Association for the Advancement of Medical Instrumentation. Dr Bettencourt reported receiving funding from the National Heart, Lung, and Blood Institute (NHLBI). Dr Beidas reported receiving royalties from Oxford University Press; serving as a consultant to the Camden Coalition of Health Care Providers; serving on the Optum Behavioral Health Clinical and Scientific Advisory Committee; and receiving grant funding from the National Institute of Mental Health (NIMH), the National Cancer Institute, the National Institute for Nursing Research, NHLBI, the National Institute on Aging, the National Institute of Allergy and Infectious Diseases, the Centers for Disease Control and Prevention, the Patient-Centered Outcomes Research Institute, the Veterans Affairs Medical Center, the Substance Abuse and Mental Health Services Administration, and the National Psoriasis Foundation. Dr Wolk reported receiving grant funding from AHRQ, NIMH, NHLBI, the Health Resources and Services Administration, and the Institute of Education Sciences. Dr Bonafide reported receiving grant funding from the AHRQ and the National Science Foundation for research related to physiologic monitoring. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Timeline
Timeline depicting the intervention including data collection, audit and feedback (A&F), and educational outreach interventions. Audit and feedback intervention consisted of bedside data collection on continuous pulse oximetry monitoring status (the audit) and 2 forms of feedback: individual real-time inquiry conducted at the time of data collection and weekly unit-level performance feedback. Educational outreach intervention consisted of the 3 core components, which included national guidelines for pulse oximetry monitoring in patients with bronchiolitis, evidence supporting intermittent rather than continuous pulse oximetry monitoring, and the hospital’s baseline and current pulse oximetry monitoring performance.
Figure 2.
Figure 2.. Questionnaire Participants
Clinicians invited to participate included nurses, physicians, and respiratory therapists.
See this image and copyright information in PMC

Comment in

References

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