Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial

Christopher P Bonafide, Rui Xiao, Amanda C Schondelmeyer, Amy R Pettit, Patrick W Brady, Christopher P Landrigan, Courtney Benjamin Wolk, Zuleyha Cidav, Halley Ruppel, Naveen Muthu, Nathaniel J Williams, Enrique Schisterman, Canita R Brent, Kimberly Albanowski, Rinad S Beidas, Pediatric Research in Inpatient Settings (PRIS) Network, Prabi Rajbhandari, Emily Knuth, Michelle Bailey, Kate Lucey, Patty Stoeck, Samantha House, Alyssa Silver, Monique Naifeh, Michael Tchou, Amy Tyler, Vivian Lee, Erin Cummings, Clifton Lee, Kyrie Shomaker, Alexandra Mihalek, Courtney Solomon, Raymond Parlar-Chun, Kathleen Berg, Nick Ryan, Tina Halley, Mary Orr, Tracey Liljestrom, Erin Preloger, Padmavathy Parthasarathy, Rashida Shakir, Andrew Chu, Morgan Greenfield, Julianne Prasto, Ann Le, Kimberly Monroe, Andrea Lauffer, Meredith Carter, Kamilah Halmon, Glen Huff, Kiran Gadani Patel, Jennie Ono, Alan Schroeder, Gregory Greg Plemmons, Michael Perry, Sumeet Banker, Jennifer Lee, Robert Willer, Begem Lee, Kyung Rhee, Richelle Baker, Polina Frolova Gregory, Vipul Parikh, Mini Wallace, Stephen Edwards, Lisa Beckner, Michelle Hamline, Lauren Solan, Leigh-Anne Cioffredi, Scarlett Johnson, John Andrake, Nicole Webb, Adam Berkwitt, Christopher P Bonafide, Rui Xiao, Amanda C Schondelmeyer, Amy R Pettit, Patrick W Brady, Christopher P Landrigan, Courtney Benjamin Wolk, Zuleyha Cidav, Halley Ruppel, Naveen Muthu, Nathaniel J Williams, Enrique Schisterman, Canita R Brent, Kimberly Albanowski, Rinad S Beidas, Pediatric Research in Inpatient Settings (PRIS) Network, Prabi Rajbhandari, Emily Knuth, Michelle Bailey, Kate Lucey, Patty Stoeck, Samantha House, Alyssa Silver, Monique Naifeh, Michael Tchou, Amy Tyler, Vivian Lee, Erin Cummings, Clifton Lee, Kyrie Shomaker, Alexandra Mihalek, Courtney Solomon, Raymond Parlar-Chun, Kathleen Berg, Nick Ryan, Tina Halley, Mary Orr, Tracey Liljestrom, Erin Preloger, Padmavathy Parthasarathy, Rashida Shakir, Andrew Chu, Morgan Greenfield, Julianne Prasto, Ann Le, Kimberly Monroe, Andrea Lauffer, Meredith Carter, Kamilah Halmon, Glen Huff, Kiran Gadani Patel, Jennie Ono, Alan Schroeder, Gregory Greg Plemmons, Michael Perry, Sumeet Banker, Jennifer Lee, Robert Willer, Begem Lee, Kyung Rhee, Richelle Baker, Polina Frolova Gregory, Vipul Parikh, Mini Wallace, Stephen Edwards, Lisa Beckner, Michelle Hamline, Lauren Solan, Leigh-Anne Cioffredi, Scarlett Johnson, John Andrake, Nicole Webb, Adam Berkwitt

Abstract

Background: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown.

Methods: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems).

Discussion: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease.

Trial registration: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

Keywords: Bronchiolitis; Children; Deimplementation; Hospital; Infants; Lung; Nursing; Overuse; Pediatrics; Pulse oximetry.

Conflict of interest statement

RSB is an Associate Editor of Implementation Science; all decisions on this paper were made by other editors. RSB is the principal at Implementation Science & Practice, LLC. She receives royalties from Oxford University Press, consulting fees from United Behavioral Health and OptumLabs, and serves on the advisory boards for Optum Behavioral Health, AIM Youth Mental Health Foundation, and the Klingenstein Third Generation Foundation, outside of the submitted work. The other authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

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Fig. 1
Trial diagram
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CONSORT diagram
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Mediation model

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