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New $5.3M Grant Funds First-of-its-Kind Deimplementation Study

October 7, 2021

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Co-posted with the Center for Pediatric Clinical Effectiveness (CPCE) at The Children’s Hospital of Philadelphia

A team of researchers at Children’s Hospital of Philadelphia and the University of Pennsylvania recently received a $5.3 million grant from the National Heart, Lung, and Blood Institute (NHLBI) for a first-of-its-kind deimplementation trial. The trial, led by CPCE faculty member Chris Bonafide, MD, MSCE, and Rinad Beidas, PhD, has two goals. The first seeks to identify effective strategies for deimplementing the overuse of pulse oximetry practices in infants experiencing bronchiolitis. The second centers on sustainability – or understanding how best to maintain these reductions in pulse oximetry practices over time.

Deimplementation studies seek to reduce the use of practices that are overused by physicians and nurses, especially practices that are known to have little or no evidence of benefit. Some practices can even put patients at greater risk or cause harm as a result of overuse. Bronchiolitis, an infectious lung disease, is the leading cause of infant hospitalization, causing over 100,000 hospitalizations and $1.7 billion hospital charges annually. The disease exclusively affects children under two, and most commonly occurs during winter seasons.

Continuous pulse oximetry monitoring of oxygen saturation is a common intervention used while treating bronchiolitis. However, overuse of pulse oximetry monitoring in stable patients no longer needing extra oxygen can lead to prolonged hospitalizations, increased risk of harm, and contribute to alarm fatigue. Beginning in more than 40 hospitals across the United States, the Eliminating Monitor Overuse, or “EMO” team will introduce various strategies into the hospital setting to observe which strategies are most effective for deimplementation. The phases of the trial will look like this:

Winter 1 Phase: Measure baseline pulse oximetry overuse in at participating hospitals. This phase is observational only – without any deimplementation strategies.
Winter 2 Phase: Introduce educational outreach and audit and feedback as deimplementation strategies in all hospitals. Additionally, in half of the hospitals, introduce an electronic health record (EHR) strategy to provide decision support for physicians and nurses. The intention is for the EHR to prompt practitioners to consider using less continuous pulse oximetry monitoring in patients who are on the road to recovery.
Winter 3 Phase: This is the sustainability phase of the study, where the EHR remain in place as the only active deimplementation strategy in half of the hospitals. Pulse oximetry overuse will be measured again to see if there is a difference between the hospitals that received the EHR strategy and those that did not.

Prior studies conducted by the EMO team have seen successful reductions in the use of pulse oximetry in the short term. But deimplementation often proves to be difficult to sustain once strategies are withdrawn. The hope is to better understand how to achieve deimplementation so it becomes usual practice, and ultimately improve outcomes for patient safety.

This study will not only improve patient safety, but also advance the field of implementation science, which is a scientific discipline focused on understanding the best ways to implement evidence-based practices and deimplement non evidence-based practices in real world settings.

“This will be one of the largest projects focused on deimplementation within the implementation science portfolio,” says Dr. Rinad Beidas, Director of the Penn Medicine Nudge Unit and the Penn Implementation Science Center at the Leonard Davis Institute (PISCE@LDI), and a multi principal investigator on this project. “Getting people not to do something is an area of research that has been less emphasized, and this project is specifically focused on sustainable change, which has been a challenge for our field.”

Dr. Bonafide also shared why this study is so important. “I’m thrilled to be co-leading this work with Dr. Beidas and our incredible partners at CHOP, Penn, Cincinnati Children’s, Boston Children’s, and more than 40 other hospitals participating from the Pediatric Research in Inpatient Settings (PRIS) Network,” says Dr. Bonafide. “PRIS is a large network of more than 100 children’s hospitals actively working to advance the science of pediatric hospital medicine. It’s a very exciting collaboration bridging this relatively new field of implementation science and the new medical subspecialty of pediatric hospital medicine.”