BACKGROUND AND OBJECTIVES: Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings. METHODS:We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages .60 days to ,24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons.RESULTS: Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased (P , .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center (P , .001) and emergency department (P 5 .001). CONCLUSIONS:We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.
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.
OBJECTIVES: Secondhand smoke exposure is associated with adverse health outcomes in children, yet tobacco cessation efforts for caregivers of hospitalized children are lacking. We sought to explore pediatric hospitalists’ attitudes and barriers to providing tobacco cessation for caregivers of hospitalized children. METHODS: We conducted a cross-sectional survey of pediatric hospitalists and fellows at 7 hospitals from November 1, 2018, to November 30, 2019. A 70-question anonymous survey was used to assess participants’ perceptions of current practices, attitudes, and barriers to providing tobacco cessation support for caregivers of hospitalized children. We used descriptive statistics to summarize the data. RESULTS: Of 207 eligible participants, 100 responded (48%). A majority (79%) agreed that offering tobacco cessation counseling for caregivers is an important part of their role in caring for hospitalized children, but 79% never received tobacco cessation training. Only half of the participants were comfortable providing brief advice and few were comfortable prescribing nicotine replacement therapy. Identified barriers included lack of time (74%), perceived lack of interest from patients’ caregivers (71%), and other medical conditions of the patient taking priority (70%). The majority of participants were interested in further training in tobacco cessation support. CONCLUSIONS: In this survey of 100 pediatric hospitalists, we found overall agreement that tobacco cessation support for caregivers of hospitalized children is important. However, most participants did not feel comfortable with provision of evidence-based counseling or pharmacotherapy because of identified barriers. Future work should target actionable barriers to improve provision of tobacco cessation support in this clinical setting.
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