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
Authors: Bonafide Christopher P. , Xiao Rui , Schondelmeyer Amanda C. , Pettit Amy R. , Brady Patrick W. , Landrigan Christopher P. , Wolk Courtney Benjamin , Cidav Zuleyha , Ruppel Halley , Muthu Naveen , Williams Nathaniel J. , Schisterman Enrique , Brent Canita R. , Albanowski Kimberly , Beidas Rinad S. ,   for the Pediatric Research in Inpatient Settings (PRIS) Network, Rajbhandari Prabi , Knuth Emily , Bailey Michelle , Lucey Kate , Stoeck Patty , House Samantha , Silver Alyssa , Naifeh Monique , Tchou Michael , Tyler Amy , Lee Vivian , Cummings Erin , Lee Clifton , Shomaker Kyrie , Mihalek Alexandra , Solomon Courtney , Parlar-Chun Raymond , Berg Kathleen , Ryan Nick , Halley Tina , Orr Mary , Liljestrom Tracey , Preloger Erin , Parthasarathy Padmavathy , Shakir Rashida , Chu Andrew , Greenfield Morgan , Prasto Julianne , Le Ann , Monroe Kimberly , Lauffer Andrea , Carter Meredith , Halmon Kamilah , Huff Glen , Patel Kiran Gadani , Ono Jennie , Schroeder Alan , Plemmons Gregory , Perry Michael , Banker Sumeet , Lee Jennifer , Willer Robert , Lee Begem , Rhee Kyung , Baker Richelle , Gregory Polina Frolova , Parikh Vipul , Wallace Mini , Edwards Stephen , Beckner Lisa , Hamline Michelle , Solan Lauren , Cioffredi Leigh-Anne , Johnson Scarlett , Andrake John , Webb Nicole , Berkwitt Adam 
Published: October 2022

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.