Investigators from Inova Children’s Hospital, Falls Church, VA, and Inova Fairfax Hospital, Fairfax, VA, conducted a survey of providers at a children’s hospital to explore attitudes regarding deimplementation of high-flow nasal cannula (HFNC) therapy as routine treatment of hospitalized children with bronchiolitis. The survey included 2 domains: acceptability of deimplementation and perceived benefits of HFNC. Six acceptability items were developed using the Theoretical Framework for Acceptability, including questions on affective attitude on deimplementation, ease of deimplementation, alignment with respondent’s values, amount of effort needed, confidence of respondents that they can deimplement HFNC, and familiarity with evidence on HFNC effectiveness. For each item, a 5-point Likert scale was used for responses, which were grouped as positive, negative, or neutral. Perceived benefit was assessed by asking respondents to indicate which of the following were benefits of HFNC: parent comfort, provider comfort, decrease in length of stay (LOS), decrease in length of oxygen supplementation, and decreased risk of ICU transfer.
The survey was sent by email to hospital nurses, physicians (including attendings and pediatric residents), advanced practice providers (APPs), and respiratory therapists (RTs). Survey responses were anonymous unless the respondent indicated a willingness to participate in an in-depth interview regarding barriers and facilitators to deimplementation. Differences in survey responses among respondents from the 3 provider groups (physicians/APPs, nurses, RTs) were compared using chi-square tests.
Surveys were emailed to 387 providers, and 152 were returned (39% response rate). Among respondents, 44 (29%) were physicians/APPs, 78 (51%) nurses, and 30 (20%) RTs. Overall, 55% of providers were positive about deimplementation of HFNC. Among the physician/APPs respondents, 77% were positive compared to 42% of nurses (P <0.001) and 53% of RTs (P =0.03). Overall, 46% of respondents had positive responses to ease of deimplementation, 46% that it aligned with their values, 58% regarding effort needed for deimplementation, and 69% that they could deimplement HFNC as a standard treatment; only 32% had positive responses related to familiarity with evidence on HFNC effectiveness. Among perceived benefits, 34% indicated that they thought HFNC decreased LOS, 38% that HFNC shortened duration of oxygen supplementation, and 52% that it reduced the risk of ICU transfer. Physician/APPs respondents were significantly less likely to identify each of these as a benefit compared to nurses and RTs. Overall, 38% and 46% of respondents indicated that HFNC increased provider and parent comfort, respectively. A total of 35 providers participated in in-depth interviews. Commonly cited barriers to deimplementation were discomfort in not intervening with HFNC, perception that it helps, and variation in risk tolerance. Facilitators of deimplementation that were cited included staff education, a culture of safety doing less, and enhanced interdisciplinary communication.
The authors conclude that providers at a children’s hospital were moderately positive about deimplementation of HFNC as routine treatment for...