Caregiver experiences with deimplementation of continuous pulse oximetry monitoring for children hospitalized with bronchiolitis: A qualitative study

Abstract

Background

Continuous pulse oximetry monitoring in stable children with bronchiolitis not requiring supplemental oxygen has been identified as a low‐value practice. However, little is known about how parents and other caregivers experience efforts to deimplement this practice.

Objectives

This study investigated caregivers' experiences during their child's recent hospitalization for bronchiolitis on units involved in a deimplementation trial.

Methods

We conducted semi‐structured qualitative interviews with 15 caregivers of children hospitalized with bronchiolitis at 11 hospitals participating in deimplementation strategies to reduce unnecessary continuous pulse oximetry monitoring as part of the Eliminating Monitoring Overuse (EMO) trial. Interviews were recorded, transcribed, and coded using an integrative analytic approach.

Results

Caregivers were a mean (SD) 31.1 (5.7) years old, predominantly female (93.3%), white (73.3%), and Non‐Hispanic (86.7%). Previous hospitalization experiences and prior knowledge and training influenced caregiver perceptions of the value of monitoring. Participants did not discuss noticing changes in monitoring practices in interviews.

Conclusions

Findings suggest that tailored education about monitoring may lessen caregiver concerns.

Visual Abstract

INTRODUCTION

Continuous pulse oximetry monitoring (cSpO₂) in children with bronchiolitis who are otherwise stable and do not require supplemental oxygen has been identified as a low‐value practice because it does not improve clinical outcomes and is associated with longer hospitalization and alarm fatigue. ¹ , ² Despite this evidence, the practice remains widespread. ³ , ⁴ Thus, there has been increased interest in how to deimplement ineffective practices like cSpO₂. ⁵

Existing studies have largely focused on clinician and hospital leader experiences with deimplementation. ⁶ These inquiries have indicated clinicians may be reluctant to stop using low‐value practices like cSpO2 due to perceptions that caregivers prefer continuous monitoring or interpret lack of monitoring as evidence of inadequate care. ⁶ Successfully deimplementing cSpO₂ necessitates developing strategies to mitigate these concerns, particularly if caregivers share them.

While family perceptions of the value of monitoring children with bronchiolitis have been previously explored, ⁷ , ⁸ families' experiences during active deimplementation of cSpO₂ monitoring remain unknown. The present study aimed to understand caregiver's experiences with deimplementation efforts during their child's recent hospitalization for bronchiolitis on units participating in a deimplementation trial. ⁹ Specifically focusing on caregiver experiences during active deimplementation of monitoring is novel and important because caregiver's direct experiences may differ from their perceptions of monitoring acceptability or hypothetical attitudes toward reducing monitoring, as assessed in prior studies. ⁷ , ⁸

METHODS

We conducted semi‐structured interviews with caregivers of children hospitalized for bronchiolitis at 11 hospitals participating in the multicenter Eliminating Monitoring Overuse (EMO) trial, a cluster‐randomized hybrid type 3 effectiveness‐implementation trial. ⁹ The institutional review board (IRB) at Children's Hospital of Philadelphia approved the study, and the remaining sites established reliance agreements with the reviewing IRB. Participants provided informed consent before completing interviews. Caregiver consent was not required for the larger EMO study, as the deimplementation efforts were deployed as standard clinical care and the strategies to facilitate deimplementation targeted clinicians, not caregivers or patients. Caregivers were not made aware of the EMO trial during their child's hospitalization. Our qualitative methods and findings are reported in accordance with the consolidated criteria for reporting qualitative studies (COREQ). ¹⁰

Participants

The intended sample size of 15 participants was determined a priori, based on our previous experience ⁶ , ⁷ and literature indicating this sample size is generally sufficient for achieving thematic saturation. ¹¹ Eligible caregivers whose children were hospitalized for bronchiolitis between December 1, 2023, and March 31, 2024, at a participating site were eligible to participate. A purposive sampling approach was used, specifically aiming to include eligible participants from multiple hospitals.

Procedures

Participants were contacted by email or phone and invited to participate. A female qualitative researcher with a master's degree and several years of qualitative research experience conducted individual interviews via teleconference or telephone, typically lasting 15 min. The researcher took unstructured notes during the interviews and had no prior relationship with the participants. With participant permission, interviews were recorded and transcribed verbatim. Identifying information was removed after transcription.

Interview guide

A semi‐structured interview guide (see Supporting Information) was developed, informed by the updated Consolidated Framework for Implementation Research (CFIR), ¹² to better understand how caregivers experienced cSpO₂ deimplementation. The guide queried about caregivers' experience with monitoring during their child's recent hospitalization for bronchiolitis and was iteratively refined with research team members and piloted before deployment.

Data analysis

Two qualitative researchers coded and analyzed the transcripts using an integrated approach ¹³ in NVivo. ¹⁴ We used an iterative process to determine emergent themes and patterns in the data and also coded for constructs determined a priori (e.g., provider type). To ensure consistent application of the codebook, the two researchers co‐coded ~25% of transcripts, meeting to resolve discrepancies. The remaining transcripts were coded by one researcher.

RESULTS

We attempted to contact 93 eligible caregivers by email or phone, and 52 responded. Of the 52, 18 agreed and 15 completed an interview, 34 declined, and 3 agreed to interviews but then became unreachable. The 15 participants' children had been hospitalized across 11 study sites. Families ranged from those for whom this was their child's first hospitalization (n = 7) to those whose children (including siblings of the child being discussed) had been previously hospitalized for any reason (n = 8); see Table 1 for a summary of other participant characteristics. We identified two broad overarching themes, each containing subthemes (see Table 2 for themes and additional illustrative quotations). No participants mentioned awareness of the EMO trial, active deimplementation efforts, or changes in monitoring practices during interviews, though we did not specifically query participants about their awareness of deimplementation activities during interviews.

Table 1.

Participant demographics.

Variable	n (%)
Mean age (SD)	30.1 (5.7)
Sex
Male	1 (6.7)
Female	14 (93.3)
Ethnicity
Hispanic and/or Latinx	2 (13.3)
Non‐Hispanic and/or non‐Latinx	13 (86.7)
Racea
American Indian or Alaska Native	1 (6.7)
Asian	1 (6.7)
Black or African American	3 (20.0)
Native Hawaiian or Pacific Islander	0 (0)
White	11 (73.3)
Prefer not to disclose	0 (0)

^a Participants could endorse more than one race.

Table 2.

Illustrative participant quotations.

Theme	Subtheme	Quotation
Perceptions of Monitoring and Discontinuation are informed by Prior Personal and Medical Experience	For some caregivers, the monitor increased anxiety or was perceived as unnecessary	“I didn't really like seeing the number [on the monitor], because ‐‐ so for example, in January, they took him off the high flow, put him on a regular oxygen, and they had that monitor set to beep like crazy if it went below like 90 or below like 88. But when he was sleeping, it would drop. So, I didn't like seeing that. It kept me awake for the most part, because I was fixating on that number…” (White female caregiver in late 20s)
		“We need a secondary approach as a medical profession to say ‘look at those children’: they [have] rosy cheeks, they are eating, they are not on oxygen support, they're not on wall suction. Their oxygen is at 89. Can they go home? Yeah, they probably can, they should go home.” (White female caregiver in late 30s)
		“Well, [the monitor beeping] was scary because most of the times I didn't know what it meant. And then, it wouldn't shut off after a while, so it would get kind of annoying.”
	For other caregivers, the monitor provided reassurance and caregivers preferred it	“I mean, I know that she's a sick kid and I know that it ‐‐ I felt like it was a little bit rushed at first, but it was […] I mean, I know y'all get paid whether or not she's there, but I just, I wasn't very happy that they took it off as soon as they did.” (White female caregiver in early 30s)
	Education or knowledge about how to interpret the monitor readings was helpful for caregivers	“And then we were kind of taught like what numbers we were looking for and we wanted it in a certain spot and if it got too low it would beep.” (White female caregiver in mid 30s)
	Caregivers looked to the care team to help interpret the monitor	“At the beginning of our stay, [the nurses were] very responsive they would come in and adjust whatever or put them back on if we were trying to take them off. Towards the end, so it wasn't quite that way. With our last nurse, [Nurse], she took him off the monitor and he kept dipping, he wouldn't stay at 86% very long, but he would dip to 86% and then he would come back up to 88%. So, she was just kind of letting it do its thing, which made me a little bit nervous, but I trust her because she's a nurse, she knows what she's doing, but we did end up getting discharged the next morning after that. So that was a little bit nerve wracking.” (White female caregiver in mid 20s)
		“[The doctors] just said that her oxygen, that she didn't seem like she needed to be, she was like getting discharged to go home and she doesn't need monitoring anymore […] I felt relieved knowing that she was being able to keep her oxygen level up and not struggle anymore to breathe.” (White female caregiver in mid 20s)
Perceptions of Care Quality are Informed by Caregiver and Patient Characteristics	Caregivers of children who had been previously hospitalized felt more prepared and less anxious	“By [the third hospitalization], it was pretty easy. That one was, we knew what was going to happen and we knew her breathing patterns by then and we knew that it was going to be, we honestly knew what was going to happen. The first time she was hospitalized… that was really scary.” (White female caregiver in early 30s)
		“Well, my son, he has Down Syndrome. So, he was actually admitted in November to a different hospital because of his glucose level. So, I'm kind of used to [monitoring], I guess. But when we were on floor 12 in a whole different unit, when he was getting better, they really weren't concerned with it. It was off for a while. They ‐ some people didn't even notice it was off…”
	Caregivers of children who had never been previously hospitalized relied more on the care team's expertise	“Personally, I don't want any, because I don't like making that decision, because I understand I have no medical experience. I don't want to make a decision that would negatively impact my child.” (White female caregiver in late 20s)
	Among caregivers with medical training, this training informed their perceptions and advocacy	“Well, my wife is a nurse so she's pretty familiar with [oxygen monitoring] and then I just follow her lead.”
		“Well, I feel like I was really uneasy that we had the responsibility of monitoring this and I felt like we had to advocate for her the entire time and maybe wonder what do parents who don't really know or they're putting their full trust into these physicians or nurses and they're not getting what they need.” (White female caregiver in late 20s)
		“But now that she's my third child, I know now, as well as being a medical assistant, I know more about calm, like you need to remain calm because then you do scare the kids if they're older and they understand, you do scare the kids. You tend to scare yourself when right away the nurses come in anyway, if there's anything they see wrong. So, now I've kind of learned to relax a little bit and I will still get up and check and make sure everything's fine, but I don't, like right away, push the button for the nurse or start worrying so bad where I'm like, running all around.” (White female caregiver in mid 20s)

Perceptions of monitoring and discontinuation are informed by prior personal and medical experience

Most participants reported they liked being able to see the monitor, finding it comforting to observe when their child's oxygen levels were in the appropriate range. One caregiver noted that continuous monitoring caused them anxiety and they would have preferred periodic spot checks.

A few participants said their child's care team taught them how to interpret the SpO₂ monitor, educating them about appropriate ranges and what to expect given their child's condition, which some caregivers found reassuring. A few participants had previous experience with SpO₂ monitoring (e.g., during previous hospitalizations), which led to increased knowledge of the purpose and practicalities of monitoring.

Caregiver interpretation of the alarms influenced provider‐caregiver relationships, sometimes negatively. For example, if a caregiver thought an alarm was cause for concern but no one on the child's care team reacted with urgency, caregivers discussed feeling nervous and unsure about their child's health status or the quality of care their child was receiving.

The tenor of the care team‐caregiver relationship similarly influenced how caregivers reacted to discontinuation of monitoring. If they trusted the care team, caregivers tended to feel better about monitoring discontinuation. However, if caregivers felt dismissed by care teams or felt their child was not getting adequate attention from their doctors or nurses, then they tended to want additional monitoring in place for their child. Some saw their child coming off the monitor as a step towards discharge, while others expressed concern that their child was not getting adequate care and the family was being pushed out of the hospital. Caregivers who were comfortable with their child being disconnected reported they liked being able to more easily hold or feed their child once the monitor was disconnected.

Two caregivers with healthcare expertise explicitly said their hospital's monitoring policies resulted in inappropriate hospitalization and wasted medical resources due to overreliance on monitors, advocating instead that the care team consider the whole health of the child instead of relying on data from monitors. Further, these caregivers advocated for doctors and parents to collaborate with one another to make decisions about the child in front of them, as opposed to relying on rigid protocols. In general, participants felt the ideal role of parents in monitoring decisions was a balance of healthcare providers having a broad medical understanding of how a patient “should” be, while caregivers were able to translate those guidelines to their specific child. For example, one caregiver stated,

…there are some parents that know their children very well, who can read their signals and cues and are really in tune with them and they can make the best call. But I think we know if you're in the medical field, that's not every family. And you have to put the child's interest, they really have to keep their child's best interest in mind. So as a parent, I want to be included in the conversation about the decisions. I don't necessarily need to be the one making the decision.

Perceptions of care quality are informed by caregiver and patient characteristics

While this was not a focus of the research question, caregivers of children with prior hospitalizations reported feeling less concerned and better educated during their child's hospitalization. Similarly, caregivers' feelings about monitoring were heavily informed by their sense of what was typical for their child, and caregivers wanted the child's care team to integrate this information as part of their decision making. In general, caregivers of children that had not been previously hospitalized more often described deferring to the expertise of the care team about the level of surveillance their child needed.

Multiple caregivers reported that they or their spouse were medical professionals, which shaped their perceptions and advocacy about monitoring. At least one caregiver talked about having to advocate for changes to their child's treatment plan.

DISCUSSION

Qualitative interviews with caregivers of children hospitalized for bronchiolitis illuminated how they experience cSpO2 monitoring in the context of an active effort to deimplement the practice in clinically stable children. While caregivers shared a range of experiences and perspectives, a key finding is that perceptions of the value of monitoring and the care their child received were greatly influenced by relationships with the care team, previous experiences with their child being hospitalized, and, in some cases, prior knowledge about the topic.

Our findings have two key implications. First, while prior studies have emphasized clinician concerns that caregivers will resist lack of monitoring, this concern may be unfounded in many, but not all, cases. In our study, which took place during the active phase of a deimplementation trial, caregiver perspectives on monitoring were varied and related to their prior hospital experience, similar to a prior hospital‐based qualitative study. ⁷ While evidence suggests caregivers may find comfort in their child being monitored, ⁷ , ¹⁵ one experimental study suggested this belief is malleable. ¹⁶ Taken together with our findings, clinician concerns about relationship rupture when discussing more judicious monitoring approaches may be lessened.

Second, our findings of differential perspectives based on caregiver knowledge and previous experience emphasize the importance of tailoring messaging and educating caregivers about monitoring. We identified that caregivers whose children have had previous hospitalization(s) and those with medical training may benefit from limited or different education tailored to their knowledge and experiences with cSpO2 monitoring. For caregivers of children hospitalized for the first time, education about the value of monitoring, the benefits of not monitoring (e.g., ease of movement and ability to comfort the child), and the other ways the care team and caregivers can assess the child's status and ensure their wellbeing is likely to provide comfort and alleviate concerns. Caregivers with previous pediatric hospitalization experience may be more oriented to the hospital context and/or less anxious about their child's condition. Future studies should engage caregivers and partner with them to co‐develop educational resources about monitoring, its appropriate use, and indications for discontinuation. More research is needed to examine if these results generalize to other deimplementation efforts beyond cSpO2 and to further explore differences in perspectives among those with and without prior knowledge of or experience with pediatric monitoring.

While the sample representativeness was limited, the study is strengthened by including caregivers whose children were hospitalized at a diverse sample of hospitals. While the sample size was sufficient to achieve thematic saturation and include multiple, contrasting perspectives, owing to the focus of the question and the relative homogeneity of the population (all families of young infants hospitalized with bronchiolitis discussing one aspect of hospitalization, monitors) we identified a limited number of themes, and it is difficult to assess the generalizability of our findings due to the limited number of participants at individual hospitals. It is possible that local hospital culture and practice influenced caregiver experiences, though we were unable to assess that. Because deimplementation occured as part of usual care, caregivers' lack of awareness of the EMO trial may indiciate that individual hospitals effectively normalized any changes in practices, however future studies that engage caregivers in the deimplemenation process are needed. Studies that examine patient experiences in different contexts and with different strategies and those that leverage co‐creation methods to develop educational resources about monitoring with caregivers would advance the science of deimplementation.

RELEVANT REPORTING CHECKLIST

Data are reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ).

CONFLICT OF INTEREST STATEMENT

Dr. Wolk received royalties from Oxford University Press, outside of the submitted work. Dr. Beidas is 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. All other authors declare that they have no competing interests.

ETHICS STATEMENT

The institutional review board (IRB) at Children's Hospital of Philadelphia approved the study, and the remaining sites established reliance agreements with the reviewing IRB. Participants provided informed consent before completing interviews.

Supporting information

Supplemental File 1 Interview Guide.

Supplemental File 2 Qualitative Codebook.

Supplemental File 3 COREQ Checklist.

Wolk CB, O'Brien CS, Bonafide C, et al. Caregiver experiences with deimplementation of continuous pulse oximetry monitoring for children hospitalized with bronchiolitis: A qualitative study. J Hosp Med. 2026;21:27‐33. 10.1002/jhm.70123

DATA AVAILABILITY STATEMENT

Data are available from the corresponding author upon reasonable request.