April 22, 2020
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Continuous pulse oximetry monitoring overused in pediatric bronchiolitis

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New data published in JAMA indicate that continuous pulse oximetry monitoring is being used often in children hospitalized with bronchiolitis who are not receiving active supplemental oxygen administration — a population in whom this is not indicated.

For the multicenter, cross-sectional study, Christopher P. Bonafide, MD, MSCE, from the Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, and colleagues evaluated a convenience sample of patients aged 8 weeks to 23 months with bronchiolitis at 56 U.S. and Canadian hospitals in the Pediatric Research in Inpatient Settings network. All patients were not receiving supplemental oxygen or nasal cannula flow at the time of observation. Their analysis included 3,612 patient observations in 33 freestanding children’s hospitals, 14 children’s hospitals within hospitals and nine community hospitals from December 2018 to March 2019.

Of those included in the study, 59% of patients were boys, 56% were white, 15% were black and 21% were Hispanic or Latino. Forty-eight percent were younger than 5 months, 28% were aged 6 to 11 months, 16% were aged 12 to 17 months and 9% were aged 18 to 23 months. Approximately two-thirds had received supplemental oxygen or flow earlier in their hospitalization.

Among these patients who were not receiving supplemental oxygen or nasal cannula flow, the overall percentage of use of continuous pulse oximetry was 46% (95% CI, 40-53) after accounting for clustering at the hospital level. Notably, among the 49 hospitals that collected 20 observations or more, hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%.

New data published in JAMA indicate that continuous pulse oximetry monitoring is being used often in children hospitalized with bronchiolitis who are not receiving active supplemental oxygen administration - a population in whom this is not indicated.
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In an adjusted analysis, the researchers found that continuous pulse oximetry monitoring was more likely in children aged 8 weeks to 5 months who were born preterm compared with those aged 18 to 23 months who were not born preterm (OR = 2.58; 95% CI, 1.65-4.02) and those who had not received supplemental oxygen for the past 2 to 4 hours compared with those who never received supplemental oxygen or flow (OR = 5.55; 95% CI, 3.91-7.89). A history of apnea or cyanosis during the present illness (OR = 1.4; 95% CI, 1.01-1.93), the presence of an enteral feeding tube (OR = 1.98; 95% CI, 1.46-2.67) and nighttime (OR = 2.07; 95% CI, 1.76-2.43) also appeared to be factors associated with use of continuous pulse oximetry monitoring.

Further analyses showed that risk standardized percentages of use of continuous pulse oximetry monitoring ranged from 6% to 82%, with the intraclass correlation coefficient suggesting that 27% (95% CI, 19-36) of the variation was due to unmeasured hospital-level factors, according to the data.

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“Because of the apparent absence of guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse,” the researchers concluded.

In an accompanying editorial, Christine C. Cheston, MD, and Robert J. Vinci, MD, both from the Boston University School of Medicine and the department of pediatrics at the Boston Medical Center, noted that these data offer insight into how continuous pulse oximetry monitoring is being used, despite guidelines recommending its use only for hospitalized children receiving supplemental oxygen, and allow physicians to consider its value outside of that indication.

“Bonafide and colleagues have laid the groundwork for pediatricians to reflect on the benefit of a simple intervention, such as continuous pulse oximetry monitoring, and to determine strategies to use it appropriately in patients with bronchiolitis,” they wrote. “At a time when implementation science is helping to bring evidence-based practices to the bedside, an even greater challenge for physicians is to advance de-implementation science as an equally necessary strategy to reduce overused care practices. Their work highlights the need to construct multifaceted approaches that incorporate education, feedback ad system-based and family-centered interventions to change clinical practice and create significant, sustainable improvements in value of medical care for patients and families.” – by Melissa Foster

Disclosures: Bonafide reports he has received grants from the NIH/National Heart, Lung, and Blood Institute, the Agency for Healthcare Research and Quality, and National Science Foundation. Please see the study for all other authors’ relevant financial disclosures. Cheston and Vinci report no relevant financial disclosures.