Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen | Pediatrics | JAMA | JAMA Network
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Original Investigation
April 21, 2020

Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen

Author Affiliations
  • 1Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 2Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 3Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 4Perelman School of Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
  • 5Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
  • 6Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 7James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 8Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 9Division of General Pediatrics, Boston Children's Hospital, Massachusetts
  • 10Harvard Medical School, Boston, Massachusetts
  • 11Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
  • 12Leonard Davis Institute of Health Economics, Penn Implementation Science Center, University of Pennsylvania, Philadelphia
  • 13Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
  • 14National Clinician Scholars Program and TACTICAL Scholar, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 15Department of Pediatrics, Children’s Hospital Colorado, Denver
  • 16Array BioPharma, Boulder, Colorado
  • 17Perelman School of Medicine, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia
  • 18Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
JAMA. 2020;323(15):1467-1477. doi:10.1001/jama.2020.2998
Key Points

Question  What percentage of children hospitalized with viral bronchiolitis who are not receiving any supplemental oxygen are continuously monitored with pulse oximetry?

Findings  In this cross-sectional study that included 56 hospitals and 3612 patient observations of children hospitalized with bronchiolitis without receipt of supplemental oxygen, pulse oximetry use ranged from 2% to 92%, with a mean of 46%.

Meaning  Continuous pulse oximetry monitoring among a sample of hospitalized children with bronchiolitis but without an apparent indication for its use had high prevalence.

Abstract

Importance  US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.

Objective  Measure continuous pulse oximetry use in children with bronchiolitis.

Design, Setting, and Participants  A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.

Exposures  Hospitalization with bronchiolitis without active supplemental oxygen administration.

Main Outcomes and Measures  The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.

Results  The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.

Conclusions and Relevance  In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.

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