Study finds excess monitoring of oxygen levels in certain pediatric populations

Monitoring blood oxygen levels with continuous pulse oximetry is overused in infants with bronchiolitis who do not require supplemental oxygen, according to a multi-institutional study published recently in JAMA. The researchers found frequent use of continuous pulse oximetry and a wide variation in its usage among hospitals in their sample, despite national recommendations advising against the practice.

The study led by Children’s Hospital of Philadelphia was a collaborative, multi-institutional effort that included researchers from several institutions. The Texas Children’s Hospital study team was led by Dr. Ricardo Quinonez, chief of Pediatric Hospital Medicine and associate professor at Baylor College of Medicine.

The study was supported by Texas Children’s Research Resources Office (RRO) which provides unified, coordinated and comprehensive researcher-focused support and education for all contracting and regulatory aspects of investigator-initiated, NIH cooperative group and pharmaceutical industry studies. The office also provides centralized resources for pre- and post-award processes for researchers involved in developing and implementing the wide range of basic, translational or clinical studies. RRO staff were led by senior research coordinator Dr. Mohammed Nassif. The team completed in-person rounds to monitor and collect overuse data for 200 subjects admitted to Texas Children’s during the study period. 

“This one-of-a-kind study was conducted in 56 U.S. and Canadian institutions to closely examine a clinical practice that has never been quantified before, with the goal of eliminating the burden of both health care costs and alarm fatigue among care providers. The study is a part of increasing national emphasis to promote evidence-based clinical practices in hospitals and to phase out practices that do not add significant value to patient outcomes,” Nassif said.

Bronchiolitis is the inflammation of bronchioles common in infants and young children. It is typically caused due to viral infections and is the leading reason for the hospitalization among infants. It is usually treated with supportive care, including fluids, suctioning and supplemental oxygen when necessary.

The Society of Hospital Medicine Choosing Wisely initiative discourages physicians from continuous pulse oximetry monitoring in infants with bronchiolitis unless they are on supplemental oxygen, and the American Academy of Pediatrics also recommends against the practice.

Pulse oximetry is the practice of non-invasive measurement of saturated oxygen levels and changes in blood indirectly through the skin using a simple oxygen-sensing device.

To examine the extent to which hospitals were using continuous pulse oximetry in infants with bronchiolitis, the research team conducted an observational study in 56 U.S. and Canadian hospitals in the Pediatric Research Inpatient Settings Network (PRIS), an independent hospital-based network. The hospitals in the study included freestanding children’s hospitals, children’s hospitals within hospitals, and community hospitals. Researchers gathered data throughout one bronchiolitis season, from Dec. 1, 2018 until March 31, 2019 and included 3,612 patients between the ages of 8 weeks and 23 months.

Of the patients in the study who did not receive any supplemental oxygen, 46% were monitored via continuous pulse oximetry. After standardizing the results to account for differences in variables across hospitals that could have influenced monitoring, researchers found the percentage of patients being unnecessarily monitored ranged from 6% to 82%.

“Widespread use of pulse oximetry and the unexpected variation for a population of patients in which guidelines suggest there is little benefit, may lead to unnecessary length of stay in the hospital, and increase risks associated with medical interventions,” Quinonez said.

The study was supported by a cooperative agreement awarded by the National Institutes of Health/National Heart, Lung, and Blood Institute (award number U01HL143475).

- By Dr. Rajalaxmi Natarajan (adapted from Children’s Hospital of Philadelphia’s news release)