Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis

Abstract

IMPORTANCEThere is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis.OBJECTIVE To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes.DESIGN, SETTING, AND PARTICIPANTS This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada.INTERVENTIONS Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher. MAIN OUTCOMES AND MEASURESThe primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction. RESULTS Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, −1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001). CONCLUSIONS AND RELEVANCEIn this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing...

Pulse oximetry respiratory monitoring for assessment of acute childhood wheeze

“…Clearly further development work is needed to allow the respiratory rate calculation to be performed in real time, and to provide real-time quality control for artefact, but both these should be readily achievable with appropriate software. In addition to these technical considerations, caution is needed before advocating widespread introduction of continuous RR monitoring: in infants with bronchiolitis, continuous SpO2 monitoring has not been shown to improve clinical outcomes compared to intermittent SpO2 monitoring 28 , and over-reliance on SpO2 measurements in bronchiolitis may lead to increased hospital admissions 29 . Larger clinical studies are needed 15 to determine whether pleth-derived monitoring of RR and of PP equivalents are effective in guiding decision-making in the acutely wheezy child.…”

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children’s Hospitals

“…Comparative effectiveness research is needed to inform how to best manage conditions in children with medical complexity, as they are often excluded from clinical trials for common conditions, such as pneumonia and bronchiolitis. 39,40 Researchers can include children with medical complexity in future studies by including additional safety measures and subgroup analyses. Further, complex care programs that bridge inpatient and outpatient care can reduce hospitalizations, hospital days, and hospital costs in medically complex children.…”

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial

“…We will also collect additional data to capture any underuse of monitoring that could plausibly occur in response to deimplementation in patients with more severe diseases [ 75 ]. We define underuse as failing to continuously monitor bronchiolitis patients receiving ≥2L/min supplemental oxygen or flow (a marker of more severe disease) [ 20 ] and will measure it using the same observational data collection methods used for the primary outcome. We will perform surveillance for additional unintended safety consequences [ 1 ]: code blue and rapid response team activations in bronchiolitis patients who were unmonitored at the time of the event and were subsequently found to be hypoxemic and (2) readmission of bronchiolitis patients to the hospital within 7 days of discharge with a finding of hypoxemia upon re-presentation to the emergency department.…”

“…Overuse of continuous SpO 2 monitoring is associated with increased oxygen administration, prolonged length of stay, unnecessary monitor alarms that can generate alarm fatigue, and increased costs [ 16 – 18 ]. Two clinical trials have demonstrated that intermittent SpO 2 measurement is an equally safe alternative to continuous SpO 2 monitoring for children in room air [ 19 , 20 ], and three sets of national guidelines now discourage the use of continuous SpO 2 monitoring in hospitalized children with bronchiolitis who are in room air [ 11 , 21 , 22 ]. Despite the evidence and guidelines, continuous SpO 2 monitoring continues to be overused in hospitalized children with bronchiolitis, making it a prime target for deimplementation.…”