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Multicenter Study
. 2020 Apr 21;323(15):1467-1477.
doi: 10.1001/jama.2020.2998.

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

Christopher P Bonafide  1   2   3   4 , Rui Xiao  5 , Patrick W Brady  6   7   8 , Christopher P Landrigan  9   10 , Canita Brent  1 , Courtney Benjamin Wolk  11   12 , Amanda P Bettencourt  13   14 , Lisa McLeod  15   16 , Frances Barg  17 , Rinad S Beidas  11   12   18 , Amanda Schondelmeyer  6   7   8 ; Pediatric Research in Inpatient Settings (PRIS) Network
Affiliations
Multicenter Study

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

Christopher P Bonafide et al. JAMA. .

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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Conflict of interest statement

Conflict of Interest Disclosures: Dr McLeod reported participating in this project when she was a faculty member at Children’s Hospital Colorado and being currently employed by Array BioPharma, where her work is unrelated to this project. Dr Bonafide reported receiving grants from the National Institutes of Health/National Heart, Lung, and Blood Institute during the conduct of the study and grants from the Agency for Healthcare Research and Quality and National Science Foundation outside the submitted work. Dr Landrigan reported receiving personal fees having equity in I-PASS Institute outside the submitted work and receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and serving as an expert witness in cases regarding patient safety, handoffs, and sleep deprivation. Ms Brent reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Wolk reported receiving grants from the National Institutes of Health during the conduct of the study and grants from the National Institutes of Health, Institute of Education Science, and Health Resources and Services outside the submitted work. Dr Bettencourt reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Beidas reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study and royalties from Oxford University Press; personal fees from Merck Sharpe & Dohme, Camden Coalition of Healthcare Providers, and the Oregon Social Learning Center; and awards from the American Psychological Association and the Association for Behavioral and Cognitive Therapies outside the submitted work. Dr Schondelmeyer reported receiving grants from the National Heart, Lung, and Blood Institute and grants from Agency for Healthcare Research and Quality during the conduct of the study and grants from the Association for the Advancement of Medical Instrumentation Foundation outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow of Hospitals and Patient Observations in a Study of the Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen
Figure 2.
Figure 2.. Continuous Pulse Oximetry Use in Patients With Bronchiolitis Not Receiving Any Supplemental Oxygen or Nasal Cannula Flow
Patients were aged 8 weeks through 23 months. Points represent the percentage of patients with bronchiolitis actively monitored with continuous pulse oximetry, measured using direct observation. The dotted blue line indicates overall percentage across all hospitals and the shaded area represents the 95% CI. The risk-standardized percentage for each hospital is the ratio of the predicted to expected use percentages multiplied by the overall percentage across all hospitals. Hospitals are ordered by risk-standardized percentage of patients monitored.
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Comment in

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