Pulse oximetry adoption and oxygen orders at paediatric admission over 7 years in Kenya: a multihospital retrospective cohort study

Abstract

Objectives: To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen.

Design: A multihospital retrospective cohort study.

Settings: All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020.

Outcomes: Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors.

Results: Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO₂ <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO₂ <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia.

Conclusion: The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.

Keywords: audit; epidemiology; paediatrics; protocols & guidelines; quality in health care; tropical medicine.

Figure 1

Flow chart of the inclusion criteria. AVPU, Alert, Verbal, Pain, Unresponsive.

Figure 2

Oxygen prescription and use of pulse oximetry at admission.

Figure 3

Average pulse oximetry use in the Clinical Information Network (CIN) hospitals over time. The number of hospitals in each study covers both presently involved and those joining the CIN later: there are 13 hospitals in the period between February 2014 and November 2018, with the lower panel representing transition to 18 hospitals by adding 5 hospitals and research studies beginning. The 5 new hospitals’ distribution among the studies in the following way: RTS, S: 2/5; RTS, S+SEARCH: 1/5; SEARCH: 1/5; None: 1/5.

Figure 4

Hospital specific rate of pulse oximetry use at admission over time divided into sites joining from January 2014 and those recruited from December 2018. Vertical red line indicates national strike disruption. The title is colour-coded to reflect the research study the hospital was recruited into (Blue: None, Orange: RTS, S, Red: SEARCH, Green: RTS, S+SEARCH). H7 exited from Clinical Information Network and is therefore not included in subsequent analysis.

Figure 5

Adapted integrative model of behavioural prediction (Enoch et al 10). Dashes indicate components of the model that are modified or added to reflect the findings from our new analyses. AVPU, Alert, Verbal, Pain, Unresponsive; HCW: healthcare worker; PAR, paediatric admission record.