Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Aug 1;6(8):e2330856.
doi: 10.1001/jamanetworkopen.2023.30856.

Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Ashraf Fawzy  1 , Tianshi David Wu  2   3 , Kunbo Wang  4 , Kenneth E Sands  5 , Arielle M Fisher  6 , Shanna A Arnold Egloff  5 , Jeffrey D DellaVolpe  5 , Theodore J Iwashyna  1   7 , Yanxun Xu  4 , Brian T Garibaldi  1
Affiliations

Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Ashraf Fawzy et al. JAMA Netw Open. .

Abstract

Importance: Many pulse oximeters have been shown to overestimate oxygen saturation in persons of color, and this phenomenon has potential clinical implications. The relationship between overestimation of oxygen saturation with timing of COVID-19 medication delivery and clinical outcomes remains unknown.

Objective: To investigate the association between overestimation of oxygen saturation by pulse oximetry and delay in administration of COVID-19 therapy, hospital length of stay, risk of hospital readmission, and in-hospital mortality.

Design, setting, and participants: This cohort study included patients hospitalized for COVID-19 at 186 acute care facilities in the US with at least 1 functional arterial oxygen saturation (SaO2) measurement between March 2020 and October 2021. A subset of patients were admitted after July 1, 2020, without immediate need for COVID-19 therapy based on pulse oximeter saturation (SpO2 levels of 94% or higher without supplemental oxygen).

Exposures: Self-reported race and ethnicity, difference between concurrent SaO2 and pulse oximeter saturation (SpO2) within 10 minutes, and initially unrecognized need for COVID-19 therapy (first SaO2 reading below 94% despite SpO2 levels of 94% or above).

Main outcome and measures: The association of race and ethnicity with degree of pulse oximeter measurement error (SpO2 - SaO2) and odds of unrecognized need for COVID-19 therapy were determined using linear mixed-effects models. Associations of initially unrecognized need for treatment with time to receipt of therapy (remdesivir or dexamethasone), in-hospital mortality, 30-day hospital readmission, and length of stay were evaluated using mixed-effects models. All models accounted for demographics, clinical characteristics, and hospital site. Effect modification by race and ethnicity was evaluated using interaction terms.

Results: Among 24 504 patients with concurrent SpO2 and SaO2 measurements (mean [SD] age, 63.9 [15.8] years; 10 263 female [41.9%]; 3922 Black [16.0%], 7895 Hispanic [32.2%], 2554 Asian, Native American or Alaskan Native, Hawaiian or Pacific Islander, or another race or ethnicity [10.4%], and 10 133 White [41.4%]), pulse oximetry overestimated SaO2 for Black (adjusted mean difference, 0.93 [95% CI, 0.74-1.12] percentage points), Hispanic (0.49 [95% CI, 0.34-0.63] percentage points), and other (0.53 [95% CI, 0.35-0.72] percentage points) patients compared with White patients. In a subset of 8635 patients with a concurrent SpO2 - SaO2 pair without immediate need for COVID-19 therapy, Black patients were significantly more likely to have pulse oximetry values that masked an indication for COVID-19 therapy compared with White patients (adjusted odds ratio [aOR], 1.65; 95% CI, 1.33-2.03). Patients with an unrecognized need for COVID-19 therapy were 10% less likely to receive COVID-19 therapy (adjusted hazard ratio, 0.90; 95% CI, 0.83-0.97) and higher odds of readmission (aOR, 2.41; 95% CI, 1.39-4.18) regardless of race (P for interaction = .45 and P = .14, respectively). There was no association of unrecognized need for COVID-19 therapy with in-hospital mortality (aOR, 0.84; 95% CI, 0.71-1.01) or length of stay (mean difference, -1.4 days; 95% CI, -3.1 to 0.2 days).

Conclusions and relevance: In this cohort study, overestimation of oxygen saturation by pulse oximetry led to delayed delivery of COVID-19 therapy and higher probability of readmission regardless of race. Black patients were more likely to have unrecognized need for therapy with potential implications for population-level health disparities.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Drs Sands, Fisher, Arnold Egloff, and DellaVolpe reported either employment or consulting work with HCA Healthcare. Dr Fawzy reported receiving grants from National Institutes of Health/National Heart, Lung, and Blood Institute outside the submitted work. Dr Wu reported grants from National Institutes of Health outside the submitted work. Dr Arnold Egloff reported employment with HCA Healthcare as an investigator working both on CHARGE during the conduct of the study and on other projects outside the submitted work. Dr DellaVolpe reported service on a medical advisory board for NovaLung; he reported receiving honoraria from NovaLung and Getinge/Maquet; he received research support from ExThera, Altrazeal, and Fresenius; and he reported consulting work with MC3, Getinge/Maquet, and Exthera. Dr Garibaldi reported grants from Templeton Foundation during the conduct of the study; he reported receiving consulting fees from Janssen Development LLC, Gilead Life Sciences, and Atea Pharmaceuticals; and he reported committee service on the FDA Pulmonary-Asthma Drug Advisory Committee and as founding board member of the Society of Bedside Medicine outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Association of Race and Ethnicity With Pulse Oximeter Accuracy and Delayed Recognition of Need for COVID-19 Therapy
Other racial and ethnic minority patients included Asian, Native American or Alaskan Native, Hawaiian or Pacific Islander, and patients with another race or ethnicity. A. Pulse oximeter accuracy defined as mean difference between pulse oximeter saturation (SpO2) and arterial oxygen saturation (SaO2). B. Delayed recognition defined as first SaO2 measurement below 94% despite SpO2 of 94% or above.
Figure 2.
Figure 2.. Cumulative Incidence of Treatment During the First 48 Hours of Hospitalization
Comparison of patients with COVID-19 admitted after July 1, 2020, with first arterial oxygen saturation (SaO2) measurement below 94% who had recognized or unrecognized need for COVID-19 therapy (concurrent pulse oximeter saturation [SpO2] at 94% or 94% and higher, respectively).
See this image and copyright information in PMC

References

    1. Mower WR, Sachs C, Nicklin EL, Safa P, Baraff LJ. Effect of routine emergency department triage pulse oximetry screening on medical management. Chest. 1995;108(5):1297-1302. doi:10.1378/chest.108.5.1297 - DOI - PubMed
    1. Infectious Diseases Society of America; US Centers for Disease Control and Prevention . Remdesivir Quick Point-of-Care Reference. COVID-19 Real-Time Learning Network. Updated May 23, 2022. Accessed October 4, 2021. https://www.idsociety.org/globalassets/covid-19-real-time-learning-netwo...
    1. Infectious Diseases Society of America; US Centers for Disease Control and Prevention . Immunomodulators. COVID-19 Real-Time Learning Network. Accessed October 4, 2021. https://www.idsociety.org/covid-19-real-time-learning-network/therapeuti...
    1. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240 - DOI - PMC - PubMed
    1. Valbuena VSM, Barbaro RP, Claar D, et al. . Racial bias in pulse oximetry measurement among patients about to undergo extracorporeal membrane oxygenation in 2019-2020: a retrospective cohort study. Chest. 2022;161(4):971-978. doi:10.1016/j.chest.2021.09.025 - DOI - PMC - PubMed

Publication types