Cardiorespiratory and Pulse Oximetry Monitoring in Hospitalized Children: A Delphi Process

Abstract

OBJECTIVES: Cardiorespiratory and pulse oximetry monitoring in children who are hospitalized should balance benefits of detecting deterioration with potential harms of alarm fatigue. We developed recommendations for monitoring outside the ICU on the basis of available evidence and expert opinion. METHODS:We conducted a comprehensive literature search for studies addressing the utility of cardiorespiratory and pulse oximetry monitoring in common pediatric conditions and drafted candidate monitoring recommendations based on our findings. We convened a panel of nominees from national professional organizations with diverse expertise: nursing, medicine, respiratory therapy, biomedical engineering, and family advocacy. Using the RAND/University of California, Los Angeles Appropriateness Method, panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting. RESULTS:The panel evaluated 56 recommendations for intermittent and continuous monitoring for children hospitalized outside the ICU with 7 common conditions (eg, asthma, croup) and/or receiving common therapies (eg, supplemental oxygen, intravenous opioids). The panel reached agreement on the appropriateness of monitoring recommendations for 55 of 56 indications and on necessity of monitoring for 52. For mild or moderate asthma, croup, pneumonia, and bronchiolitis, the panel recommended intermittent vital sign or oximetry measurement only. The panel recommended continuous monitoring for severe disease in each respiratory condition as well as for a new or increased dose of intravenous opiate or benzodiazepine.CONCLUSIONS: Expert panel members agreed that intermittent vital sign assessment, rather than continuous monitoring, is appropriate management for a set of specific conditions of mild or moderate severity that require hospitalization.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

“…Delphi processes are designed to incorporate expert opinion over a series of structured anonymous ratings [31][32][33] and are commonly used when evidence is sparse, low quality, or conflicting, as is often encountered in pediatrics. 3,[34][35][36][37][38]…”

Improving Value in Bronchiolitis Care

“…The revised 2014 AAP guidelines that formed the scientific premise for the analysis by House and colleagues 2 were noteworthy on this front given the recommendation to avoid continuous pulse oximetry (CPOX) in patients not receiving oxygen. This recommendation is similar to the 2013 Choosing Wisely recommendation, 1 and later, the 2020 Best Evidence for Effective Monitoring Practice (BEEP) guidelines, 6 making CPOX an opportune target for deimplementation. Although we do not have any data on temporal trends in CPOX use, a recent study suggests that the practice is still common and remarkably variable across hospitals.…”

Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis

“…Educational outreach started before audit and feedback, then continued at a frequency determined by the site principal investigator based on study site needs. Education included 3 components: national guidelines for cSp o 2 monitoring in patients with bronchiolitis, 2 , 3 , 4 evidence supporting intermittent pulse oximetry rather than cSp o 2 monitoring, and their hospital’s baseline cSp o 2 use 10 (eFigure 1 in Supplement 2 ). Site principal investigators tailored non–core content (eg, logos and location-specific context) and the setting of sessions.…”

“… 21 We also measured perceived safety of intermittently spot-checking oxygen saturation instead of using cSp o 2 . To estimate penetration 24 of guideline-concordant care 2 , 3 , 4 of patients with bronchiolitis not receiving supplemental oxygen, we assessed the change in cSp o 2 use between the baseline 10 and intervention periods.…”

“… 1 Bronchiolitis is a self-limited viral illness with a well-documented clinical course and national evidence-based practice guidelines. 2 , 3 , 4 In addition to management recommendations, guidelines advise against continuous pulse oximetry monitoring (cSp o 2 ) for patients who are not receiving supplemental oxygen, as it increases health care use without improving outcomes. 2 , 3 , 5 , 6 , 7 , 8 , 9 Although none of the guidelines that discourage cSp o 2 explicitly define it, we consider any use of pulse oximetry beyond a spot check (an in-person assessment of the oxygen saturation, with the probe applied and removed by staff during a single visit to the patient’s room) to represent continuous measurement.…”