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Intermittent pulse oximetry sufficient for infants with stable bronchiolitis

JAMA Pediatrics
Reuters Health - 01/03/2021 - For hospitalized infants with stable bronchiolitis, continuous pulse oximetry may not be better than intermittent monitoring, a new study suggests.

The analysis was based on data from 229 infants hospitalized for stabilized bronchiolitis with and without hypoxia who had been randomized to receive either continuous or intermittent pulse oximetry, and revealed no significant differences in safety or length of hospital stay between the two groups, according to the report published in JAMA Pediatrics.

"We found that no important differences between intermittent and continuous monitoring with respect to length of hospital stay, patient safety and parent reported outcomes, such as anxiety and days missed from work," said the study's lead author, Dr. Sanjay Mahant, a professor in the department of pediatrics and the Institute for Health Policy, Management and Evaluation at the University of Toronto and an associate research scientist at the Hospital for Sick Children. "Thus, 'doing more' (continuous monitoring) doesn't add value to the care."

Some practitioners and parents prefer continuous monitoring because they fear that intermittent monitoring will delay the detection of hypoxia and compromise patient safety, Dr. Mahant said in an email. "Our results do not support this fear," he added.

The benefits of intermittent monitoring are many, Dr. Mahant said. For example, nurses' workload is lighter because of fewer oximeter alarms and patient safety is enhanced because of reduced alarm fatigue, he added.

It's important to recognize that infants recovering from bronchiolitis often experience transient desaturations that are of little clinical importance, "so continuous monitoring does not add value," Dr. Mahant said. Moreover, "intermittent monitoring is better aligned with the parent and child hospital-to-home transition preparation."

To take a closer look at whether continuous oximetry was a better option than intermittent monitoring, Dr. Mahant and his colleagues ran a six-center parallel group randomized clinical trial between November 1, 2016 and May 31, 2019.

The study was conducted by the Canadian Pediatric Research Network and included general pediatric inpatient units at three children's hospital and three community hospitals. Data were deidentified.

Of the 229 infants, 136 (59.4%) were male, with a median age of 4 months when they were enrolled in the study. One hundred of the infants received supplemental oxygen before randomization on the inpatient unit and 34 (14.8%) were receiving supplemental oxygen at randomization. The median time from inpatient unit admission to randomization was 16.4 hours.

Except for gender, the baseline characteristics of the infants were similar between the two groups, including the number receiving supplemental oxygen, feeding adequacy, and time from inpatient unit admission to randomization.

The median length of hospital stay from randomization to discharge was 27.6 hours in the intermittent group and 25.4 hours in the continuous group. Gender adjusted analysis that included hospital site as a stratification variable did not show a statistically significant difference in the hazard of discharge between the two groups.

Fewer infants in the intermittent group had oxygen supplementation initiated after randomization than in the continuous group. The need for ICU transfer was similar between the two groups: one out of 114 in the intermittent group and two out of 114 in the continuous group.

Parent anxiety score during hospitalization, frequency of unscheduled visits to a physician within 15 days of discharge and median workdays missed by parents did not significantly differ between the two groups.

Nurse satisfaction with the monitoring strategy assigned to their patient was measured on each of 10 workdays using a 0-10 scale, with 10 indicating complete satisfaction. Mean nursing satisfaction score was significantly greater (mean difference 1.5) in the intermittent (8.6 out of 10 days) than the continuous group (7.1 out of 10 days), the study found.

Dr. Laura Nell Hodo applauded the researchers for performing a randomized controlled trial.

Whether the study leads to changes in practice remains to be seen, said Dr. Hodo, an assistant professor of pediatrics at the Icahn School of Medicine at Mount Sinai and a pediatric hospitalist at the Mount Sinai Kravis Children's Hospital in New York City. "Stopping people from doing something they've been doing for a long time may involve a ton of work and require a lot of resources," she said.

A drawback of the study is that the children had been in the hospital for 16 hours on average before randomization, Dr. Hodo said. "For the population they are studying on the timeline they are studying, it's a really great study," she added. "But they're not looking at infants immediately on admission so I don't think it answers the question of which unit a baby should be admitted to - one that continuously monitors or one that doesn't. Maybe the next step would be to do a study looking at children starting at admission," she said.

"One thing that is really great and that I love is that they did surveys of the nurses and they looked at how much time families missed at work," Dr. Hodo said. "Medical studies that involve families' experiences and those of the multidisciplinary team are not common. There should probably be more."

SOURCE: https://bit.ly/3b3kpQz and https://bit.ly/3dXesGy JAMA Pediatrics, online March 1, 2021.

By Linda Carroll

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