Every winter, doctors put sick babies on a continuous oxygen monitor that alerts clinicians if a particular type of respiratory infection is worsening. But a growing body of research shows the monitoring actually doesn't carry a lot of evidence, and can actually cause unnecessary alarm fatigue and rack up hospital charges.
A team of researchers from the Children's Hospital of Philadelphia will soon embark upon a multi-year clinical trial to see if they can reduce that monitoring, and potentially reduce infant harm. The National Heart, Lung, and Blood Institute recently gave the effort a $5.3 million grant for what's called a deimplementation study.
"There are certain things we do in medicine that we do too much of, that are not supported by science," said Chris Bonafide, an attending physician and a faculty member at the Center for Pediatric Clinical Effectiveness at CHOP. "There are plenty of medications that are life saving and incredible. But we don't give them to every patient. It's the same thing with pulse oximetry. We're dealing with one of those situations where the reason that it's appropriate to deimplement is because it really isn't adding value for the patient."
Bronchiolitis is the #1 cause of infant hospital visits, with about 100,000 admissions each year usually during the winter months. It's similar to a cold, but some babies can have trouble breathing or feeding. Standard treatment for the past 15 years in hospitals has included continuous pulse oximetry, which monitors oxygen levels.
But, in 2014, the American Academy of Pediatrics told doctors that they don't need to use this monitoring for babies with lower respiratory tract infections, because there's not a strong connection between how much oxygen is in the blood and if an infection is worsening. The Choosing Wisely campaign from the ABIM Foundation in 2013 recommended against continuous pulse oximetry in children with acute respiratory illness unless they're on supplemental oxygen and need to keep levels in check.
So why do hospitals continue the practice?
"It's hard to let go of certain practices once they become part of the culture," Bonafide said. "It becomes, 'the way we do things,' and even when you strictly teach them to not do something, it becomes harder to pry those practices away."
Multiple studies have shown that in stabilized babies that don't need extra oxygen, the practice can lead to longer inpatient days, and an increased risk of harm because of that longer hospital stay.
"Because technology is imperfect, when you have a young toddler who's moving around a lot, there are a lot of false alarms, and when you get a false alarm, the tech might lead you to believe that the patient has a lower oxygen level than is accurate," Bonafide said. "Which might lead us to say, 'We should keep this baby in the hospital one more night to make sure. And the longer you're in the hospital, the more at risk you are of unnecessary harm, like from an IV infection."
In addition, because alarms can can often go off, staff end up seeing them as not important, which can lead to ignoring warning sounds.
But use persists, and in some hospitals, up to 96% of infants undergo this monitoring. In a study from CHOP and the University of Pennsylvania in April 2020 of more than 3,000 patients from 56 hospitals, use ranged from 2% to almost 100% of pediatric patients. The middle and most common use was around 46% of patients. Adult hospitals that had internal pediatric departments were most likely to have higher uses of the continuous monitoring.
The trial will involve more than 40 hospitals and will span three winters—when most cases of the respiratory infection occur. Researchers will look at how much overuse is occurring at each individual hospital, and then start an educational outreach campaign, followed by testing different electronic health record decision support models. Eventually hospitals will be evaluated on what decreases they saw, and researchers will pull best practices.
Bonafide and the team at CHOP will provide clinicians with ongoing feedback on how they're performing with data from other hospitals. Their goal, Bonafide said, is to provide enough evidence that the monitoring is harmful that the practice will end at hospitals across the country.