Spot checks suffice for monitoring pediatric bronchiolitis

NEW ORLEANS – Intermittent spot checks are as safe as continuous pulse oximetry monitoring in children hospitalized with bronchiolitis, according to interim results from an ongoing randomized controlled trial.

Among 104 patients, the average length of stay was 1.9 days with intermittent monitoring and 2.0 days with continuous monitoring (P = .98).

There was no difference in ICU admissions and no deaths, Dr. Russell McCulloh said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

The Choosing Wisely campaign recommends against continuous pulse oximetry use in otherwise healthy children hospitalized with bronchiolitis. Still, a variety of monitoring strategies exist for pulse oximetry in hospitalized patients, with rates of hospitalization more than tripling after institutionalization of pulse oximetry in emergency departments. Prior studies have also shown that pulse oximetry increases readmission rates and may prolong time to discharge, he said.

Dr. McCulloh and his associates in Rhode Island, Texas, and Missouri sequentially and separately randomized 104 patients within 24 hours of floor admission to continuous monitoring with a pulse oximeter in place, regardless of oxygen saturation status, or to intermittent monitoring with scheduled nursing vital signs checks every 4 hours, supplemental oxygen and continuous monitoring if blood oxygen saturation was consistently below 90%, and a return to spot checks once the patient was weaned from oxygen. Pulse oximetry was monitored at the bedside, not centrally.

The intermittent and continuous monitoring groups had similar rates of utilization of diagnostic tests including chest x-rays (58% vs. 48%, respectively), multiplex viral testing (34.6% vs. 46.2%), rapid respiratory syncytial virus testing (25% vs. 29%), and blood cultures (29% vs. 25%), said Dr McCulloh, who started the study while an infectious disease fellow at Rhode Island Hospital in Providence and is now with Children’s Mercy Hospital in Kansas City, Mo.

Therapeutic measures were also similar in the two groups, including use of IV fluids (65.4% intermittent vs. 73% continuous), supplemental oxygen (33% vs. 36.5%), bronchodilators (88.5% vs. 90.4%), and antibiotics (21.2% vs. 17.3%).

Children monitored continuously incurred no additional health care costs compared with those intermittently monitored, Dr. McCulloh said at the meeting, cosponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The average cost of all diagnostic testing, including pulse oximetry monitoring, was similar: $203.80 for continuous monitoring and $179.80 for intermittent monitoring (P = .19). The lack of a significant difference is not surprising since the children didn’t enter the study until after they were admitted to the hospital, and much of the diagnostic testing occurs in the emergency department and not on the hospital floor, he said in an interview.

Dr. McCulloh observed that parental acceptance of the monitoring strategy varied by patient age. Parents of younger children were happier with continuous monitoring, while those with older children were more comfortable with intermittent spot checks.

At baseline, children monitored intermittently were significantly older (6.6 months vs. 3.5 months), more likely to have otitis media on admission (23% vs. 7.7%), and less likely to be admitted by a hospitalist (44.2% vs. 65%). A family history of wheeze was similar in both groups (54% vs. 40.4%), as was tobacco exposure (31% vs. 25%).

Among staff, experience played a key role in monitoring adherence and acceptance.

"We tended to have newer nurses coming on to the floor who were very uncomfortable with children of any age going onto the intermittent arm," Dr. McCulloh said. "Most of the older nurses were like, ‘Of course.’

"We’re not talking about not doing cardiac apnea monitoring if someone wants to do that; we’re just saying don’t do continuous monitoring."

Random checks on the floor and outreach with respiratory and nursing staff helped maximize adherence, he noted.

The study is expanding to include Children’s Mercy Hospital, with a goal of 266 patients and completion anticipated in spring 2014.

Dr. McCulloh reported that the study is supported by a Thrasher Research Fund Early Career Award.

[email protected]

NEW ORLEANS – Intermittent spot checks are as safe as continuous pulse oximetry monitoring in children hospitalized with bronchiolitis, according to interim results from an ongoing randomized controlled trial.

Among 104 patients, the average length of stay was 1.9 days with intermittent monitoring and 2.0 days with continuous monitoring (P = .98).

There was no difference in ICU admissions and no deaths, Dr. Russell McCulloh said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

The Choosing Wisely campaign recommends against continuous pulse oximetry use in otherwise healthy children hospitalized with bronchiolitis. Still, a variety of monitoring strategies exist for pulse oximetry in hospitalized patients, with rates of hospitalization more than tripling after institutionalization of pulse oximetry in emergency departments. Prior studies have also shown that pulse oximetry increases readmission rates and may prolong time to discharge, he said.

Dr. McCulloh and his associates in Rhode Island, Texas, and Missouri sequentially and separately randomized 104 patients within 24 hours of floor admission to continuous monitoring with a pulse oximeter in place, regardless of oxygen saturation status, or to intermittent monitoring with scheduled nursing vital signs checks every 4 hours, supplemental oxygen and continuous monitoring if blood oxygen saturation was consistently below 90%, and a return to spot checks once the patient was weaned from oxygen. Pulse oximetry was monitored at the bedside, not centrally.

The intermittent and continuous monitoring groups had similar rates of utilization of diagnostic tests including chest x-rays (58% vs. 48%, respectively), multiplex viral testing (34.6% vs. 46.2%), rapid respiratory syncytial virus testing (25% vs. 29%), and blood cultures (29% vs. 25%), said Dr McCulloh, who started the study while an infectious disease fellow at Rhode Island Hospital in Providence and is now with Children’s Mercy Hospital in Kansas City, Mo.

Therapeutic measures were also similar in the two groups, including use of IV fluids (65.4% intermittent vs. 73% continuous), supplemental oxygen (33% vs. 36.5%), bronchodilators (88.5% vs. 90.4%), and antibiotics (21.2% vs. 17.3%).

Children monitored continuously incurred no additional health care costs compared with those intermittently monitored, Dr. McCulloh said at the meeting, cosponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The average cost of all diagnostic testing, including pulse oximetry monitoring, was similar: $203.80 for continuous monitoring and $179.80 for intermittent monitoring (P = .19). The lack of a significant difference is not surprising since the children didn’t enter the study until after they were admitted to the hospital, and much of the diagnostic testing occurs in the emergency department and not on the hospital floor, he said in an interview.

Dr. McCulloh observed that parental acceptance of the monitoring strategy varied by patient age. Parents of younger children were happier with continuous monitoring, while those with older children were more comfortable with intermittent spot checks.

At baseline, children monitored intermittently were significantly older (6.6 months vs. 3.5 months), more likely to have otitis media on admission (23% vs. 7.7%), and less likely to be admitted by a hospitalist (44.2% vs. 65%). A family history of wheeze was similar in both groups (54% vs. 40.4%), as was tobacco exposure (31% vs. 25%).

Among staff, experience played a key role in monitoring adherence and acceptance.

"We tended to have newer nurses coming on to the floor who were very uncomfortable with children of any age going onto the intermittent arm," Dr. McCulloh said. "Most of the older nurses were like, ‘Of course.’

"We’re not talking about not doing cardiac apnea monitoring if someone wants to do that; we’re just saying don’t do continuous monitoring."

Random checks on the floor and outreach with respiratory and nursing staff helped maximize adherence, he noted.

The study is expanding to include Children’s Mercy Hospital, with a goal of 266 patients and completion anticipated in spring 2014.

Dr. McCulloh reported that the study is supported by a Thrasher Research Fund Early Career Award.

[email protected]

NEW ORLEANS – Intermittent spot checks are as safe as continuous pulse oximetry monitoring in children hospitalized with bronchiolitis, according to interim results from an ongoing randomized controlled trial.

Among 104 patients, the average length of stay was 1.9 days with intermittent monitoring and 2.0 days with continuous monitoring (P = .98).

There was no difference in ICU admissions and no deaths, Dr. Russell McCulloh said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

The Choosing Wisely campaign recommends against continuous pulse oximetry use in otherwise healthy children hospitalized with bronchiolitis. Still, a variety of monitoring strategies exist for pulse oximetry in hospitalized patients, with rates of hospitalization more than tripling after institutionalization of pulse oximetry in emergency departments. Prior studies have also shown that pulse oximetry increases readmission rates and may prolong time to discharge, he said.

Dr. McCulloh and his associates in Rhode Island, Texas, and Missouri sequentially and separately randomized 104 patients within 24 hours of floor admission to continuous monitoring with a pulse oximeter in place, regardless of oxygen saturation status, or to intermittent monitoring with scheduled nursing vital signs checks every 4 hours, supplemental oxygen and continuous monitoring if blood oxygen saturation was consistently below 90%, and a return to spot checks once the patient was weaned from oxygen. Pulse oximetry was monitored at the bedside, not centrally.

The intermittent and continuous monitoring groups had similar rates of utilization of diagnostic tests including chest x-rays (58% vs. 48%, respectively), multiplex viral testing (34.6% vs. 46.2%), rapid respiratory syncytial virus testing (25% vs. 29%), and blood cultures (29% vs. 25%), said Dr McCulloh, who started the study while an infectious disease fellow at Rhode Island Hospital in Providence and is now with Children’s Mercy Hospital in Kansas City, Mo.

Therapeutic measures were also similar in the two groups, including use of IV fluids (65.4% intermittent vs. 73% continuous), supplemental oxygen (33% vs. 36.5%), bronchodilators (88.5% vs. 90.4%), and antibiotics (21.2% vs. 17.3%).

Children monitored continuously incurred no additional health care costs compared with those intermittently monitored, Dr. McCulloh said at the meeting, cosponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The average cost of all diagnostic testing, including pulse oximetry monitoring, was similar: $203.80 for continuous monitoring and $179.80 for intermittent monitoring (P = .19). The lack of a significant difference is not surprising since the children didn’t enter the study until after they were admitted to the hospital, and much of the diagnostic testing occurs in the emergency department and not on the hospital floor, he said in an interview.

Dr. McCulloh observed that parental acceptance of the monitoring strategy varied by patient age. Parents of younger children were happier with continuous monitoring, while those with older children were more comfortable with intermittent spot checks.

At baseline, children monitored intermittently were significantly older (6.6 months vs. 3.5 months), more likely to have otitis media on admission (23% vs. 7.7%), and less likely to be admitted by a hospitalist (44.2% vs. 65%). A family history of wheeze was similar in both groups (54% vs. 40.4%), as was tobacco exposure (31% vs. 25%).

Among staff, experience played a key role in monitoring adherence and acceptance.

"We tended to have newer nurses coming on to the floor who were very uncomfortable with children of any age going onto the intermittent arm," Dr. McCulloh said. "Most of the older nurses were like, ‘Of course.’

"We’re not talking about not doing cardiac apnea monitoring if someone wants to do that; we’re just saying don’t do continuous monitoring."

Random checks on the floor and outreach with respiratory and nursing staff helped maximize adherence, he noted.

The study is expanding to include Children’s Mercy Hospital, with a goal of 266 patients and completion anticipated in spring 2014.

Dr. McCulloh reported that the study is supported by a Thrasher Research Fund Early Career Award.

[email protected]