Sanjay Mahant1,2,3, Gita Wahi4, Ann Bayliss1,5, Lucy Giglia4, Ronik Kanani1,6, Catherine M Pound7, Mahmoud Sakran8,9, Natascha Kozlowski9, Karen Breen-Reid10, Dana Arafeh3, Myla E Moretti2,3,11, Amisha Agarwal12, Nick Barrowman12, Andrew R Willan11,13, Suzanne Schuh1,3, Patricia C Parkin1,2,3. 1. Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. 2. Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. 3. Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada. 4. Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada. 5. Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada. 6. North York General Hospital, Toronto, Ontario, Canada. 7. Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada. 8. Department of Pediatrics, Queens University, Kingston, Ontario, Canada. 9. Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada. 10. Learning Institute, Hospital for Sick Children and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada. 11. Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada. 12. Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada. 13. Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
Abstract
Importance: There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis. Objective: To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes. Design, Setting, and Participants: This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada. Interventions: Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher. Main Outcomes and Measures: The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction. Results: Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, -1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001). Conclusions and Relevance: In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis. Trial Registration: ClinicalTrials.gov Identifier: NCT02947204.
Importance: There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis. Objective: To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes. Design, Setting, and Participants: This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada. Interventions: Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher. Main Outcomes and Measures: The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction. Results: Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, -1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001). Conclusions and Relevance: In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis. Trial Registration: ClinicalTrials.gov Identifier: NCT02947204.
Authors: Christopher P Bonafide; Rui Xiao; Amanda C Schondelmeyer; Amy R Pettit; Patrick W Brady; Christopher P Landrigan; Courtney Benjamin Wolk; Zuleyha Cidav; Halley Ruppel; Naveen Muthu; Nathaniel J Williams; Enrique Schisterman; Canita R Brent; Kimberly Albanowski; Rinad S Beidas Journal: Implement Sci Date: 2022-10-21 Impact factor: 7.960
Authors: Peter J Gill; Mohammed Rashidul Anwar; Thaksha Thavam; Matt Hall; Jonathan Rodean; Sunitha V Kaiser; Rajendu Srivastava; Ron Keren; Sanjay Mahant Journal: JAMA Netw Open Date: 2021-07-01