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What’s New in the Patient Safety World

August 2020

Pulse Oximetry in Children

Anything we can do to reduce the risk of alarm fatigue is welcome. The most obvious one we’ve discussed is eliminating unnecessary telemetry monitoring. But, perhaps the next most obvious one is reducing pulse oximetry alarms that are not clinically important.

Continuous pulse oximetry monitoring is commonly performed in hospitalized children. An expert panel, utilizing the best evidence in the literature plus their own experience, recently utilized a modified Delphi Method to evaluate the need for continuous vs. intermittent pulse oximetry monitoring in a variety of conditions in hospitalized children outside the ICU (Schondelmeyer 2020).

For children with mild or moderate asthma, croup, pneumonia, and bronchiolitis, the panel recommended intermittent vital sign or oximetry measurement only. For those with severe disease in each respiratory condition as well as for a new or increased dose of intravenous opiate or benzodiazepine, the panel recommended continuous monitoring.

Children receiving supplemental oxygen should have continuous oximetry monitoring, but they should be transitioned from continuous monitoring to intermittent monitoring within 1 hour of achieving stable oxygen saturation levels of at least 90%.

We’ve, of course, done many columns on the dangers of respiratory depression by opioids or sedating agents. The panel recommends that intravenous opioid or benzodiazepine therapy requires continuous cardiorespiratory and oximetry monitoring only when there is a new medication or an increased dose of a current medication. Intermittent monitoring is otherwise sufficient.

We’re not so sure about the latter recommendation. Hypoxemia is a relatively late manifestation of drug-induced respiratory depression. Hypercapnia occurs before there is a significant reduction in oxygen saturation in most instances. It’s probably more appropriate to be using capnography to monitor patients receiving drugs that may depress respiration, such as opioids and benzodiazepines. We’ve certainly seen patients become obtunded while they still had good oxygen saturations, even on continuous pulse oximetry monitoring. If capnography is not available in such circumstances, we’d still feel more comfortable using continuous rather than intermittent pulse oximetry.

The panel did acknowledge there is a relative dearth of high quality evidence in the literature, which consists primarily of observational study designs, and that there was little or no evidence for some of the respiratory conditions.

Overall, the panel recommended that intermittent vital sign assessment is appropriate for most mild-moderate forms of childhood respiratory illnesses. For patients weaned from oxygen, transitioning to intermittent oximetry within one hour is appropriate.

There’s no question these new guidelines would significantly reduce alarms on pediatric units and, thus, reduce the risk of alarm fatigue.

Some of our previous columns on opioid safety issues in children:

• September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
• March 2013 “Further Warning on Codeine in Children Following Tonsillectomy”
• May 2014 “Pediatric Codeine Prescriptions in the ER”
• November 2015 “FDA Safety Communication on Tramadol in Children”
• January 2016 “FDA Gets Even Tougher on Codeine in Kids”
• October 2016 “Another Codeine Warning for Children”
• May 2017 “FDA Finally Restricts Codeine in Kids; Tramadol, Too”
• February 2018 “FDA Warning on Cough Meds”

Prior Patient Safety Tips of the Week pertaining to alarm-related issues:

• March 5, 2007 “Disabled Alarms”
• March 26, 2007 “Alarms Should Point to the Problem”
• April 2, 2007 “More Alarm Issues”
• June 19, 2007 “Unintended Consequences of Technological Solutons”
• April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
• February 23, 2010 “Alarm Issues in the News Again”
• March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”
• March 16, 2010 “A Patient Safety Scavenger Hunt”
• November 2010 “Alarms in the Operating Room”
• February 22, 2011 “Rethinking Alarms”
• February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal”
• May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety”
• July 2, 2013 “Issues in Alarm Management”
• August 2013 “Joint Commission Formalizes 2014 NPSG on Alarm Management”
• February 4, 2014 “But What If the Battery Runs Low?”
• October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”
• December 15, 2015 “Vital Sign Monitoring at Night”
• February 9, 2016 “It was just a matter of time…”
• August 16, 2016 “How Is Your Alarm Management Initiative Going?”
• February 21, 2017 “Alarm Fatigue in the ED”
• April 18, 2017 “Alarm Response and Nurse Shift Duration”
• April 25, 2017 “Dialysis and Alarm Fatigue”
• October 17, 2017 “Progress on Alarm Management”
• November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
• May 1 2018 “Refrigerator Alarms”
• April 16, 2019 “AACN Practice Alert on Alarm Management”
• September 2019 “Alarm Fatigue in the Emergency Room”
• October 8, 2019 “Another Freezer Accident”
• June 23, 2020 “Telemetry Incidents”

Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:

• January 4, 2011 “Safer Use of PCA”
• July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
• May 12, 2009 “Errors With PCA Pumps”
• September 21, 2010 “Dilaudid Dangers”
• November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
• February 22, 2011 “Rethinking Alarms”
• May 17, 2011 “Opioid-Induced Respiratory Depression – Again!”
• September 6, 2011 “More Tips on PCA Safety”
• December 6, 2011 “Why You Need to Beware of Oxygen Therapy”

• February 21, 2012 “Improving PCA Safety with Capnography”

• September 2012 “Joint Commission Sentinel Event Alert on Opioids”
• September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
• July 3, 2012 “Recycling an Old Column: Dilaudid Dangers”
• February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
• February 19, 2013 “Practical Postoperative Pain Management”
• May 6, 2014 “Monitoring for Opioid-induced Sedation and Respiratory Depression”
• March 3, 2015 “Factors Related to Postoperative Respiratory Depression”
• June 2, 2015 “Reminders of Dilaudid Dangers”
• August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”
• August 18, 2015 “Missing Obstructive Sleep Apnea”
• December 2015 “Opioid Alert Fatigue”
• March 2016 “Guideline for Management of Postoperative Pain”
• June 14, 2016 “Nursing Monitoring of Patients on Opioids”
• October 11, 2016 “New Guideline on Preop Screening and Assessment for OSA”
• December 6, 2016 “Postoperative Pulmonary Complications”
• May 2017 “Another Twist in Opioid-Induced Respiratory Depression”
• June 2017 “Masterpiece: Monitoring for Opioid-Induced Respiratory Depression”
• June 20, 2017 “Dilaudid Dangers #4”
• October 3, 2017 “Respiratory Compromise: One Size Does Not Fit All”
• November 2017 “Bad Combination: Gabapentin and Opioids”
• November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
• July 31, 2018 “Surgery and the Opioid-Tolerant Patient”
• February 12, 2019 “2 ER Drug Studies: Reassurances and Reservations”
• March 2019 “Gabapentin and Pregabalin on the Radar Screen”
• June 18, 2019 “Found Dead in a Bed”
• January 2020 “FDA Warning on Gabapentinoids”
• January 2020 “Opioids and Apnea: Not Just Surgical Patients”

• Tools: PCA Pump Audit Tool and the PCA Pump Criteria

References:

Schondelmeyer AC, Dewan ML, Brady PW, et al. Cardiorespiratory and Pulse Oximetry Monitoring in Hospitalized Children: A Delphi Process. Pediatrics 2020; e20193336

https://pediatrics.aappublications.org/content/early/2020/07/15/peds.2019-3336

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