Society of Hospital Medicine – Adult Hospital Medicine
View all recommendations from this societyReleased May 27, 2022
Don’t maintain a peripheral capillary oxygen saturation (SpO2) of higher than 96% when using supplemental oxygen, unless for carbon monoxide poisoning, cluster headaches, sickle cell crisis, or pneumothorax.
Ideal oxygen saturation levels for patients getting supplemental oxygen therapy is at or below 96%. The overuse of supplemental oxygen has been shown to increase mortality in numerous studies of patients with a variety of critical illnesses, including cardiac arrest, stroke, and trauma, as well as following emergency surgery. Higher oxygen levels may be needed for those with certain medical conditions such as carbon monoxide poisoning, special types of headaches like cluster headaches, sickle cell crisis, or pneumothorax. An important caveat to this recommendation is the higher incidence of occult hypoxemia, defined as an arterial oxygen saturation of less than 88% with a pulse oximetry measurement of 92 to 96%, in black patients compared to white patients.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
(1–5)
The Society of Hospital Medicine (SHM) created a Choosing Wisely® subcommittee comprised of representatives of the Hospital Quality and Patient Safety committee and included diverse representation of academic, community and adult hospitalists. SHM committee members submitted 150 recommendations for consideration, which were discussed for frequency of occurrence, the uniqueness of the tests and treatments and whether the cost burden for a specific test or treatment proved to be significant, narrowing the list to 65 items. The Choosing Wisely subcommittee ranked these items and a survey was sent to all SHM members to arrive at 11 recommendations, of which the final five were determined utilizing the Delphi method. SHM’s Board approved the final recommendations.
(6–11)
These recommendations were created by the SHM Hospital Quality and Patient Safety Committee’s High Value Care Sub-Committee (HVCC).
Phase 1: Crowdsourcing and Brainstorming – An online questionnaire requesting examples of low-value care in adult hospital medicine was sent to the SHM listserv, along with ABIM Foundation and affiliated social media outlets. All examples of low-value care from the questionnaire were compiled, edited, counted, and categorized into 5 domains: laboratory, imaging, medication, diagnostics and other. Duplicate or similar recommendations were also taken into account. Recommendations in the previous SHM CW Top 5 list were removed. All items with 10 or more mentions were taken into the next phase in an effort to capture the most prominent themes.
Phase 2: Literature Search and Developing Recommendations – All items brought into this phase were individually reviewed and discussed through an iterative process. Items were divided among HVCC members, and a literature search was performed in the PubMed database. Focused recommendations were developed and presented to the committee for review. Items that were duplicative or had insufficient evidence to support the recommendation were removed, leaving 22 items.
Phase 3: Modified Delphi Voting – For the remaining recommendations, a Delphi scoring process was utilized to reach consensus among clinicians and patient advocates. A total of 7 HVCC members and 7 patient advocates voted on the recommendations.
For each recommendation on the voting survey, clinician respondents were asked to rate on a 1-5 Likert scale on three criteria: (1) strength of evidence, (2) potential for avoiding patient harm, and (3) relevance to hospital medicine. Patient advocates were asked to rate each recommendation based on the same Likert scale on a slightly different criteria: (1) strength of evidence, (2) potential for avoiding patient harm, and (3) relevance to patients.
SHM’s disclosure and conflict of interest policy can be found at www.hospitalmedicine.org/industry.
Sources
Chu DK, Kim LH, Young PJ et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. 2018 Apr 28;391(10131):1693-1705
Sjoding MW DR, Iwashyna TJ et al. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240.
