Clearing the Air to Reduce Hospital Stays
As Amanda Schondelmeyer, MD, searched for a quality improvement project at her new fellowship in early 2013, the Society of Hospital Medicine (SHM) released its recommendations for Pediatric Hospital Medicine as part of the Choosing Wisely campaign.
One recommendation in particular—Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen—resonated with Dr. Schondelmeyer and her colleagues in the Department of Pediatrics at Cincinnati Children’s Hospital Medical Center.
Prior to the recommendation, Dr. Schondelmeyer said use of continuous pulse oximetry to monitor blood oxygen levels in children with respiratory illnesses varied greatly—and kept some patients in the hospital longer than necessary.
“Nurses and physicians had their own rules on when it was OK to stop monitoring,” Dr. Schondelmeyer said. “Some people would wait six hours, and others would wait 24 hours. It’s really hard to improve a practice if it’s not standard.”
SHM’s Choosing Wisely recommendation served as the inspiration for Dr. Schondelmeyer’s quality improvement project, which also aligned with local guidelines to use intermittent pulse oximetry for patients with asthma and bronchiolitis outside of the intensive care unit setting who are on room air.
She shared evidence that continuous pulse oximetry did not add value for some patients with colleagues, including other hospitalists and nurses, and they worked together to develop criteria on when to discontinue monitoring. To determine the impact of the new criteria, data about continuous pulse oximetry was collected from electronic health records, vital signs and nursing documentation beginning in July 2013.
The intervention, which involved incorporating the criteria into nurse handoffs and ordering sets, started about a month later and yielded positive results.
“We reduced median time per patient on continuous pulse oximetry by about seven hours,” Dr. Schondelmeyer said. “We sustained that for a year now. I met the most success when I was on the floor talking to the nurses. You really have to know the process well to make it better.”
Dr. Schondelmeyer said she received interest about implementing the Choosing Wisely recommendation when she presented her project during the 2014 Pediatric Hospital Medicine Conference. Earlier this year, she was named the grand-prize winner in the pediatric category of the Society of Hospital Medicine’s Choosing Wisely Case Study Competition. In March, her research was published in Pediatrics.
As Dr. Schondelmeyer and her team continue to monitor pulse oximetry use, they’re considering looking into the use of heart rate and respiratory rate monitors to determine whether or not they consistently add value to patient care.
“Choosing Wisely galvanized our team and inspired a conversation on care we thought might be unneeded,” Dr. Schondelmeyer said. “We have a lot of enthusiastic support to get things implemented.”