Health professionals' views of newborn pulse oximetry screening in a midwifery-led maternity setting. "It's a good thing to do, but fund it!"

OBJECTIVE: To understand from health professionals who care for newborns their views on the introduction of pulse oximetry screening for the detection of hypoxaemia in a midwifery-led maternity setting. Although oximetry screening for newborns is internationally accepted, national screening is not yet introduced in New Zealand. In this context, we drew on maternity carers' reflections during a feasibility study of oximetry screening to provide perspectives on barriers and enablers to universal screening. METHODS: Data were generated from nine focus groups during five months of 2018 in two north island regions of New Zealand. Participants' (n = 45) opinions about the use of oximetry screening in newborns were analysed thematically using an inductive approach. FINDINGS: Overall, participants stated pulse oximetry screening was easy to do, non-invasive, and worthwhile. Midwives were reassured by screening that provided evidence of either a healthy baby or a need for urgent review. From participants' reports, we identified three themes: (1) oximetry screening for newborns is reassuring, practical and worthwhile; (2) midwifery services workload expectations and under-resourcing will hinder universal screening, and (3) location of the baby at the time of screening could impede universal access. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives viewed implementing a national pulse oximetry screening programme as sensible but problematic unless resourced and funded appropriately. Policymakers should view the concerns of midwives about human and physical resources as significant and account for the need to resource this screening programme appropriately as a priority before implementation.

I feel it in my finger: Measurement device affects cardiac interoceptive accuracy.

In recent years, measures of cardiac interoceptive accuracy have been heavily scrutinised. The focus has been on potentially confounding physiological and psychological factors; little research has examined whether the device used to record objective heartbeats may influence cardiac interoceptive accuracy. The present studies assessed whether the device employed influences heartbeat counting (HCT) accuracy and the location from which heartbeats are perceived. In Study One, participants completed the HCT using a hard-clip finger pulse oximeter, electrocardiogram (ECG) and a smartphone application. In Study Two, an ECG, hard-clip and soft-clip oximeter were compared. Moderate-strong correlations were observed across devices, however, mean HCT accuracy and confidence varied as a function of device. Increased sensation in the finger when using a hard-clip pulse oximeter was related to increased accuracy relative to ECG. Results suggest that the device employed can influence HCT performance, and argue against comparing, or combining, scores obtained using different devices.

Effects of divided attention and operating room noise on perception of pulse oximeter pitch changes: a laboratory study.

BACKGROUND: Anesthesiology requires performing visually oriented procedures while monitoring auditory information about a patient's vital signs. A concern in operating room environments is the amount of competing information and the effects that divided attention has on patient monitoring, such as detecting auditory changes in arterial oxygen saturation via pulse oximetry. METHODS: The authors measured the impact of visual attentional load and auditory background noise on the ability of anesthesia residents to monitor the pulse oximeter auditory display in a laboratory setting. Accuracies and response times were recorded reflecting anesthesiologists' abilities to detect changes in oxygen saturation across three levels of visual attention in quiet and with noise. RESULTS: Results show that visual attentional load substantially affects the ability to detect changes in oxygen saturation concentrations conveyed by auditory cues signaling 99 and 98% saturation. These effects are compounded by auditory noise, up to a 17% decline in performance. These deficits are seen in the ability to accurately detect a change in oxygen saturation and in speed of response. CONCLUSIONS: Most anesthesia accidents are initiated by small errors that cascade into serious events. Lack of monitor vigilance and inattention are two of the more commonly cited factors. Reducing such errors is thus a priority for improving patient safety. Specifically, efforts to reduce distractors and decrease background noise should be considered during induction and emergence, periods of especially high risk, when anesthesiologists has to attend to many tasks and are thus susceptible to error.

Pulse oximetry as a screening test for congenital heart defects in newborn infants: a test accuracy study with evaluation of acceptability and cost-effectiveness.

BACKGROUND: Screening for congenital heart defects (CHDs) relies on antenatal ultrasound and postnatal clinical examination; however, life-threatening defects often go undetected. OBJECTIVE: To determine the accuracy, acceptability and cost-effectiveness of pulse oximetry as a screening test for CHDs in newborn infants. DESIGN: A test accuracy study determined the accuracy of pulse oximetry. Acceptability of testing to parents was evaluated through a questionnaire, and to staff through focus groups. A decision-analytic model was constructed to assess cost-effectiveness. SETTING: Six UK maternity units. PARTICIPANTS: These were 20,055 asymptomatic newborns at ≥ 35 weeks' gestation, their mothers and health-care staff. INTERVENTIONS: Pulse oximetry was performed prior to discharge from hospital and the results of this index test were compared with a composite reference standard (echocardiography, clinical follow-up and follow-up through interrogation of clinical databases). MAIN OUTCOME MEASURES: Detection of major CHDs - defined as causing death or requiring invasive intervention up to 12 months of age (subdivided into critical CHDs causing death or intervention before 28 days, and serious CHDs causing death or intervention between 1 and 12 months of age); acceptability of testing to parents and staff; and the cost-effectiveness in terms of cost per timely diagnosis. RESULTS: Fifty-three of the 20,055 babies screened had a major CHD (24 critical and 29 serious), a prevalence of 2.6 per 1000 live births. Pulse oximetry had a sensitivity of 75.0% [95% confidence interval (CI) 53.3% to 90.2%] for critical cases and 49.1% (95% CI 35.1% to 63.2%) for all major CHDs. When 23 cases were excluded, in which a CHD was already suspected following antenatal ultrasound, pulse oximetry had a sensitivity of 58.3% (95% CI 27.7% to 84.8%) for critical cases (12 babies) and 28.6% (95% CI 14.6% to 46.3%) for all major CHDs (35 babies). False-positive (FP) results occurred in 1 in 119 babies (0.84%) without major CHDs (specificity 99.2%, 95% CI 99.0% to 99.3%). However, of the 169 FPs, there were six cases of significant but not major CHDs and 40 cases of respiratory or infective illness requiring medical intervention. The prevalence of major CHDs in babies with normal pulse oximetry was 1.4 (95% CI 0.9 to 2.0) per 1000 live births, as 27 babies with major CHDs (6 critical and 21 serious) were missed. Parent and staff participants were predominantly satisfied with screening, perceiving it as an important test to detect ill babies. There was no evidence that mothers given FP results were more anxious after participating than those given true-negative results, although they were less satisfied with the test. White British/Irish mothers were more likely to participate in the study, and were less anxious and more satisfied than those of other ethnicities. The incremental cost-effectiveness ratio of pulse oximetry plus clinical examination compared with examination alone is approximately £24,900 per timely diagnosis in a population in which antenatal screening for CHDs already exists. CONCLUSIONS: Pulse oximetry is a simple, safe, feasible test that is acceptable to parents and staff and adds value to existing screening. It is likely to identify cases of critical CHDs that would otherwise go undetected. It is also likely to be cost-effective given current acceptable thresholds. The detection of other pathologies, such as significant CHDs and respiratory and infective illnesses, is an additional advantage. Other pulse oximetry techniques, such as perfusion index, may enhance detection of aortic obstructive lesions. FUNDING: The National Institute for Health Research Health Technology programme.

Maternal perceptions of labor with fetal monitoring by pulse oximetry in a research setting.

OBJECTIVE: Little research has evaluated maternal experience with fetal pulse oximetry for fetal surveillance. The purpose of this study was to compare maternal perceptions of labor with intrapartal cardiotocography with or without fetal pulse oximetry in a research setting. METHODS: One hundred women with vaginal, vertex deliveries and uncomplicated fetal outcomes were enrolled. The study group was a subset of 50 mothers who had participated in a pulse oximetry trial. The control group of 50 mothers was monitored by cardiotocography only. Both groups were matched for age, parity, weeks of gestation, epidural anesthesia use, and duration of labor. A global measure of maternal perception of labor was established by experience with labor, general attitude toward monitoring devices, satisfaction with monitoring, nursing and medical care, and anxiety, each of which was evaluated separately. The mothers in the study group were also interviewed about aspects related to the fetal pulse oximetry research setting, such as information, movement restriction, discomfort, care, privacy, and safety. The questionnaires were based on a standardized rating scale model, and the interviews were conducted two to four days after delivery. The results were analyzed by chi-squared, paired t test, and ANOVA. RESULTS: No significant differences were observed between the study and control participants in any parameter concerning the maternal perception of labor. Mothers' experiences with pulse oximetry as assessed by interview was overwhelmingly positive. CONCLUSIONS: Fetal monitoring by pulse oximetry in a research setting did not affect maternal perceptions of labor. Mothers' experiences with pulse oximetry were highly positive, suggesting that research in fetal pulse oximetry need not compromise maternal perceptions of labor.

Stability of women's perceptions of fetal intrapartum oximetry.

We have previously reported women's perceptions of their experience with fetal intrapartum oxygen saturation monitoring and participation in a research project, assessed within a few days of delivery when the "halo effect' may have influenced responses. To determine whether women's perceptions had changed over time, we sent a second, identical questionnaire to the 49 women in the original sample who had delivered 3-12 months previously. Thirty-eight questionnaires were returned. Wilcoxon signed rank sum test was used to compare the ratings. Women's responses to the first and second questionnaire were not significantly different. Written comments were provided by 23 (61%) of the women. This stability of women's perceptions over time suggests that the original practice of surveying within a few days of delivery accurately reflects women's evaluation of their experience with the research project.