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Pulse oximetry adoption and oxygen orders at paediatric admission over 7 years in Kenya: a multihospital
Timothy Tuti1, Jalemba Aluvaala2,3, Samuel Akech2
1Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya TTuti@kemri-wellcome.org.
Insights
Pulse oximetry adoption in low-income countries is slow and variable, often influenced by factors other than hypoxemia. Improving access requires long-term strategies for guideline adherence and impact assessment.
Area of Science:
- Global Health
- Pediatric Critical Care
- Health Systems Strengthening
Background:
- Pulse oximetry is crucial for assessing hypoxemia in children with severe illness, as recommended by international guidelines.
- Adoption and effective utilization of pulse oximetry and oxygen therapy in low- and middle-income countries (LMICs) remain significant challenges.
- Understanding factors influencing the use of these essential tools is critical for improving pediatric care in resource-limited settings.
Purpose of the Study:
- To characterize the adoption trends of pulse oximetry and oxygen use in Kenyan public hospitals.
- To identify clinical and patient factors influencing pulse oximetry and oxygen utilization over time.
- To provide actionable insights for programs aimed at enhancing access to pulse oximetry and oxygen in LMICs.
Main Methods:
- A retrospective cohort study was conducted using data from 132,737 pediatric admissions across 18 hospitals in Kenya between March 2014 and December 2020.
- Growth-curve modeling was employed to analyze the association of patient and hospital factors with pulse oximetry use and oxygen prescription.
- Key outcomes included the proportion of admissions with pulse oximetry measurement and oxygen prescription, and the presence of hypoxemia (SpO2 <90%).
Main Results:
- Pulse oximetry was used in 48.8% of admissions, with adoption rates increasing over time within the Clinical Information Network (CIN).
- Hospital-level factors significantly influenced adoption patterns, indicating variability in implementation.
- Oxygen was prescribed in 8.6% of cases, often without documented pulse oximetry or confirmed hypoxemia; respiratory symptoms were associated with oxygen use, irrespective of hypoxemia.
- Hypoxemia (SpO2 <90%) was present in 7% of patients who underwent pulse oximetry measurement.
Conclusions:
- The slow and erratic adoption of pulse oximetry highlights systemic and organizational weaknesses in healthcare delivery in LMICs.
- Oxygen prescription decisions frequently appear driven by clinical presentation rather than objective hypoxemia measurement.
- Successful implementation of pulse oximetry and oxygen systems necessitates long-term strategic planning, robust guideline development, consistent adherence, and ongoing impact evaluation.
Objectives:
To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen.
Design:
A multihospital retrospective cohort study.
Settings:
All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020.
Outcomes:
Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors.
Results:
Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia.
Conclusion:
The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.
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