Pulse Oximetry Screening: UK Survey and BWH Experience

1. Pulse Oximetry Screening: UK Survey and BWH Experience Quad Network Study Day Anju Singh, SV Rasiah, Andy Ewer 29/11/2012

2. Neonatal pulse oximetry screening: a national survey. Kang et al. Arch Dis Child Fetal Neonatal Ed 2011;96:F312 7% routine use of pulse oximetry to supplement postnatal examination

3. Pulse oximetry screening for critical congenital heart defectsin asymptomatic newborn babies: a systematic review andmeta-analysis.Shakila Thangaratinam, Kiritrea Brown, Javier Zamora, Khalid S Khan, Andrew K Ewer Lancet. 2012 Jun 30;379(9835):2459-64. doi: 10.1016/S0140-6736(12)60107-X. Epub 2012 May 2 • 13 eligible studies • Sensitivity: 76.5% (95% CI 67·7–83·5) • Specificity: 99·9% (99·7–99·9) • False-positive rate of 0·14% (0·06–0·33) • False-positive rate for critical CHD • Before 24 h 0·50 [0·29–0·86] • After 24 h 0·05% [0·02–0·12] p=0·0017 Pulse oximetry is highly specifi c for detection of critical congenital heart defects with moderate sensitivity, that meets criteria for universal screening.

4. Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A • Who does the Routine Screening? • Who intends to do it? • Who doesn’t? • Anticipated Barriers?

5. Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A • 204/ 204 (100%) Units responded • Routine screening: 36 (18%) units • In process of introducing screening: 8 units • Considering routine screening: 111 (70%) units

6. Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A • Commonest Concerns • Resource issues: • Cost : 63% • Staff Time: 28% • Availability of Echocardiography: 25% • Staff Training: 24% • Lack of national and local guidelines: 36% • Excess False Positives: 10% • Delayed discharge: 5% • Cross infection: 3%

7. Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A • Reasons for units not considering screening (49 units) • Staffing: 57% • False Positives: 55% • Availability of echocardiography: 33% • Cost: 31% • Unconvinced by evidence: 22% • Adequate current screening methods: 18%

8. Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A • Threshold Saturation for positive test: 90-97% • 20/36: 95% • Postductal Saturations Only: 18 • Screening Time: • Before discharge: 55% • Within 48Hours: 4% • Before 24 hours: 13/14 • After 24 hours: 1

9. Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A Conclusion Shift of opinion of among UK Neonatologists regarding pulse oximetry screening with a significant majority now in favour, albeit with some reservations

10. The impact of pre- discharge pulse oximetry screening in a Regional Neonatal unit Singh A, Rasiah SV, Ewer A • To evaluate the impact of routine pulse oximetry screening on the rate of unexpected admissions and need for echocardiography. • To review the outcomes of babies admitted as a result of positive pulse oximetry screening.

11. Routine pre-discharge pulse oximetry screening at BWH • Pre and postductal Sats • Abnormal Test: <95% or a difference of >2% • Expedited Clinical Examination • Repeat Pulse Ox in 1-2 hrs • Test Positive • 2 abnormal pulse ox readings • 1 abnormal pulse ox reading + abnormal Clinical Exam

12. Methods • Retrospective review of all unexpected admissions to the unit • April’10 –March’12 • Review of • Indication for admission • Clinical diagnosis • Management • Outcome

13. CHD Classification Results • Total admissions: 2137 • Unexpected admissions: 1021 • Test positive pulse oximetry: 123 (12%) • Congenital heart lesions: • Critical CHD: 4 • Serious CHD: 1 • Significant CHD: 3 • Critical - HLHS, PA/IVS, TGA or IAA or dying and/or intervention in 1st month with CoA, AS, PS, ToF, PA/VSD or TAPVD • Serious – Requiring intervention in 1st year • Significant - Requiring FU > 6 mths or drug Rx

14. Other significant diagnosis • Congenital Pneumonia- ↑inflam markers ± +ve culture, X-Ray changes, O2 requirement, abs ≥ 5 days. • Sepsis - ↑ inflammatory markers ± culture +ve, abs ≥ 5 days • MAS – h/o meconium , respiratory distress, O2 requirement, X-Ray changes • TTN requiring oxygen: Tachypnoea with X-Ray changes of fluid retention, oxygen requirement, no rise in inflam markers or +ve culture • Congenital pneumonia: 33 • Sepsis: 17 • PPHN: 8 • MAS: 3 • TTN requiring oxygen: 21 • Hyperinsulinaemia: 1 • Pneumothorax: 1 • Depressed skull fracture: 1 • Early onset jaundice: 1

15. Results • Transitional circulation: 29 (23%) • No collapse in the postnatal wards during study period • Echocardiograms performed for Test Postive pulse Ox: 39/123 (32%) • Abnormal ECHO’s: 16/39 (41%)

16. Conclusions • Test positive pulse oximetry resulted in approx one admission per week • It leads to a modest increase in the number of echocardiograms performed. • Routine use of Pulse oximetry identifies babies with illnesses, which if not identified early could potentially lead to postnatal collapse

17. References • Ewer AK, et al. Pulse oximetry as a screening test for congenital heart defects in newborn infants: the PulseOx test accuracy study. The Lancet 2011 Aug 27;378(9793):785-94. • Kang et al. Neonatal pulse oximetry screening: a national survey. Arch Dis Child Fetal Neonatal Ed 2011;96:F312.