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A Model for Implementing Routine Pulse Oximetry Screening for Congenital Heart Disease in a Local Acute Hospital: Protocol, Outcomes and Quality Improvement

Presented at the Neonatal Society 2014 Autumn Meeting.

Jones AJ, Howarth C, Mellor P, Nicholl R

Neonatal Unit, Northwick Park Hospital, Harrow, UK

Background: Pulse oximetry is an effective screening tool for CHD in neonates (1), but it has not yet been evaluated if it can be successfully implemented in a local acute hospital without on-site paediatric cardiology services. We introduced routine pulse oximetry in September 2011 with a protocol based on work by de-Wahl Graneli et al (2) meaning all babies have pre and post ductal saturations measured within 2 hours of age and again pre discharge.

Methods: After introduction of this protocol SEND summaries for all NNU admissions over 24 months were reviewed to determine which were prompted by a positive pulse oximetry screening result. Furthermore 429 neonatal records (gestation >35 weeks) from the postnatal ward were audited for protocol adherence in two cohorts.

Results: Between September 2011 and September 2013, after discounting babies admitted to NNU before screening could take place, there were 10,237 babies suitable for screening. From these 13 babies, 0.12% (95% CI 0.07% – 0.2%) were admitted based on screen positive pulse oximetry recording. Two of the 13 babies, 15.4% (95% CI 4.3% to 42.2%) went on to have echocardiograms and both had critical CHD. Sensitivity of screening in this context is 100% (95% CI 19.3 to 100%), and specificity 99.9% (95% CI 99.8 to 100%). 13.9% of post ductal recordings taken within two hours of birth were abnormal, compared to only 0.7% at discharge (p <0.0001) Two audits were performed; the first cohort indicated protocol was only being followed in 37.4% of cases and 6.7% of babies were not screened at all before discharge, creating the potential to miss babies with critical CHD. After implementing numerous quality improvement measures (based on a fishbone analysis), a subsequent second cohort audited showed 100% (95% CI 96.4 to 100%) of babies were screened at least once before discharge.

Conclusion: Data from the NICOR database (3) indicates that no babies with critical CHD who needed surgical or catheter intervention were missed by our screening programme. There is currently no national policy for implementing pulse oximetry screening, however at the National Screening Committee’s March meeting it was decided it should be piloted in England (4). Our experience not only demonstrates effective introduction of such screening in a local acute hospital, but also highlights quality improvement measures that enabled protocol adherence. Furthermore our data suggests an initial saturation check within two hours could be useful to capture early critical CHD, but as the fetal circulation is still in transition we expect more abnormal results that will likely normalise on repeat tests.

Corresponding author: claire.howarth@nhs.net

References
1. Thangaratinam S, Brown K, Zamora J, et al. Pulse oximetry screening for critical congenital heart defects in asymptomatic newborn babies: a systematic review and meta-analysis. Lancet 2012;379:2459–64.
2. de-Wahl Granelli A, Wennergren M, Sandberg K, et al. Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39,821 newborns. BMJ 2009;8;338:a3037
3. National Institute for Cardiovascular Outcomes Research. http://www.ucl.ac.uk/nicor
4. UK National Screening Committee Meetings and Minutes.http://ww.screening.nhs.uk/getdata.php?id=16671

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