American Journal of Critical Care. 2002;11: 529-534
An Educational Project to Improve Knowledge Related to Pulse Oximetry
By
Mina Attin, RN, MN,
Suzette Cardin, RN, DNSc,
Vivien Dee, RN, DNSc,
Lynn Doering, RN, DNSc,
Dieula Dunn, RN,
Kathi Ellstrom, RN, PhD,
Virginia Erickson, RN, PhD, CCRN,
Maria Etchepare, RN,
Anna Gawlinski, RN, DNSc,
Theresa Haley, RN, MSN,
Elizabeth Henneman, RN, PhD,
Maureen Keckeisen, RN, MN,
Marcia Malmet, RN and
Lisa Olson, RN, MN.
From the Nursing Practice Research Council, University of California, Los Angeles, Medical Center, Los Angeles, Calif.
 |
Abstract
|
|---|
• Background Pulse oximetry is a frequently used, noninvasive monitoring tool for assessing arterial blood oxygenation. Physicians, registered nurses, and respiratory therapists are responsible for the accurate interpretation of pulse oximetry data as part of the evaluation and management of acutely and critically ill patients.
• Objectives (1) To evaluate the extent of current knowledge about pulse oximetry and (2) to increase clinicians’ knowledge of research-based practices related to the appropriate use of pulse oximetry and interpretation of its results.
• Methods A test/survey of 17 true-false questions based on the research-based practice protocol of the American Association of Critical-Care Nurses was developed to evaluate current knowledge of pulse oximetry. A convenience sample of medical, nursing, and respiratory therapy staff was invited to complete the test/survey before and several months after an educational program to improve staff members’ knowledge of pulse oximetry. The program included educational forums, policy changes, competency checklists, and verification of inclusion of research-based principles in orientation programs.
• Results A total of 442 staff members completed the test/survey given before the educational program: 331 nurses, 82 physicians, and 29 respiratory therapists. The overall mean percentage of correct answers was 66%. Differences between disciplines were significant: respiratory therapists scored slightly higher (76%) than did nurses (64%) and physicians (66%) (P = .01). The scores on the test/survey given after the educational program increased significantly, from 66% to 82% (P < .01).
• Conclusions This educational project improved staff members’ knowledge of pulse oximetry monitoring.
Pulse oximetry is an important and frequently used advance in noninvasive monitoring and assessment of arterial blood oxygenation. Physicians, registered nurses, and respiratory therapists are responsible for the accurate interpretation of pulse oximetry data as part of the evaluation and management of acutely and critically ill patients.
The Nursing Practice Research Council at the University of California, Los Angeles, Medical Center conducted an educational project on pulse oximetry. The goals were twofold. The first was to evaluate whether current knowledge about pulse oximetry monitoring is consistent with the research-based recommendations.1 The second goal was to improve practice patterns by increasing clinicians’ knowledge of research-based practices related to the appropriate use of pulse oximetry and interpretation of its results, linking knowledge to practice.
|
Determining the Problem
|
|---|
Through an electronic mail and flyer survey, staff nurses indicated that pulse oximetry was a primary problem in patients’ care. Members of the nursing staff were asked the following question: What issue has occurred in your clinical practice that requires more information or research? Many responses were received. Among the most common topics were the following:
- nasogastric tube feeding,
- cooling measures,
- instillation of isotonic sodium chloride solution during suctioning,
- flushing pressure catheters: heparin vs isotonic sodium chloride solution,
- weaning from mechanical ventilation,
- pain management,
- most effective sedation for patients being weaned,
- heparin adjustment protocol,
- inner cannula tracheostomy changes,
- frequency of changes of intravenous tubing,
- pulse oximetry,
- noninvasive measurement of blood pressure,
- continuous airway pressure monitoring, and
- cardiac monitoring.
Each item was evaluated by using predetermined criteria ascertained by the Nursing Practice Research Council and in published literature. Table 1
gives the criteria and the instrument used to select the best clinical issue for the project.1
Pulse oximetry was identified as the top clinical issue because it was a commonly used technology in the medical center, it affected patients of all ages and all specialty areas, it had multidisciplinary implications, and it affected patients’ care and management. Simultaneously, the medical center was examining the financial impact this technology had on costs for patients’ care. When this project was started, the center was spending $800 000 a year for disposable pulse oximetry probes. Therefore, pulse oximetry was also a relevant concern for the institution.
|
Assessing Research-Based Knowledge
|
|---|
A review of the literature revealed a broad spectrum of studies related to pulse oximetry. Some studies established the validity and reliability of pulse oximetry, and some studies addressed the clinical conditions affecting oxygen saturation as measured by pulse oximetry (SpO2) 2–6 In addition, the American Association of Critical-Care Nurses (AACN) had published a protocol that summarized the research findings on pulse oximetry.2 The protocol was organized by levels of research-based evidence, extending from case studies to clinical studies of groups of patients. Each recommendation was rated according to the level of scientific information available to support the statement. Levels of research-based evidence are as follows:
- manufacturer’s recommendations only;
- theory based, no research data to support recommendations; recommendations from expert consensus group may exist;
- laboratory data only, no clinical data to support recommendations;
- limited clinical studies to support recommendations;
- clinical studies in more than 1 or 2 different populations or situations; and
- clinical studies in a variety of populations of patients and situations to support recommendations.
Finally, the council members also reviewed the medical center’s policy on pulse oximetry in relation to the research-based evidence. The existing policy was vague and nonspecific in linking research knowledge to practice.
|
Developing the Survey Tool
|
|---|
After the Nursing Practice Research Council reviewed the literature and AACN’s research-based protocol, a survey tool was developed to evaluate current knowledge about pulse oximetry among clinical staff members at the medical center. The items on the survey were developed from AACN’s practice protocol and consisted of 17 true-false questions (Table 2). Content validity of the survey instrument was established by 5 clinical experts in nursing, respiratory therapy, and pulmonary medicine, as well as by nurse researchers. The test/survey addressed 6 main categories:
View this table:
[in this window]
[in a new window]
|
Table 2 Mean scores (% correct answers) for each question by discipline for tests given before and after an educational program on pulse oximetry
|
|
- definition of SpO2,
- clinical conditions affecting SpO2 values,
- accuracy and reliability,
- probe placement,
- use in specific populations of patients, and
- use of SpO2 to guide therapy.
Tests/surveys were distributed to a convenience sample of nurses, physicians, and respiratory therapists throughout the medical center before the start of the educational project and then several months after its completion. Strategies to improve knowledge included dissemination of the survey results, education of staff members in all 3 disciplines, and development of a new policy and competency checklist. Results of the test/survey were disseminated via e-mail and presentations to staff members in all disciplines.
Education to correct deficiencies in knowledge was provided by means of traveling posters, newsletters, "night owls" (in-service programs for the night shift), staff meetings, and morbidity/mortality conferences for physicians. Educational programs stressed the areas (eg, differences between oxygenation and ventilation, applicability and limitations of pulse oximetry, relating knowledge to case scenarios and clinical practice) in which the test/survey results indicated participants were deficient. A medical center policy on competency for pulse oximetry was developed and implemented.
|
Results
|
|---|
A total of 442 staff members completed the test/survey given before the start of the educational program: 331 registered nurses, 82 physicians, and 29 respiratory therapists (Table 2
). Registered nurses from 18 patient care units responded. The overall mean percentage of correct answers among the 3 disciplines was 66%. Analysis of variance indicated a significant difference among disciplines; respiratory therapists scored slightly higher (76%) than did nurses (64%) and physicians (66%) (P = .01; see Figure). Specific scores for each of the 3 disciplines for the 17 questions are given in Table 2. Areas with the highest knowledge scores (>80%) included accuracy of pulse oximetry, clinical conditions affecting SpO2, and use of pulse oximetry during invasive procedures and transport. Areas that showed knowledge deficiencies (<60%) included the definition of SpO2, and the use of SpO2 values in lieu of results of arterial blood gas analyses when weaning patients from mechanical ventilation by decreasing the fraction of inspired oxygen. Other areas in which the participants lacked knowledge included the effect of body positioning, probe placement in darkly pigmented patients, and use of trend data (Table 2).
View larger version (19K):
[in this window]
[in a new window]
|
Mean percentage of correct responses by discipline for tests/surveys given before and after an educational program on pulse oximetry
|
|
The same test/survey was given to staff members from the same 3 disciplines several months after implementation of the educational program. The overall mean percentage of correct responses increased significantly, from 66% to 82% (P < .01) for all disciplines (see Figure). Nurses and respiratory therapists had the greatest increases in scores. The lack of change in the score for physicians may be attributed to our having only a single opportunity to discuss survey results with physicians and difficulty in reaching all the physicians. Post hoc comparisons with a Bonferroni adjustment indicated significant differences between nurses and the other 2 groups (P < .01), respiratory therapists and the other 2 groups (P < .01), and physicians and the other 2 groups (P < .01).
During this project, we realized that different probes were being used in different areas of the medical center. Lack of standardization of the pulse oximeters resulted in use of several probes in a short period. Standardization of probes resulted in a reduction of cost from $800000 a year to $500000 a year (net annual savings of $300 000).
|
Discussion
|
|---|
Previous studies on knowledge of pulse oximetry targeted pediatric house staff or small numbers of medical and nursing staff. No reports specifically compared the knowledge level among disciplines that most commonly used pulse oximetry to guide patients’ management (ie, physicians, respiratory therapists, and nurses). In addition, no reports based their survey instrument on research-based guidelines for use of pulse oximetry or tried strategies to improve knowledge.
The results of the test/survey given before the educational program were similar to those reported in other studies in which the knowledge of hospital staff was evaluated. Kruger and Longden7 studied the responses of 203 hospital staff members. Only 68.5% of their sample correctly stated what pulse oximeters were measuring. Answers to questions on principles of pulse oximetry, normal ranges, measurement errors, and physiology of oxygen hemoglobin dissociation varied and reflected limited understanding.
Stoneham et al8 also reported similar results among 30 medical and surgical house staff members and 30 nursing staff members. Ninety-five percent of the doctors and nurses in that study did not understand the physiological basis for pulse oximetry measurement and were confused about factors that influence SpO2 values. Respondents in that study reported a wide range of acceptable SpO2 values for an adult patient, indicating a less than ideal understanding of pulse oximetry. When given hypothetical clinical situations, those respondents made serious errors in interpreting SpO2 values.8
Rodriguez et al9 studied pediatric house staff members’ knowledge of pulse oximetry and the members’ ability to interpret SpO2 information. A 16-item multiple-choice questionnaire was given to a total of 134 pediatric house staff members from 5 residency programs affiliated with medical schools in New York City. The mean percentage of correct answers was 64.3% (SD, 1.9%; range, 10%–100%). Only 17% of respondents answered the 3 questions about the oxyhemoglobin dissociation curve correctly. Of the 3 questions that assessed knowledge about accuracy of SpO2, only 36% of the respondents answered all questions correctly. Despite the relatively low scores, only 43% of the respondents judged their knowledge about the use of pulse oximetry as inadequate.
Our educational project had limitations. To encourage completion of the survey as honestly as possible, we told subjects that data collection would be completely anonymous, and no subject identifiers were used. Many subjects who completed the test/survey given before the start of the educational program did not complete the test/survey given after the program. Therefore, the participants who completed the second test/survey included some of the same persons who took first test/survey and some persons who did not.
|
Conclusions
|
|---|
The educational project resulted in improved knowledge related to pulse oximetry among staff members. The strategies implemented (eg, a policy change, competency development, and incorporation of research-based practices into orientation programs) should be useful in maintaining the increase in knowledge over time. Future strategies and research must be directed at more appropriate use of pulse oximetry and at cost issues. For example, guidelines on the consistent use of pulse oximetry in weaning patients from mechanical ventilation could facilitate less use of arterial blood gas analyses and decrease cost. Further efforts must be made to find the best strategy to reach physicians. Continued education and future research will help facilitate the appropriate integration of this technology into patients’ care.
|
ACKNOWLEDGMENTS
|
|---|
We thank Lynn Doering, RN, DNSc, and Jill Jesurum, RN, for their statistical consultation in preparation of the manuscript. This educational project was funded by the American Association of Critical-Care Nurses, Data Driven Clinical Practice Grant.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
|
REFERENCES
|
|---|
- Granger BB, Chulay M. Research Strategies for Clinicians. Stamford, Conn: Appleton & Lange; 1999.
- Grap MJ. Pulse Oximetry. Aliso Viejo, Calif: American Association of Critical–Care Nurses; 1996.
- Jensen LA, Onyskiw JE, Prasad NGN. Meta-analysis of arterial oxygen saturation monitoring by pulse oximetry in adults. Heart Lung. 1998;27:387–408.[Medline]
- Tittle M, Flynn MB. Correlation of pulse oximetry and co-oximetry. Dimens Crit Care Nurs. 1997;16:88–95.[Medline]
- Ralston C, Webb RK, Runciman WB. Potential errors in pulse oximetry, I: pulse oximeter evaluation. Anaesthesia. 1991;46:202–206.[Medline]
- Webb RK, Ralston C, Runciman WB. Potential errors in pulse oximetry, II: effects of changes in saturation and signal quality. Anaesthesia. 1991;46:207–212.[Medline]
- Kruger PS, Longden PJ. A study of a hospital staff’s knowledge of pulse oximetry. Anaesth Intensive Care. 1997;25:38–41.[Medline]
- Stoneham MD, Saville GM, Wilson IH. Knowledge about pulse oximetry among medical and nursing staff. Lancet. 1994;344:1339–1342.[Medline]
- Rodriguez LR, Kotin N, Lowenthal D, Kattan M. A study of pediatric house staff’s knowledge of pulse oximetry. Pediatrics. 1994;93:810–813.[Abstract/Free Full Text]
Top
Abstract
Determining the Problem
