Vol. 14 •Issue 2 • Page 56
Pulse Oximetry a Benefit to Home Care Patients
As chronically ill respiratory patients require more sophisticated care to live independently, home care nurses and respiratory therapists must be able to make detailed assessments of oxygenation. Pulse oximetry provides the tools required to objectively evaluate oxygen saturation in patients requiring home care.
Pulse oximetry was introduced in the 1980s. By the early ’90s, many home health agencies began using it as an adjunct to assessing respiratory status and the efficacy of oxygen therapy. The Joint Commission on Accreditation of Healthcare Organizations set standards for its use in home care in 1997. Since then, pulse oximetry has become a standard in home care due to its safe application and the high value of information it provides.
ADMINISTERING IN-HOME OXIMETRY
The American Association for Respiratory Care states pulse oximetry should be performed with a physician’s order. The Food and Drug Administration confirms that an authorized individual must order pulse oximetry. Individual state laws and regulations determine which medical professionals can be considered authorized individuals (physicians, dentists, nurse practitioners or physicians assistants).
Although any trained medical personnel can perform oximetry once it’s ordered, many home health agencies only permit licensed staff to perform it due to the level of assessment it requires. It’s essential for these staff members to be trained in the use of oximetry equipment and knowledgeable regarding the interpretation of the readings, taking into consideration device limitations.
Pulse oximetry must be used sensibly in conjunction with the patient’s physical and respiratory assessment. Accuracy is crucial because physicians frequently give orders to adjust oxygen therapy in order to maintain SpO2 at or above a particular reading.
Oximetry providers should be able to assess patients and determine how often pulse oximetry is needed. For example, a patient’s decreased ability to ventilate usually requires continuous pulse oximetry monitoring. A decreased ability to oxygenate the blood may stem from cyanosis, dyspnea, decreased level of consciousness, increased work of breathing, or tachypnea. The ability to anticipate conditions in which hypoxia could be present permits earlier intervention before unfavorable outcomes occur.
Caregivers also must be able to assess factors that may inhibit the accuracy of the oxygenation measurement before they obtain it such as motion artifact, abnormal hemoglobin, intravascular dyes, sensor exposure to ambient light during testing, low perfusion, skin pigmentation, and dark nail polish or bruising under the nail.
Additionally, cardiac arrhythmias may interfere with the reading due to improper calculation of a patient’s pulse rate, so caregivers must be sure to measure the correct values. Misleading readings also may occur when assessing patients with anemia and tachypnea related to carbon dioxide buildup.
Teaching patients and their families about the merits of pulse oximetry ultimately will aid in its success in the home setting. By explaining the purpose for determining oxygen saturation, home nurses and therapists can enhance patient cooperation and decrease anxiety related to oximetry testing. Answer any patient questions as they arise, and reinforce information as needed.
Describe how the equipment and sensors work and that patient cooperation aids accurate oxygenation measurements. Explain that the values displayed on the device may vary due to patient movement, environmental light, level of patient consciousness (awake vs. asleep), and position of the sensor. This may help reduce anxiety associated with the variability of numbers appearing on the oximetry monitor.
Providing an understanding of an oximeter’s alarm system is important to the overall management of the patient. For patients hesitant to have an alarming system in their homes, discuss the importance of an audible alarm system. Alarms are set to sound if oxygen saturation falls below an acceptable limit. Demonstrate the alarm system, showing the patient and family different alarms and what to expect. It’s important to point out potential causes of false alarms such as sensor displacement.
Most importantly, discuss with home care patients that oximetry measurements are part of a larger assessment of oxygenation status. This prepares patients for other possible diagnostic tests for oxygenation such as arterial blood gas analysis, which may be administered at a later time.
Home health agencies are no strangers to the challenges of managing the chronically ill at home. To meet these challenges, CarePartners Visiting Health Professionals, Asheville, N.C., has looked to technology as a way to provide home care that promotes independence and contributes to increased quality of life.
To aid in pulse oximetry, CarePartners VHP has coordinated its 59 home care oximeters with a hospital-grade FDA Class II medical device. This telemonitoring system collects patient vital signs, including oxygen saturation, on a daily basis. It provides clinicians with trended, relevant reports while providing patients with a secure, consistent connection to caregivers at times they aren’t available to visit the home.
At a prescribed time each day, a voice programmed by the system guides the patient through a step-by-step process to measure oxygen saturation. Additional peripheral attachments can be added to measure pulmonary function and electrographic heart signals.
Data automatically are transmitted via phone line or digital two-way pager to a central station located at CarePartners VHP’s facility for clinician review. Each patient has preprogrammed parameters for his or her individual pulse oximetry readings, allowing for an alert when those limits are exceeded. This allows the central station clinician to quickly prioritize which patients require first response.
This information significantly affects patient care and quality of life. Nurses and therapists can be sent to a patient’s home based on that person’s individual needs. They also can use reports generated by the telemonitoring system to work directly with a patient’s physician to adjust medical therapy.
Clinical data support the efficacy of this model of care. A study conducted by Strategic Healthcare Programs concluded that reductions in hospitalizations for congestive heart failure and chronic obstructive pulmonary disease patients using this mode of care could be as high as 65.9 percent. Emergent care could be reduced by as much as 61.7 percent, according to the study.
In conclusion, pulse oximetry combined with telemonitoring technology can be of great benefit to patients admitted to home care programs. When paired with thorough patient assessment and patient education, these tools can significantly decrease hospitalizations and emergent care visits in diagnoses known to consume health care resources.
1. Schutz SL. Oxygen saturation monitoring by pulse oximetry. In: Lynn-McHale DJ, Carlson KK, editors. AACN procedure manual for critical care. 4th ed. Philadelphia: W.B. Saunders; 2001.
2. Joint Commission on Accreditation of Healthcare Organizations. Physician’s orders to perform pulse oximetry. 2002 (update). Access via: URL: www.jcaho.org
3. American Association for Respiratory Care. AARC clinical practice guideline. Pulse oximetry. Respir Care. 1991;36:1406-9.
Fox is the cardiopulmonary program director for CarePartners Health Services in Asheville, N.C.