Experiences with use of a pulse oximeter multimodal device in outpatient management of children with Acute Respiratory Infection during Covid pandemic

Designing a Smartphone-Based Pulse Oximeter for Children in South Africa (Phefumla Project): Qualitative Analysis of Human-Centered Design Workshops With Health Care Workers

Background

Pulse oximeters noninvasively measure blood oxygen levels, but these devices have rarely been designed for low-resource settings and are inconsistently available at outpatient clinics.

Objective

The Phefumla project aims to develop and validate a pediatric smartphone-based pulse oximeter designed specifically for this context. We present the process of human-centered oximeter design with health care workers in South Africa.

Methods

We purposively sampled 19 health care workers from 5 clinics in Khayelitsha, Cape Town. Using a human-centered design approach, we conducted participatory workshops with four activities with health care workers: (1) they received 3D-printed prototypes of potential oximeter designs to provide feedback; (2) we demonstrated on dolls how they would use the novel oximeter; (3) they used pile sorting to rank design features and suggest additional features they desired; and (4) they designed their preferred user interface using a whiteboard, marker, and magnetized features that could be repositioned. We audio recorded the workshops, photographed outputs, and took detailed field notes. Analysis involved iterative review of these data to describe preferences, identify key design updates, and provide modifications.

Results

Participants expressed a positive sentiment toward the idea of a smartphone pulse oximeter and suggested that a pediatric device would address an important gap in outpatient care. Specifically, participants expressed a preference for the prototype that they felt enabled more diversity in the way it could be used. There was a strong tendency to prioritize pragmatic design features, such as robustness, which was largely dictated by health care worker context. They also added features that would allow the oximeter device to serve other clinical functions in addition to oxygen saturation measurement, such as temperature and respiratory rate measurements.

Conclusions

Our end user-centered rapid participatory approach led to tangible design changes and prompted design discussions that the team had not previously considered. Overall, health care workers prioritized pragmatism for pediatric pulse oximeter device design.

An innovative method to prevent infection when measuring the arterial blood gas SpO2 saturation

Background

Patients are hospitalized for extended periods, particularly in intensive care units (ICUs). As a result, the saturation probe (pulse oximeter) remains attached for an extended period and microorganisms can grow in the wet environment. If the pulse oximeters are not reprocessed, cross-infection may occur. The literature contains several studies in which gloves were used for the measurement while various SpO2 (peripheral arterial oxygen saturation) measurements were compared with each other. However, such comparisons have yet to be made with the results of arterial blood gas SpO2 measurements by pulse oximeter, considered as the gold standard. The present study aimed to compare arterial blood gas values with the fingertip saturation measurement performed by having adult patients wear gloves of different colors, one after the other, on their fingers and determining the effect of the differently colored gloves (transparent, white, black, light blue) on saturation values.

Methods

The study was conducted on 54 patients in an ICU. Intra-arterial blood gas SpO2 results were measured. Oxygen saturation was measured while the patient 1. did not wear gloves and 2. sequentially wore a series of gloves of different colors. Paired t-test, correlation analysis, and Bland Altman charts were used to evaluate the results.

Results

The mean SpO2% value of the participants' intra-arterial blood gas measurements was 97.76±2.04. The mean SpO2% value obtained from the measurements of the fingers with a transparent glove was 0.43 points lower than the mean SpO2% value of the intra-arterial blood gas measurements (t=0.986, p=0.61). The mean SpO2% value obtained from the measurements of the fingers with a white glove was 0.93 points lower than the mean SpO2% value of the intra-arterial blood gas measurements (t=1.157, p=0.093).

Conclusion

Of the measurements performed with a glove, the mean SpO2% value obtained from the measurements of the fingers with a transparent glove was more consistent with the mean SpO2% value of the intra-arterial blood gas measurements than measurement of the fingers without a glove.

Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study

BACKGROUND

In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children's Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA).

METHODS

Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis.

RESULTS

All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended.

CONCLUSION

Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.

Patient and clinician use characteristics and perceptions of pulse oximeter use: A scoping review

BACKGROUND AND OBJECTIVES

The need to monitor patients outside of a formal clinical setting, such as a hospital or ambulatory care facility, has become increasingly important since COVID-19. It introduces significant challenges to ensure accurate and timely measurements, maintain strong patient engagement, and operationalise data for clinical decision-making. Remote Patient Monitoring (RPM) devices like the pulse oximeter help mitigate these difficulties, however, practical approaches to successfully integrate this technology into existing patient-clinician interactions that ensure the delivery of safe and effective care are vital. The objective of this scoping review was to synthesise existing literature to provide an overview of the variety of user perceptions associated with pulse oximeter devices, which may impact patients' and clinicians' acceptance of the devices in a RPM context.

METHODS

A search over three databases was conducted between April 2021 - June 2021 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) guidelines. A total of 16 articles were included in this scoping review.

RESULTS

Results indicate there has been an increase in use of pulse oximeters across hospital and community settings for continuous vital signs monitoring and remote monitoring of patients over time. Research in this area is shifting towards increasing accessibility of care through the development and implementation of telehealth systems and phone oximeters. Aspects of pulse oximeter UX most frequently investigated are usability and acceptability, however, these terms are often undefined, or definitions vary across studies. Perceived effectiveness, opportunity costs, and attitude towards use remain unexplored areas of UX. Overall, patients and clinicians view the pulse oximeter positively and find it user-friendly. A high level of learnability was found for the device and additional benefits included increasing patient self-efficacy and clinician motivation to work. However, issues getting an accurate reading due to device usability are still experienced by some patients and clinicians.

CONCLUSION

This scoping review is the first to summarise user perceptions of the pulse oximeter in a healthcare context. It showed that both patients and clinicians hold positive perceptions of the pulse oximeter and important factors to consider in designing user-focused services include ease-of-use and wearability of devices; context of use including user's prior health and IT knowledge; attitude towards use and perceived effectiveness; impact on user motivation and self-efficacy; and finally, potential user costs like inconvenience or increased anxiety. With the rapid increase in research studies examining pulse oximeter use for RPM since COVID-19, a systematic review is warranted as the next step to consolidate evidence and investigate the impact of these factors on pulse oximeter acceptance and effectiveness.

Effect of using disposable polyethylene bag as a probe cover or finger cover in pulse oximetry

Background

Consumer-grade pulse oximeters are used to monitor blood oxygen levels (SpO2) at home. Sharing a pulse oximeter with family members in isolation centers or home isolation due to COVID-19 may increase the chances of cross-infection.

Aim

We aimed to find if using commonly available disposable polyethylene covers either on the finger and/or on the pulse oximeter provides the same reading of SpO2 or not.

Methods

Two operators measured SpO2 on 10 healthy subjects with three randomly selected pulse oximeters. Six types of commonly available polythene bags (transparent, translucent, and opaque) were used to cover the fingers and/or device. After measuring the baseline SpO2 (i.e., without using covers), the measurements were taken with a covered finger, and/or covered oximeter probe.

Results

The mean age of the research participants (five male, five female) was 23.9 ± 5.11 years. Perfusion index was 9.12 ± 1.63 (males 9.6 ± 1.42, females 8.64 ± 1.85, P = 0.38). Black opaque polyethylene bag as finger or probe cover did not detect any signal. There was no difference in SpO2 reading when a pulse oximeter probe is covered, and/or a finger is covered. There was excellent inter-observer and inter-device agreement.

Conclusion

Commonly available transparent and translucent polyethylene plastic bags may be used as finger or pulse oximeter cover without compromising the SpO2 reading. However, an opaque black plastic bag is not suitable for finger or probe cover. These easily available and cheap pulse oximeter covers may be used by multiple patients or family members in an emergency like the COVID-19 pandemic with the potential to prevent cross-infection.