TOPIC

A STUDY TO EVALUATE KNOWLEDGE OF PULSE

OXIMETRY AMONG HEALTH PERSONNEL

WORKING AT NEURO HOSPITAL, BIRATNAGAR.

NAME OF CANDIDATE

RASHMI JHA

SANJITA ACHARYA

GUIDE

MR. RAJKUMAR MEHTA

 INTRODUCTION

Since its invention in 1972, pulse oximetry has represented a major advance in

assisting those monitoring patients in intensive care units and during anesthesia. It is now

widely used on medical and surgical wards, with oxygen saturation measurements

included in baseline observations for most patients.

Pulse oximetry is a simple, non-invasive way of measuring the saturation of

hemoglobin with oxygen in arterial blood. It operates on the principle that the light

absorbance of oxyhaemogobin is different to that of reduced haemoglobin .A pulse

oximeter measures the differential absorption of red and infrared light by

oxyhaemoglobin and haemoglobin across a pulsatile fraction of blood in a vascular bed

(usually the nail bed) (1)

The human eye is poor at recognizing hypoxemia. Even under ideal conditions,

skilled observers cannot consistently detect hypoxemia until the oxygen (o2) saturation is

below 80%. The difficulty that physicians have in detecting hypoxemia was recently

exemplified in a study of over 14000 patients being evaluated at the UCLA emergency

department. Patients were monitored by oximetry but recordings were given to physicians

only after they completed their initial assessment. Changes in diagnostic testing and

treatment were most likely at ano2 saturation of 89%, and changes were actually less

common at lower saturations, probably because the physicians were able to detect

evidence of hypoxemia without requiring a pulse oximeter.

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 The accuracy of commercially available oximeters differ widely, probably

because of the different algorithms employed in signal processing. These algorithms are

limited by the range of saturations that can be safely obtained in volunteers, and also the

accuracy of the measurement standard (co-oximeter).Comparison of pulse oximetry with

direct co-oximeter measurements should be reported in terms of the mean difference

between the two techniques (bias) and the standard deviation of the differences

(precision).

Oximeters have a number of limitations which may lead to in accurate readings.

Pulse oximeters measures Sao2 that is physiologically related to arterial oxygen tension

(Pao2) according to the O2 HB dissociation curve because the O2HB dissociation curve

has a sigmoid shape, oximetry is relatively insensitive in detecting the development of

hypoxemia in patients with high baseline levels of Pao2.

The potential usefulness of pulse oximetry as a screening tool that could

supplement or supplant respiratory rate as a pulmonary vital sign was investigated. Paired

measurement of respiratory rate (counted while ausculting breath sounds for 1 min) and

spo2 were obtained in over 12000 adult patients in the triage area of an emergency

department .The relationship between SPO2 and respiratory rate revealed co-relation

coefficients of 0.378 to 0.454 with a weighted man of 0.160, in other words, a weak

inverse relationship between SPO2 and below 90% exhibited an increase in respiratory

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rate (defined as any rate in the upper five percentile by age). The study confirmed

previous observations that respiratory rate alone is not accurate in detecting hypoxemia.

Salsona et al. measured the number of blood gas measurements the number of

blood gas Measurements in 417 patients admitted to a medical surgical ICU during a 12 –

month period in which only two pulse oximeters were available. (i.e. control period).

They then studied 306 patients admitted over a 9 month period when 12 pulse oximeters

were available for the same number of beds (i.e. intervention period). Less frequent use

of mechanical ventilation and a slightly lower number of arterial blood samples were

observed when pulse oximetry was fully available .In man et al. examined the effect of

implementing pulse oximetry without any specific algorithm for its appropriate use. They

studied 148 patients before the implementation of oximetry in their ICU and 141 patients

after its implementation. The number of ABG samples decreased from 7.2 to 6.4 per

patient per day, a reduction of only 10.3% compared with average reductions of 39% in

the previous studies.

This suggests that, without explicit guidelines, the pulse oximeter was used in

addition to, rather than instead of, ABG samples.

Pulse oximetry is probably one of the most important advances in respiratory

monitoring. Over the last 15 years, numerous studies have focused on the technical

aspects of pulse oximeters and found that these instruments have reasonable degree of

accuracy. This degree of accuracy, coupled with the ease of operation of most

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instruments, has led to the widespread use of pulse oximetry for monitoring patients in

the ICU .perhaps the major challenge facing pulse oximetry is whether this technology

can be incorporated effectively in to diagnostic and management algorithms. That can

improve the efficacy of clinical management in the intensive care unit. (2)

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 NEED OF THE STUDY

Pulse oximetry is an important and frequently used advance in non invasive

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 evaluation and management of acutely and critically ill patients.(3)

Many reports have questioned the accuracy of pulse oximetry in clinical practice.

Recent studies have found that the accuracy of contemporary oximeters is within

clinically acceptable limits. The accuracy of the technique is reduced at physiologically

extremes. Threshold oxygen saturation s of 92- 97% are quoted as being necessary to

ensure against hypoxemia.

The lack of understanding about how and why pulse oximetry works may led to

unjustified criticism and decreased the clinical value of the technique. We believe that

when used by trained operator with understanding of the clinical implications and

limitations of oximetry, it remains a valuable tool. (4)

Few studies conducted in this topic reflect the minimal importance given by the

authority from research perspective. More qualitative and quantities studies are necessary

to elicit the data required to stimulate policy oriented ,legal based actions that would

address the present problem of knowledge about pulse oximetry among nursing staff. So,

the researcher is highly interested to investigate in this topic.

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PROBLEM STATEMENT

• A study to evaluate knowledge of pulse oximetry among health personnel.

OBJECTIVES

GENERAL OBJECTIVES

• To assess level of understanding of pulse oximetry among health personnel

working at Neuro Hospital, Biratanagar.

SPECIFIC OBJECTIVES

• To identify the extent of current knowledge of pulse oximetry among health

personnel working at Neuro Hospital, Biratnagar.

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 SIGNIFICANCE OF THE STUDY

1. The results of this study help to provide baseline data.

2. The policy making body can utilize the finding in planning of health awareness

program.

3. Finding of this study will help to identify the level of knowledge about pulse

Oximetry among nursing staff.

4. The study will also help other researcher for further research on this topic to find

out other pulse oximetry related factors and health education program on various

aspects.

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 REVIEW OF LITERATURE

Review or literature is undertaken in order to find out what works have already

been conducted in the area of concerned research problem. It also helps to minimize the

risk of duplication and choosing rejected methods. It promotes greater understanding of

problem under study, provides comparative data to evaluate and interpret the significance

of findings, and provides fruitful sources of hypothesis .Review of literature is taken from

different sources such as related journal,articles,and books .Relevant articles are also

searched through internet source also.

A study conducted in a district general hospital in Exeter, UK among medical and

nursing staff showed that junior doctors and staff nurse were untrained in pulse oximetry,

lacked knowledge of basic principles, and made serious errors in interpretation of

readings.

A study conducted at Obafemi Awolowo University Teaching Hospitals complex

(OA UTHC) Ice-Ife, Nigeria among 25 health care professional about knowledge related

to pulse oximetry revealed that most (92%) of the participants (medical M 44%, nursing

(N) 52% and medical student (MS) 4% had seen the equipment before, being used in the

hospital. Only 28% claimed to have been trained in its use though. The answers to the

clinical questions generally reflected a poor understanding of the principles of pulse

oximetry

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 An audit of nursing and medical staff understanding on pulse oximetry conducted

on 50 staff within a large general hospital (Sunder land Royal Hospital), comprising

trained and untrained nurses and medical staff. Participants responses to a questionnaire

and to six clinical scenarios were analyzed. Overall, there was a deficit in participants

knowledge on pulse oximetry. The answers given by the medical staff to the clinical

scenarios showed no greater level of knowledge than many of the trained nurses.

A study conducted at Christ Church Hospital, Christ church, New Zealand

revealed that higher proportion of nurses than doctors demonstrated an awareness of the

physiological limitations of pulse oximetry.The majority of respondents correctly

identified normal ranges for adult patients. Twenty nine percent of respondents did not

know how a pulse oximeter worked .Respondent failed to recognize the clinical

implications of low oxygen saturations in many of the hypothetical scenarios. Only 16%

of respondents had received any formal training in the use of pulse oximetry, with 65%

identifying a need for more training.

A study conducted explores the research which has examined clinician’s

comprehension of pulse oximetry.14 studies examining clinician’s knowledge of pulse

oximetry were reviewed. These knowledge of pulse oximetry were reviewed. These

studies revealed significant knowledge deficits about pulse oximetry amongst nurses,

doctors and allied health professionals, all of whom used this technology frequently.

Alarmingly, those lacking an adequate understanding of pulse oximetry included senior,

experienced clinicians.

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 The study conducted at Lack and Lucy dark department of pediatrics, Mount

Sinai school of medicine, New York. Showed that there is marked variability in pediatric

house staff’s knowledge of all aspects of pulse oximetry.This could contribute to patient

morbidity.

The study conducted on post anesthesia care unit nurses at Taylor hospital, Ridley

Park, Pennsylvania, USA related to knowledge of pulse oximetry among 19 nurses

revealed that nurses demonstrated a knowledge deficit in pulse oximetry .Competency in

the use of pulse oximetry is vital to ensure a positive clinical outcome. Nurse educators

are responsible for identifying knowledge deficits among staff and implementing

strategies to correct these deficits.

The study conducted on Intensive Care Unit, St. Thomas. Hospital, Guy’s and

St.Thomas foundation Trust, London between 1980 and 2006, focused on pulse oximetry

knowledge of nurses and/ or doctors, revealed that other criteria for inclusion were links

between pulse oximetry and knowledge in clinical practice, nurse and/ or doctors as

participants in studies addressing this, as well as the clinical competency in relation to the

device. Improving knowledge may not necessarily be the answer in improving clinical

competency.

The study conducted on USA on knowledge base related to pulse oximetry

technology and clinical interpretation of the data given revealed that 84% of the

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clinicians felt they received adequate training, 84% correctly identified what a pulse

oximeter measured,40% correctly identified how a pulse oximeter worked, but only 15%

had a correct understanding of the oxy hemoglobin dissociation curve. Although the

majority of pediatric staff felt well trained and knowledgeable about pulse oximetry,

there was a lack of knowledge of basic principles.

The study conducted on department of Anesthesiology, Mercy hospital and

medical center, San Diego about pulse oximeter revealed that although pulse oximetry is

considered sufficiently accurate for many clinical purposes, there are significant

limitation on the accuracy and availability of pulse oximetry data. The article of this

research study reviews both the clinical uses of the pulse oximeter and the limitation on

its performance.

The study conducted at department of critical care, Barnes- Jewish Hospital,St.

Louis, Missouri, USA about pulse oximetry revealed that it is one of the most commonly

applied technologies in acute and critical care. It has the potential to continuously

monitor pulmonary function ,avoid unnecessary blood gases, and alert clinicians to

hypoxemic events that are not readily apparent by physical assessment, Due to these

advantages, pulse oximetry has a firm place in health care.Oximetry has the potential to

be misused owing to its widespread application. In order to obtain the maximum benefits

from this technology, clinicians must be educated about the strength and limitation of

oximetry.

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 The study conducted among orthopedic nurses about using the pulse oximetry to

make clinical nursing decisions revealed that sound clinical nursing judgments can be

based on Oximetry readings .If the nurse combines effective operation and trouble-

shooting of the oximeter with knowledge of the principle of oxygenation and their

relationship to a patient’s total clinical picture.

The study conducted in Norwich about principles and limitations of pulse

oximetry in patient reveals that although there are many advantages to using pulse

oximetry as a tool for monitoring oxygen saturation in arterial blood, there are also

potential pitfalls. Nurse must understand its limitation or there is a risk that they may be

falsely reassured by in accurate reading. The article of this research discusses the

principles behind pulse oximetry and outlines some common misunderstanding.

The study conducted at Henry Ford health system’s Heart and Vascular Institute,

Detroit, MI, USA about pulse oximetry in adults revealed that It is a straight forward

method for estimating arterial oxygen saturation ,can detect hypoxemia early; it’s used

often and in a variety of settings. But what’s not always clear is how frequently or even

whether patients should be monitored, and unless guidelines are understood and

followed.

The study conducted on CA about use of pulse oximetry in critical ill adults

revealed that its technology has given practioners a safe, accurate, and continuous method

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for assessing arterial oxygen saturation. A comprehensive understanding of the variables

of oxygen transport and hypoxemia is essential to ensure correct data interpretation.

The study conducted about increasing clinical use of pulse oximetry revealed that

the change in nursing practice with the use of pulse oximetry.The authors discuss three

areas:(1) Demonstration of the correlation between O2 saturation as measured by the

pulse oximeter and arterial blood gas saturations (2) Introduction of pulse oximeter as a

reliable alternative to ABGs when monitoring oxygenation, and (3) The establishment of

guidelines for using pulse oximetry within the clinical setting

The study conducted on pulse oximeters for the detection of hypoxemia at Royal

Brompton and Harefield NHS Trust revealed that pulse oximetry is an accurate and

widely used method of monitoring peripheral saturation. As with any monitoring device,

care, must be taken to monitor the patient’s vital signs. Pulse oximetry measures the

saturation of arterial hemoglobin, not the adequacy of ventilation.

The study conducted at USA about the application of pulse oximetry and the

oxyhaemoglobin dissociation curve in respiratory management revealed that the article of

the research study explores the value of the oxyhaemoglobin dissociation curve in this

context and also reinforces the basic principles of pulse oximetry in respiratory

management for nurses in the United States and abroad.

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 The study conducted at Urology Department, Royal Survey country

Hospital,Egerton Road,Guildford,Survey, about pulse oximetry in general practice that

how would a pulse oximeter influence patient management revealed that with the

increasing affordability of the oximetry and recognition of its clinical applications ,there

is an increasing interest in its role in primary care. The decision was made that a

systematic review was not feasible due to lack of data concerning the influence of pulse

oximetry on patient management and on the extent of oximetry use in general practice

setting.

The study conducted at USA revealed that mean SPO(2) had a stastically

significant decreases with brown and blue nail polish using both machines (PC0.05) but

this was not clinically significant (<1% difference). Using the side to side configuration,

the N595 oximeter had a stastically significant decrease in mean SPO(2) with red nail

polish but again this was not clinically significant conclusion is fingernail polish does not

cause a clinically significant change in pulse oximeter readings in healthy people.

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 SUMMARY

The study conducted about knowledge of pulse oximetry among nursing staff,

medical and other hospital staff those who are handling the instrument in their daily work

assignment revealed that these personnel had poor knowledge about it and need

additional educational training. These studies are conducted in different part of the world.

The study also revealed that there is significant limitation on the accuracy, and also one

of most commonly applied technology, it detects hypoxemia, it influence in patient

management and fingernail polish does not cause a clinically significant change in pulse

oximeter reading in healthy people.

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 VARIABLES

a) INDEPENDENT VARIABLES

• Work\ experience

• Training

• Orientation

• Designation

b) DEPENDENT VARIABLES

• Knowledge

MATERIAL AND METHOD

RESEARCH APPROACH

• It will be quantitative survey method.

RESEARCH DESIGN

• It will be descriptive research conducted to evaluate the knowledge of pulse

oximetry.

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SETTING

• ICU, Post – op, Neuro surgery ward of Neuro Hospital, Biratnagar.

POPULATION

• All health personnel working in Neuro Hospital, Biratnagar.

SAMPLE SIZE

• Minimum 30 respondents working in various wards of Neuro Hospital will be

involved.

SAMPLING TECHNIQUE

• Non – probability sampling technique will be used in this study.

TOOL

• Standardized and validated tool.

• AACN’S practice protocol.

• Consists of 17 true – false questionnaires.

INCLUSION CRITERIA

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 • The respondents who are willingly to participate will be included.

• ANM, Staff nurse, BN, Bsc nursing, Medical officer will be included in this

study.

• Health personnel working at Neuro surgery ward, ICU, Post – op will be

involved.

• Health personnel with experience of 1 month above will be included.

DATA COLLECTION PROCEDURE

• AACN’S practice protocol will be used.

• Subject data sheet will be developed.

• Standardized and valid tool will be used.

• Ethical clearance will be taken from the authorized committee.

• Respondents will be chosen based on inclusion criteria.

• Explanation about the study to the respondents will be given.

• Written consent will be obtained.

DESCRIPTION OF TOOL

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 • A structured questionnaire for collecting information about demographic data of

health personnel.

• It will be developed to evaluate current knowledge.

STATISTICAL ANALYSIS

• Appropriate statistical analysis will be used.

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