Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis

Author summaryWhy was this study done? Pulse oximeters are an easy to use, relatively inexpensive technology that helps to detect low levels of oxygen in the blood, which assists healthcare workers in determining a child's diagnosis and appropriate treatment. Studies show that, even when available, pulse oximeters are often not used in low- and middle-income countries, but little research has looked into why. We therefore carried out this study to determine when and why healthcare workers do or do not use pulse oximeters with children admitted to Kenyan hospitals. What did the researchers do and find? We carried out statistical analyses on a data set of 27,906 children admitted to 7 Kenyan hospitals and interviews with 30 healthcare workers and staff at 14 Kenyan hospitals. We found that there was variability in the use of pulse oximeters and that healthcare workers were most likely to use pulse oximeters with children in certain hospitals, at later time periods, and with children who were not alert or had chest indrawing or a high respiratory rate. The main factors that prevent healthcare workers from using pulse oximeters appropriately are if there is an inadequate supply, a delay in repairing broken pulse oximeters, and the healthcare workers have not had sufficient training on when, how, and why to use pulse oximeters and interpret their results. What do these findings mean? The findings suggest that healthcare workers are likely to use pulse oximeters with more children if there are efficient and transparent systems for procurement and repair, oxygen therapy is available, training and feedback are provided, and senior doctors advocate for the use of pulse oximeters. If healthcare workers use pulse oximeters with more children at admission, this may increase the number of children who are correctly diagnosed and appropriately treated, potentially leading to fewer child deaths. Background Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use. Methods and findings We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups. Conclusions There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized.