Challenges to CCHD pulse oximetry screening identified

Challenges to CCHD pulse oximetry screening identified
Challenges to CCHD pulse oximetry screening identified

Healthcare providers have experienced a number of challenges implementing pulse oximetry to screen newborns for critical congenital heart disease since the procedure was officially recommended in October 2010.

Gerard R. Martin, MD, of the Children's National Medical Center, and an expert panel of stakeholders recently met in Washington, D.C., to highlight areas for improvement and discuss strategies for achieving these goals. The panel's recommendations were published in Pediatrics.

“Screening for CCHD presents novel challenges and opportunities. However, addressing these will strengthen newborn screening and newborn care networks, and ultimately improve health outcomes,” they wrote.

CCHD affects approximately 1.2 infants per 1,000 live births. Although visual observation is sometimes sufficient to diagnose CCHD, pulse oximetry can often catch cases that otherwise go undetected. The test measures the amount of hemoglobin in blood that is oxygen-saturated, which can indicate the presence of hypoxemia -- a common feature of CCHD.

Martin and colleagues discussed six key areas of CCHD pulse oximetry screening: selection of screening equipment, standards for reporting of screening outcomes to stakeholders, training of health care providers and educating families, future research priorities, payment for screening and related tests, and advocacy to facilitate effective and comprehensive screening. 

When discussing equipment, it was noted that the FDA approval for oximeters used for screening had been based on their performance on adults, and that new standards for using oximeters on newborns should be established.  Additionally, sensors made specifically for neonates should be used so as to avoid damaging their skin.

The panel also hoped to increase awareness of the screening process and to properly train those administering it.  They proposed public awareness campaigns, use of social media and dissemination of guidelines. 

In particular, they noted both the limitations and the capabilities of CCHD screening.

“All providers should understand that a negative screen does not rule out the presence of all forms of congenital heart disease,” the researchers wrote. However, they acknowledged that pulse oximetry is also helpful in identifying non-cardiac conditions, such as pulmonary disease, metabolic disease and sepsis.

Regarding the actual screening procedure, priorities included establishing more accurate and helpful diagnosis, and the panel agreed “the initial focus should be on outcomes in the first few weeks of life, often the most risky time period for patients with CCHD.”

Alternative methods for discovering CCHD were also discussed, as potentially 60% of CCHD can be detected prenatally via routine fetal ultrasounds and fetal echocardiography. In the future, new technologies like the peripheral perfusion index and biomarkers might be used to obtain necessary data in lieu of pulse oximetry.

Even though CCHD screening for newborns has been added to the recommended uniform screening panel (RUSP) and endorsed by Secretary of Health and Human Services Kathleen Sebelius, state level action may still be required to promote implementation. Some states including Indiana, Virginia and California, have been quick to adopt legislation regarding the screening, whereas others have found specific, unique challenges. For example mountain states have identified a need to determine thresholds for high-altitude screening.

States looking to evaluate their commitment to CCHD screening should look to New Jersey as an example, since the Garden State was the first to make it mandatory. Challenges that New Jersey identified included “the short implementation period, the unfunded mandate, and barriers associated with initiation of a new surveillance system.”

"Addressing the challenges and acknowledging the opportunities for further work provides an opportunity to strengthen screening and newborn care networks in ways that should benefit children born with CCHD," the panel concluded.

by Walker Harrison, an undergraduate student at Columbia University and editorial intern with Clinical Advisor.


References

  1. Martin GR et al. Pediatrics. 2013; doi:10.1442/peds.2012-3926.
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