Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data

Kelly T Gleason; Alberta Tran; Ashraf Fawzy; Li Yan; Holley Farley; Brian Garibaldi; Theodore J Iwashyna

doi:10.1016/j.ijnurstu.2024.104770

Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data

Int J Nurs Stud. 2024 Apr 6:155:104770. doi: 10.1016/j.ijnurstu.2024.104770. Online ahead of print.

Authors

Kelly T Gleason¹, Alberta Tran², Ashraf Fawzy³, Li Yan³, Holley Farley⁴, Brian Garibaldi⁵, Theodore J Iwashyna⁶

Affiliations

¹ Johns Hopkins University School of Nursing, Baltimore, MD, USA. Electronic address: Kgleaso2@jhmi.edu.
² MedStar Health, Washington, DC, USA.
³ Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁴ Johns Hopkins Hospital, Baltimore, MD, USA.
⁵ Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Hospital, Baltimore, MD, USA.
⁶ Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Hospital, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

PMID: 38676990
DOI: 10.1016/j.ijnurstu.2024.104770

Abstract

Background: Pulse oximetry guides clinical decisions, yet does not uniformly identify hypoxemia. We hypothesized that nursing documentation of notifying providers, facilitated by a standardized flowsheet for documenting communication to providers (physicians, nurse practitioners, and physician assistants), may increase when hypoxemia is present, but undetected by the pulse oximeter, in events termed "occult hypoxemia."

Objective: To compare nurse documentation of provider notification in the 4 h preceding cases of occult hypoxemia, normal oxygenation, and evident hypoxemia confirmed by an arterial blood gas reading.

Methods: We conducted a retrospective study using electronic health record data from patients with COVID-19 at five hospitals in a healthcare system with paired SpO₂ and SaO₂ readings (measurements within 10 min of oxygen saturation levels in arterial blood, SaO₂, and by pulse oximetry, SpO₂). We applied multivariate logistic regression to assess if having any nursing documentation of provider notification in the 4 h prior to a paired reading confirming occult hypoxemia was more likely compared to a paired reading confirming normal oxygen status, adjusting for characteristics significantly associated with nursing documentation. We applied conditional logistic regression to assess if having any nursing documentation of provider notification was more likely in the 4-hour window preceding a paired reading compared to the 4-hour window 24 h earlier separately for occult hypoxemia, visible hypoxemia, and normal oxygenation.

Results: There were data from 1910 patients hospitalized with COVID-19 who had 44,972 paired readings and an average of 26.5 (34.5) nursing documentation of provider notification events. The mean age was 63.4 (16.2). Almost half (866/1910, 45.3 %) were White, 701 (36.7 %) were Black, and 239 (12.5 %) were Hispanic. Having any nursing documentation of provider notification was 46 % more common in the 4 h before an occult hypoxemia paired reading compared to a normal oxygen status paired reading (OR 1.46, 95 % CI: 1.28-1.67). Comparing the 4 h immediately before the reading to the 4 h one day preceding the paired reading, there was a higher likelihood of having any nursing documentation of provider notification for both evident (OR 1.45, 95 % CI 1.24-1.68) and occult paired readings (OR 1.26, 95 % CI 1.04-1.53).

Conclusion: This study finds that nursing documentation of provider notification significantly increases prior to confirmed occult hypoxemia, which has potential in proactively identifying occult hypoxemia and other clinical issues. There is potential value to encouraging standardized documentation of nurse concern, including communication to providers, to facilitate its inclusion in clinical decision-making.

Keywords: COVID-19; Electronic health record data; Nurse documentation; Nurse/provider communication; Occult hypoxemia; Pulse oximetry.