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Health services administration

Respiratory disease Letters 6 June 2022 Free

COVID‐19 highlights the need for action on pulse oximeter accuracy in people with dark skin

To the Editor: Recently published studies have highlighted concerns that pulse oximeter devices may underestimate hypoxia (overestimate oxygen saturation) in patients with dark skin. This occurs at levels where key decisions are made around supplemental oxygen and hospital admission (arterial oxygen saturation [SaO2] 88–94%). Amid the coronavirus disease 2019 (COVID‐19) pandemic, this important public health issue prompted the Therapeutic Goods Administration (TGA) to publish a medical device safety update.1 Long‐standing concerns about reduced pulse oximeter accuracy in people with dark skin2,3 have evolved into characterisation of significant racial discrepancies. A recent article compared 48097 pairs of measurements by pulse oximetry and arterial blood gas (ABG) in adults receiving oxygen across 179 hospitals in the United States. Among patients saturating >92% on pulse oximetry, hypoxaemia (ABG saturation<88%) was nearly three times more common in black patients than in white patients. Graphs illustrate the median oxygen saturation bias for black patients was 3% in the 89–96% range.4 A recent retrospective cohort study analysed registry SaO2 data in 372 individuals (73.1% with COVID‐19) about to undergo extracorporeal membrane oxygenation for respiratory failure. In patients with pulse oximeter readings of 92–96%, ABG oxygen saturation was <88% in 21.5% of black patients and in 10.2% of white patients.5 In these retrospective audits, patient ethnicity was based on hospital record identification, not skin colour. The oximetry devices used were not specified. COVID‐19 guidelines may incorporate pulse oximeter readings into decisions regarding hospital transfer of home‐care patients. Clinicians and services should arguably have lower thresholds for hospital review and admission of patients with dark skin (including Indigenous Australians and those of African and South Asian descent) with borderline oxygen saturations, while balancing risks of increased ABG and invasive treatment rates. Device manufacturers should develop pulse oximeters that perform accurately across more diverse populations. Further research must identify mechanisms of racial discrepancies in oxygen saturation and address them through device design. Calibration and testing processes for existing devices should be strengthened. The pre‐market approval processes of the US Food and Drug Administration currently require that only 15% of a study population have darker skin, while Australia has no specified requirement. The TGA does not regulate pulse oximeters sold directly to consumers (in stores or online) for general wellness or sporting purposes only. There are significant constraints on the scope for regulatory interventions for medical device pulse oximeters: this essential equipment cannot be excluded from the market or its supply compromised; mandating changes to instructions for use may have limited impact; differentiating between devices is hampered by evidence limitations and any consequent actions would be legally fraught; and mandating accuracy studies would be difficult to enforce. Contemporary evidence demonstrates that dark skin is a risk factor for hypoxia being undetected by pulse oximetry. Clinicians should adjust treatments and guidelines accordingly and consider audits of devices used in their institutions. Failure to address this problem at a design and testing level compromises racial equity in health care outcomes.

Jeffrey J Brownscombe · Heather Loane · Bridget Honan

Mja2 51522
Infectious diseases Research 4 April 2022 Free

The COVID Positive Pathway: a collaboration between public health agencies, primary care, and metropolitan hospitals in Melbourne

About 80% of participants could be adequately supported by primary care and community organisations

Seok Ming Lim · Nicole L Allard · Janelle Devereux · Benjamin C Cowie · Michelle Tydeman · Alistair Miller · Khanh Ho · Brigitte Cleveland · Liz Singleton · Karen Aarons · Paul Eleftheriou · Thomas Chan · George Braitberg · Andrea Maier

Mja2 51449
Endocrinology Letters 4 April 2022 Free

The Virtual Inpatient Diabetes Management Service: COVID‐19 brings the future to inpatient diabetes management

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has strained health systems in New South Wales, and hospitals have rapidly adapted to care for inpatients with COVID‐19. In the 4 weeks leading up to 9 September 2021, 9330 locally acquired cases were diagnosed in Western Sydney alone.1 The management of large numbers of COVID‐19 inpatients with diabetes has been challenging. People with diabetes are a vulnerable population who are at risk of adverse outcomes from COVID‐19, with a two‐ to threefold likelihood of death compared with people without diabetes.2 Hyperglycaemia is associated with higher risk;3 hence, good glucose management is desirable. Exacerbation of diabetes by dexamethasone therapy, used to treat patients with COVID‐19, and the development of steroid‐induced hyperglycaemia in non‐diabetic patients present further challenges. Traditional models of care relying on referrals from parent teams to an endocrinologist (or registrar), who then reviews the patient daily to chart insulin, are inefficient and impractical for this situation. We have developed a virtual inpatient diabetes management service (vIDMS) as a means for a small diabetes team to manage COVID‐19 inpatients with diabetes. The success of this model has revolved around an electronic medical record, electronic inpatient prescribing, a diabetes dashboard, and videoconferencing communications. The recording of all glucose measurements (including point of care) within the electronic medical record has enabled the systematic capture and display of hospital‐wide glucose data on a diabetes dashboard (Box). This also allows viewing and filtering by any variable in the electronic medical record, such as ward, age, biochemistry (including formal laboratory glucose and glycated haemoglobin), development of hypoglycaemia, prescribed medications (including corticosteroids), and COVID‐19 status. Therefore, COVID‐19 patients with diabetes or hyperglycaemia are easily identified. The vIDMS, comprising of a consultant, a registrar and a diabetes educator, reviewed patients with COVID‐19 and hyperglycaemia on a daily basis, using the dashboard and electronic medical record, by sharing a screen on a videoconferencing platform. Remote management was undertaken through the electronic medical record, including medication and insulin dose adjustments. Communication with ward staff and patients with COVID‐19 through the electronic medical record, or by telephone or video, was undertaken when needed, including for diabetes education. Entry into the COVID‐19 wards and usage of personal protective equipment was not required. In the 6 weeks to 5 September 2021, 112 COVID‐19 patients with diabetes were thus managed in Westmead Hospital (median age, 62 years; range, 23–91 years), with up to 40 patients reviewed per day. Necessitated by COVID‐19, the future of inpatient diabetes management is now here. With one‐quarter of patients in metropolitan hospitals having self‐reported diabetes4 but insufficient specialised diabetes staff to provide individual management, the vIDMS will become a significant part of the wider model of diabetes care for large hospitals.5 While initial and intermittent face‐to‐face contact remains valuable to build a relationship and discuss relevant issues, and careful review of medical records is necessary to understand perturbations in glucose levels (eg, fasting, missed medication), the vIDMS enables daily specialist care for large numbers of patients with diabetes by a small team. The health system needs to facilitate its wider application for the management of both COVID‐19 and non‐COVID‐19 patients with diabetes in hospital. Box – Diabetes dashboard showing hospital‐wide glucose data for patients with coronavirus disease 2019 (COVID‐19)

N Wah Cheung · Amanda Hor · Tien‐Ming Hng

Mja2 51456

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