3.20 Pulse Oximetry Check & Continuous Monitoring (Includes Ambulating SPO2)
Category: UWHC Clinical Policy
Policy Number: 3.20
Effective Date: November 1, 2015
Manual: Respiratory Care Services
Section: Patient Assessment
Oximetry is a non‐invasive method of measuring/monitoring arterial oxygen saturation.
A. The use of continuous oximetry in general care requires a provider’s order.
B. An oximeter linked to the nurse call system must be used when providing continuous
oximetry in general care
C. The following guidelines for appropriate utilization of continuous oximetry in general care should be
1. Patients with a significant probability of respiratory depression/failure.
2. Post‐operative patients at risk of developing sleep apnea until recovered from
3. Patients requiring procedural sedation until recovered from sedation. These include
patients receiving sedation by any route including neuraxial sedation (epidural, spinal,
caudal catheter or single shots).
4. Patients on the Trauma Service during the first 24 hours of hospitalization.
5. Patients with dysfunctional ventricular shunts. (At risk for respiratory depression due to
increased intracranial pressure.)
6. Patients with dysfunctional baclofen pumps (at risk for respiratory depression due to
7. Patients with deteriorating respiratory status while awaiting transfer to an IMC or ICU.
D. The following groups of patients may benefit from monitoring via continuous oximetry:
1. Patients receiving continuous intravenous narcotics, intermittent narcotics or analgesia
with agents that depress respiration, and narcotic patches.
2. Patients with cyanotic heart disease (may require management of pulmonary artery
pressure by limiting hemoglobin saturation to a specified range).
E. The location of reusable oximeter sensors should be changed every 8 hours if they are being used for
F. All patients that receive CPAP or BiPAP at night and with naps must be placed on continuous pulse
oximetry that is linked to the nurse call system.
G. To determine a patient’s home oxygen prescription, inpatient oximetry must be done within 48 hours
of discharge due to reimbursement requirements.
A. Respiratory Care performs ambulating oximetry in a variety of settings including inpatient areas
and the ambulatory clinics. Ambulating oximetry will be ordered for:
1. Determination of home O
2. Lung transplant patients.
3. Pulmonary hypertension patients
4. Diagnosis of PCP pneumonia.
B. Hold ambulation if:
1. Resting heart rate >130.
2. Consistent desaturation < 88% despite significant increases in FiO
C. Falsely high readings may occur with:
1. Excessive ambient light
2. Carboxyhemoglobin greater than 4%.
3. Heavy (2‐3 packs/day) smoker
4. Smoke inhalation
D. Falsely low readings may occur with:
1. Ambient temperature outside the range 0‐45 degrees Celsius.
2. Peripheral vasoconstriction secondary to hypothermia, hypotension, Raynaud’s disease
E. Outpatient oximetry for prescriptive purposes must be done within 30 days to qualify for an
F. Inpatient oximetry for prescriptive purposes must be done within 48 hours of discharge to
qualify for an oxygen prescription.
A. Oximeter with appropriate sensor.
B. For Ambulation:
1. A battery operated oximeter.
2. A measuring wheel to measure distance when doing ambulating oximetry for transplant
3. Portable oxygen equipment.
A. Determine whether the ambulating oximetry is for home oxygen needs, or a lung transplant patient.
1. For home oxygen prescriptions, see related link “Ambulating Oximetry Procedure for
Home Oxygen Prescription.”
2. For lung transplant patients, see related link “Six Minute Walk for Lung Transplant
A. Spot checks and continuous oximetry are documented on the RC flow sheet.
B. Ambulating oximetry is documented on the Ambulating Oximetry Test Form, and placed into the Patient
C. Overnight oximetry results are uploaded into the medical record and can be found in the
Procedure/Diagnostic Test tab.
A. Respiratory Care P&P 3.21, Nocturnal Oximetry Studies
B. Related link “Ambulating oximetry Procedure for Home Oxygen Prescription.”
C. Related link “Six Minute Walk for Lung Transplant Candidates.”
D. Related link “Six Minute Walk for Post‐Lung Transplant Patients.”
E. American Thoracic Society
Approved by Director and Medical Director of Respiratory Care.
A copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].