In September 2011, the U.S. Secretary of Health and Human Services recommended that
critical congenital heart defects (CCHD) be added to the Recommended Uniform Screening
Panel (RUSP) for newborns. Anecdotal reports in early 2012 suggested that some Georgia
hospitals had begun screening for CCHD using pulse oximetry. To better understand
the prevalence of routine CCHD screening, specific practices among screening hospitals,
and barriers to screening among all birthing hospitals in the state, CDC and the Georgia
Department of Public Health (DPH) conducted two surveys of Georgia hospitals in June
2012. Eleven pulse oximetry screenings at five hospitals also were observed to estimate
screening time. The initial survey was sent to 89 birthing hospitals, among which
71 (80%) responded; 22 (31%) reported currently screening for CCHD and 20 (28%) planned
to start in 2012. Barriers to screening included lack of a clear follow-up protocol
for positive screening tests, uncertainty about reporting screening results to public
health organizations, and cost concerns. Sixteen (73%) currently screening hospitals
responded to the second survey. Only one third of screening hospitals followed the
CCHD screening protocol endorsed by the American Academy of Pediatrics; the remaining
hospitals screened at different times or had different criteria for a positive screen.
Screening time averaged 10 minutes per newborn. In the absence of a state mandate,
routine screening has begun in many Georgia hospitals. Use of a standardized screening
protocol for CCHD could reduce current variation in screening practices among Georgia
hospitals. Working agreements between hospitals also are needed to ensure access to
echocardiography and follow-up of newborns with possible CCHD.
Congenital heart defects are associated with approximately eight births per 1,000
(1); approximately 25% of these defects are CCHD and require surgery or cardiac catheterization
at age <1 year (2). Many CCHDs are detected prenatally or during physical examination
after birth, but some infants with CCHD are discharged home without a diagnosis, putting
them at risk for severe disability or death (3). In 2010, the Secretary’s Advisory
Committee on Heritable Disorders in Newborns and Children recommended that CCHD be
added to the RUSP, and in September 2011, the Secretary accepted the committee’s recommendation.*
Currently, screening for CCHD is accomplished through pulse oximetry, a noninvasive
test used to detect hypoxemia, which typically is present for the seven CCHD that
are the primary targets of pulse oximetry screening (3). The predictive values and
sensitivity of pulse oximetry screening varies based on the screening protocol that
is used (e.g., timing of screening after birth or number of extremities measured)
(4). Despite this federal recommendation to include CCHD on the RUSP, implementation
is a state decision. Although universal CCHD screening currently is not mandated in
Georgia, anecdotal reports in early 2012 indicated the practice had begun in some
birthing hospitals.
DPH requested assistance from CDC to assess the current practices and feasibility
of routine screening for CCHD in Georgia. In June 2012, CDC and DPH distributed a
survey about CCHD screening practices using pulse oximetry to nurse managers at all
the 89 Georgia birthing hospitals. Hospitals could complete the survey online, via
fax, or by telephone. The 71 hospitals that completed the initial survey represented
80% of all birthing hospitals in Georgia and accounted for 87% of all live births
in the state in 2011 (5). CDC and DPH distributed a follow-up online survey about
specific screening procedures to the 22 hospitals that reported in the initial survey
that they were currently screening for CCHD using pulse oximetry; 16 (73%) responded.
From the 22 hospitals currently screening, a convenience sample of five were selected,
at which CDC and DPH staff members observed five screening demonstrations and six
actual screenings. Assessment of five screenings included quantification of transport
time to and from the nursery, and six did not because other procedures (e.g., metabolic
screening) were conducted during these same nursery visits. Two-sided Fisher’s exact
tests (significance level of 0.05) were used to assess the statistical significance
of differences in the prevalence of hospital characteristics by screening status.
Of the 71 hospitals that responded to the initial survey, 22 (31%) reported currently
screening for CCHD using pulse oximetry in their well-baby nursery (11 began in 2010
or 2011, nine in 2012, and two did not indicate when they started); 34 (48%) had plans
to start (20 by the end of 2012 and 14 at other times); 14 (20%) had no plans to start;
and one did not know of plans to start. No differences by hospital screening status
were noted in the number of live births in 2011, availability of echocardiography
onsite for infants, or in the availability of pediatric cardiologists for follow-up
of babies with CCHD (Table). Several barriers to CCHD screening were reported more
frequently among nonscreening hospitals (Table). Overall, 46 (65%) hospitals reported
that they could perform echocardiography on-site. For follow-up of patients with suspected
CCHD, 32 (45%) had to transfer patients. The median driving distance to a transfer
hospital was 54 miles (range: 0–211 miles).
Among 16 (73%) of the 22 screening hospitals that responded to the follow-up survey,
five (31%) reported following the CCHD screening protocol† endorsed by the American
Academy of Pediatrics, the American College of Cardiology, and the American Heart
Association (6). The remaining hospitals either screened at different times or used
different criteria for a positive screen. No hospital reported providing written documentation
to parents about the screening. Among the 16 hospitals, 12 did not know how often
to send screening data to DPH and 11 did not know what types of screening data, such
as true and false positives and negatives, could be sent to DPH. Four of the 16 screening
hospitals had identified one or more infants with a CCHD through screening. Thirteen
of the hospitals neither hired extra staff nor added extra staff hours to accommodate
CCHD screening, and three did not respond to the question. The average time to conduct
and document the 11 observed screens was 10 minutes per screen (range: 3–15 minutes).
CDC recommended that 1) guidance be provided to hospitals on the type of data to report
to DPH, and the frequency of reporting; 2) an educational webinar be developed for
hospitals on signs and symptoms of CCHD and the pulse oximetry screening protocol
endorsed by the American Academy of Pediatrics; 3) educational materials that hospitals
can provide to parents about CCHD screening be developed and disseminated; and 4)
working agreements between hospitals be established to ensure access to echocardiography
and follow-up for all newborns with possible CCHD.
Editorial Note
In Georgia, a state without mandated CCHD screening, at least 42 birthing hospitals,
accounting for 60% of births in the state (5), are conducting routine CCHD screening
in their well-baby nursery (20) or planned to start (22) by the end of 2012. Frequently
cited barriers to CCHD screening include the lack of a clear protocol for follow-up
for positive screening results, uncertainty about how to report results to Georgia
DPH, and cost concerns. In addition, many hospitals are unable to perform echocardiography
on-site or have to transfer patients for follow-up of suspected CCHD. Even among hospitals
already screening, screening protocols and practices varied.
What is already known on this topic?
In September 2011, the U.S. Secretary of Health and Human Services recommended that
critical congenital heart defects (CCHD) be added to the Recommended Uniform Screening
Panel for newborns. Universal screening for CCHD using pulse oximetry is not mandated
in Georgia, but anecdotal reports in early 2012 suggested screening had begun in some
birthing hospitals.
What is added by this report?
Among 71 of 89 Georgia birthing hospitals that responded to the initial survey, 42
(59%) reported currently (22) or planning to start (20) screening for CCHD using pulse
oximetry by the end of 2012. Barriers to screening in some hospitals and variation
in screening practices remain. Nearly one third of hospitals are unable to perform
echocardiography for infants on-site in their facility and almost half need to transfer
newborns with possible CCHD to another facility for follow-up and diagnosis.
What are the implications for public health practice?
Implementation of routine screening for CCHD in the absence of a state mandate has
led to variation in screening protocols. Use of a standard screening protocol and
educational programs might alleviate these differences. Hospitals need recommendations
as to what screening data to collect and report. Working agreements between hospitals
are needed to ensure access to echocardiography and follow-up of newborns with suspected
CCHD.
Published reports from other states are limited. A survey of Wisconsin hospitals found
similar results to this assessment; approximately 25% of Wisconsin hospitals had voluntarily
begun screening. Barriers to screening included lack of access to echocardiography,
long transfer hospital distances, and variation in screening procedures and protocols
(7). The average screening time of 10 minutes per newborn from this assessment is
greater than previous estimates of 2–3.5 minutes (8,9). Despite the added potential
burden of approximately 274 hours per year devoted to CCHD screening for the typical
Georgia birthing hospital (based on a mean of 1,642 births among hospitals currently
screening or planning to begin screening by the end of 2012), none of the hospitals
that responded to the survey added staff or hours to accommodate screening.
The findings in this report are subject to at least three limitations. First, the
survey response rates were 80% to the initial survey and 73% to the second survey.
Nonresponders might have had different CCHD screening experiences from responders;
if so, these results might not be applicable to all birthing hospitals in Georgia.
Second, screening practices were reported by the nurse manager who filled out the
survey and might not reflect those of all nurses in a given facility. Finally, the
numbers of hospitals conducting CCHD screening and the specific screening procedures
used are likely to change over time, so the results of this assessment might not reflect
Georgia hospitals’ current screening practices.
The findings from this assessment of CCHD screening practices in Georgia might be
useful to other states. Routine screening has voluntarily begun in many Georgia hospitals,
although screening practices vary and not all hospitals are able to provide appropriate
follow-up for infants with possible CCHD. Georgia hospitals need guidance on a standardized
screening protocol for CCHD. Working agreements also need to be created between hospitals
to ensure access to echocardiography and follow-up of newborns with possible CCHD
in Georgia hospitals.