evaluation of pulse oximetry screening in middle tennessee cases for consideration before universal screening objective pulse oximetry screening of asymptomatic newborns is suggested as a lifesaving procedure for the timely detection of critical congenital heart disease chd in asymptomatic newborns we evaluated this screening and report cases that demonstrate problems with screening in a nonresearch settingstudy design an elective statedirected public health screening program was evaluated in middle tennessee 14564 infants were screened after 24h of age and before discharge the screening was performed in a nonresearch setting by nurses at the local hospitals a parallel investigation of the methods and timing of diagnosis in middle tennessee revealed a surprisingly high incidence of antenatal diagnosis 66result using a saturation value of 94 as the defined normal the positive predictive value was less than 1 with 112 infants having a false positive case and 1 having a true positive case identified incidence 134775 the one true positive case was not referred for evaluation one falsepositive case resulted in a costly referral and hospitalization antenatal diagnosis when combined with physical examination detected 43 of 44 infants with critical chd during the yearlong evaluationconclusion before universal screening can be implemented a system of care must be defined to address the educational and referral issues raised by this report