Limiting Oxygen Therapy in the Neonatal ICU: A Quality Improvement Initiative

Abstract

Background: Oxygen therapy in the premature neonatal population is associated with negative outcomes and neonatal intensive care units (NICU) use continuous pulse oximetry to limit its use in these vulnerable subjects. The NICU at a large university hospital has a 4-pronged Target Oxygen Protocol 1) Set correct SpO₂ alarm limits 2) Use Nellcor OxiMax N-600x pulse oximeter (Covidien, Mansfield, Massachusetts) to display histogram of percent time in each SpO₂ quintile per 24h period 3) Display correct postmenstrual age oxygen target saturation card 4) Set oxygen blender FIO₂ < 10% above current support. We hypothesized that performing daily audits would not increase compliance with oxygen management strategies compared to random audits. Methods: Before fall 2018, random audits of target oxygen protocol parameters were performed by NICU staff. Analysis of audit data identified drift from NICU strategies. A multidisciplinary team consisting of physicians, respiratory (RT), and nurses, met to identify possible solutions. RT trialed adding the audit to their workflow for one week and based on feedback, the form was modified to allow tracking of one week of data for each 12-hour shift. RT also noted varying levels of knowledge about oxygen strategies and need for continued education. Education was given and RT began daily data collection in September 2018. Results: Audit data before, January-March 2018 (n = 120), and after, October-December 2018 (n = 135), daily audit implementation was compared. Chi square analysis showed that three of the four parameters saw clinically significant improvement: Nellcor use increased from 91-98% (P = .02), gestational oxygen saturation card use increased from 87-96% (P = .007) and setting the oxygen blender10% above current respiratory support increased from 79-95% (P = <0.001). Conclusions: Results suggest that daily audits increase compliance with the target oxygen management strategies. Continued surveillance may identify barriers and strategies to improve compliance with target oxygen protocol strategies.