The Science Journal of the American Association for Respiratory Care

2008 OPEN FORUM Abstracts

SETTING THE TARGET: IMPROVING OUTCOMES USING OXYGEN TARGETING

Deborah A. Igo1



Background: Oxygen is an integral part of the respiratory support offered in the NICU; the goal should be to achieve adequate oxygen delivery without creating oxygen toxicity. Oxygen has been associated with both chronic lung disease (CLD) and retinopathy of prematurity (ROP) in very low-birth weight infant population (VLBW). Published information describes practice changes that may impact both the incidence of CLD and ROP in VLBW infants. Institution of a policy for strict management of oxygen delivery and management may improve patient outcomes.

Methods:
NICU Inter-disciplinary Quality Improvement Team developed a targeting protocol after a literature search (BOOST Trial, STOP-ROP Trial, and Chow Abstract). We attempted to change practice on how we monitor and treat VLBW infants by having specific pulse oximetry saturation ranges ordered for specific birth weights and diagnosis. Babies <1500 grams were ordered (via CPOE) to be maintained in the 88-92% SPO2 range. Alarm settings were set at 85-95%. Orders printed out on the daily care plan. Algorithm guidelines were developed on how to treat babies falling outside the ordered range. We attempted to avoid frequent "up" and "down" changes in inspired oxygen concentration and making small incremental changes (2%-5%) to maintain the target. A visual tool was posted on the bedside monitor with the target range and parent education provided to have parents involved in the process. Once a baby was weaned to room air the targeting procedure is discontinued. Education of all nursing, physician and respiratory staff was mandatory and auditing of compliance was frequent. Targeting oxygen saturation needs to be a team effort. Compliance was very difficult to achieve as the oxygen alarms could become a nuisance. Frequent re-education was essential.

Results:
We demonstrated a change in greater than stage 2 ROP from 15.2% to 3.9%, with the need for inborn babies requiring surgery for ROP eliminated. Our CLD rates changed from 31.6% to 25%.

Conclusions:
While targeting oxygen saturations in babies below 1500 grams, we were able to improve our rates of Chronic Lung Disease and Retinopathy of Prematurity even while struggling to achieve compliance with the bedside practioners. Continued education, auditing and reinforcement is essential to maintain the improvements.