Excessive oxygen use or hyperoxia among preterm neonates is associated with morbidities like retinopathy of prematurity (ROP) and chronic lung disease (CLD) [1]. Delivering optimal oxygen involves maintaining the oxygen saturation (SpO2) within a narrow range by adjusting the inspired oxygen concentration. In our neonatal intensive care unit (NICU), we observed that nurses faced difficulty in maintaining SpO2 of neonates within the unit’s target range, often resulting in fluctuating SpO2 values. We planned this quality improvement (QI) study to evaluate the existing compliance with oxygen saturation targeting in our NICU, and whether implementation of a unit policy on oxygen administration would improve the compliance.

We enrolled preterm neonates (26 to 34 weeks gestation) who were receiving oxygen while intubated or non-invasively by any mode for a consecutive 10 h interval (coinciding with pulse-oximetry data retrieval called an epoch) during the first week of life. Neonates with major malformations were excluded. Each enrolled neonate could contribute SpO₂ data for a maximum of 14 epochs (2 per day for 7 days). The oximetry data was not collected if the neonate was on high frequency ventilation or had persistent pulmonary hypertension of newborn (PPHN) or shock.

In phase-1, enrolled neonates were managed as per existing unit protocol. Intermittent survey of pulse-oximeter alarm settings was done and pulse-oximeter data was collected for measuring baseline SpO2 targeting. Pulse-oximeters used were Mindray System Beneview T5 (Shenzhen Mindray Bio-Medical Electronics, China) with SpO₂ pick up range of 0-100% (resolution 1%, accuracy 3% between SpO₂ 70-100% and averaging time 7-11 seconds). The SpO₂ data recorded at 1-minute interval for 10-hour epoch was analyzed using R programming language.

The mean (SD) percentage of time within the target SpO₂ range during phase-1 was calculated to be 65.9 (21.4) %. Our aim was to improve baseline compliance of 65% by 20% over the next 10 weeks by implementing a unit policy on oxygen administration.

A QI team was formed consisting of a neonatologist, a nurse educator, resident doctor and charge nurse of the unit. The team reviewed the literature and developed a comprehensive policy addressing saturation targets, alarm settings, an algorithm for responding to low and high SpO₂ alarms and issues like pre-oxygenation. The unit’s goal of targeting SpO₂ between 90 to 93% with the low and high alarm limits set at 88 and 95%, respectively remained the same.

In phase-2, the nurse educator and resident doctor conducted educational sessions for nurses on the unit’s oxygen policy over a period of 4 weeks. A pre-post test assessment was done to ensure knowledge transfer. Visual reminders in the form of postcards depicting SpO2 targets, alarm limits and the algorithm were displayed in the unit. QI team provided feedback to nurses when incongruent alarm settings were noted during surveys. In phase-3, compliance with unit’s oxygen policy was reinforced and saturation histograms made from the retrieved pulse-oximeter data were presented to nurses during morning rounds. The histograms provided immediate visual feedback of neonate’s SpO₂ trend in the previous 10 hours.

The primary outcome measure for the study was the percentage of time per epoch spent within the target SpO₂ range of 88-95%. Other outcomes were the percent time per epoch spent in hyperoxia (SpO₂ >95%) or hypoxia (SpO₂ < 88%), and clinical outcomes such as in-hospital mortality, duration of supplemental oxygen therapy (in days), incidence of Bronchopulmonary dysplasia (oxygen requirement on day 28 of life) and ROP requiring therapy. As process measures, we noted the pre-post test scores of nurse’s assessment after educational intervention and compliance with alarm settings in pulse-oximeter.

Statistical analyses: We considered whether percentage of time spent in various target SpO₂ ranges were associated with individual characteristics of the neonate using generalized estimating equation (GEE) and also adjusted for NICU characteristics (nurse strength per shift, bed occupancy per shift and the number of neonates on invasive and non-invasive ventilation modes).

TABLE I Characteristics of the Study Population and Neonatal Unit in Phase-1 and Phase-3 of Study

TABLE II  Percentage of Time Spent per Epoch Within, Above and Below the Target Saturation Range 

Many units have demonstrated improved oxygen targeting using strategies like implementing written unit policy on SpO₂ targets [2,3], practice change models/QI initiatives [4-7] like educating caregivers on the hazards of hypo and hyperoxia and implementing guidelines for adjusting fraction of inspired oxygen (FiO2). Our baseline compliance is similar to an earlier report [8]. Oxygen saturation histograms for feedback has been used in some earlier studies [9,10] in addition to other strategies but failed to demonstrate significant improvement in oxygen targeting.

The ideal method of oxygen targeting is a bedside nurse with a single patient assignment who can maintain SpO2 within the target range by making manual FiO₂ adjustments [8]. In a busy unit where nurses have high workload and multiple responsibilities, such dedicated attention becomes difficult. This QI study shows that with the available equipment and nursing strength, it is possible to improve oxygen targeting by implementing a written policy through staff education. In order to sustain the improvement, we continue to use visual reminders, periodic checks on pulse-oximeter alarm settings, and regular in-service education. Use of saturation histograms for regular feedback is possible only with the help of pulse-oximeters with built-in program and needs to be explored further.

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