Improving Oxygen Management in Very Low Birth Weight Neonates

Abstract

Background: Oxygen toxicity in preterm neonates contributes to the development of Retinopathy of Prematurity (ROP) and Chronic Lung Disease (CLD).  A proactive approach to reducing the levels and time of oxygen exposure in this population is an important step in the management of preterm infants and likely to impact their health outcomes.  The healthcare professionals at the bedside play a key role in optimal oxygenation of the preterm neonate because ongoing adjustments are crucial to adequate management.  The focus of this project was to incorporate evidence-based research findings into daily nursing practice in a 49-bed Level III Neonatal Intensive Care Unit (NICU) to improve neonatal outcomes associated with oxygen toxicity.  The target group in this study includes infants that are less than 32 weeks or less than 1500 grams at birth. 

Purpose: Therefore, the purpose of this project was to assess the impact of implementing evidence-based oxygen weaning guidelines and its effects in a NICU.

Methods: A two-dimensional baseline assessment revealed that clinical alarms related to oxygen saturation monitoring at the bedside were not consistently being set according to recommended parameters.  In addition, the clinical alerts received on the nurses’ phones were not consistently being acknowledged due to the increased number of alarms that do not always require a nursing intervention leading to alarm fatigue.  Following IRB approval, a multidisciplinary team convened to conduct a literature review using terms such as ‘standardized care for infants on oxygen’, ‘oxygen saturation targets’, and ‘chronic lung disease’. Following this review the team worked to develop oxygen weaning guidelines to standardize care across the unit. The team developed a pre-/post-test design to appreciate compliance with the new guidelines, changes in the number of alerts nurses receive for oxygen saturation alarms, a nurse change readiness assessment, and the number of days the premature infant required oxygen. The project involved approximately 123 premature infants who were less than 32 weeks gestation or 1500 grams at birth who were oxygen dependent in the NICU from June 2014 to February 2015.  Weekly rounds were initiated during the time this protocol was implemented to monitor nurse compliance with the new guidelines and review the oxygen saturation limits set on each monitor; which when triggered alert nurses to assess their neonatal patients’ status.

Results: As a result, there was a significant increase in the compliance with time spent within the recommended oxygen saturation parameters for prematurity program patients from 3% to 95%.  In addition, there was a 50% reduction in the amount of alerts received on nurses’ phones in a 12 hour shift.  Furthermore, in the four month period post implementation of the oxygen weaning guidelines, there was a decreased amount of oxygen days and an increase in the amount of time premature infants remained within the set oxygen saturation parameters.  The average time the neonates required oxygen was reduced from 25.98 oxygen dependent days pre study to an average of 24.74 oxygen dependent days post study following the protocol implementation.  In addition, as a result of an alarm assessment conducted at the beginning of this project, practice changes were implemented resulting in a reduction in the amount of alarms nurses received by more than 50%.

Conclusions: These immediate post implementation findings suggest that the infants who experienced the new protocol and received less oxygen will less likely suffer the results of oxygen toxicity and therefore have lower risk of developing the chronic comorbid consequences of oxygen toxicity such as Retinopathy of Prematurity and Chronic Lung Disease.  Oxygen is a drug.  Therefore, it is important to implement appropriate strategies and protocols surrounding its use in the NICU to impact the management of the preterm neonates on oxygen.