Care Bundle to Improve Oxygen Maintenance and Events

Abstract

Prolonged periods spent outside the target range of oxygen saturation (SpO₂) in preterm infants, along with frequent desaturation events, predispose them to retinopathy of prematurity (ROP) and long-term neurodevelopmental impairment. The primary aim of this study was to increase the mean time spent within the target SpO₂ range (WTR) by 10% and to reduce the frequency of desaturation events by 5 events per patient day, respectively, within 18 months of implementing a care bundle.

Methods: This study was completed in a 46-bed neonatal intensive care unit (NICU), involving 246 staff members and led by a quality improvement team. The change interventions included implementing new practice guidelines, reviewing daily summaries of SpO₂ maintenance, daily infant wellness assessment, standardizing workflow, and responding to SpO₂ alarms. In addition, we collected staff satisfaction and compliance with change interventions, resource use, and morbidity and mortality data at discharge.

Results: The mean time spent WTR increased from 65.3% to 75.3%, and the frequency of desaturation events decreased from 25.1 to 16.5 events per patient day, respectively, with a higher magnitude of benefit in infants on days with supplemental oxygen. Postimplementation, the duration of high-frequency ventilation and supplemental oxygen were lower, but morbidity and mortality rates were similar. Staff satisfaction with training workshops, coaching, use of the infant wellness assessment tool, and SpO₂ alarm management algorithms were 74%, 82%, 80%, and 74%, respectively.

Conclusion: Implementing a care bundle to improve oxygen maintenance and reduce desaturation events increased the time spent WTR and reduced the frequency of desaturation events.

Fig. 1.

Cause-and-effect diagram. Understanding the challenges of SpO₂ maintenance and frequent desaturations. O₂ indicates oxygen; SpO₂, saturation of oxygen.

Fig. 2.

Key driver diagram to improve oxygen saturation maintenance and reduce desaturation events.

Fig. 3.

ROSE tool. *Desaturation event occurring in isolation or concurrently with bradycardia and/or apnea. The black arrow indicates a transition from one infant wellness state to another. Blue arrows indicate the trajectory of the infant wellness state. Callouts indicate suggested actions for care teams during bedside rounds. Needs discussion includes: discussing possible etiology, further workup, and optimizing supportive care. Needs corrective action includes elements under discussion plus (1) writing respiratory care plans in an order sheet, (2) discussing contingency plans for anticipated problems during rounds, and (3) sharing the plans with the evening team at handover. If an infant fits into the watcher and an unstable category under different wellness assessment elements, label infant wellness as “unstable”. This tool is for use on days with oxygen supplementation.

Fig. 4.

Control charts showing the mean percentage of time spent within and below the target SpO₂ range and mean frequency of desaturation events per patient per day. Annotated p-charts (A) and (B) and u-chart (C). Each dot represents the mean % of time spent within the target SpO₂ range and below the target SpO₂ range per day by all patients in that week and the mean desaturation events per day by all patients in that week. Diamond and circle-shaped dots represent unstable points (out-of-control process) and stable points, respectively. Centerline shifts conformed to standard statistical process control rules (8 points in a row). Dotted lines indicate upper and lower control limits.

Fig. 5.

Control charts showing the mean percentage of time spent above, within, and below the target SpO₂ range and mean frequency of desaturation events per patient per oxygen supplementation day during the study. Annotated p-charts (A)–(C) and u-chart (D). Each dot represents the mean % of time spent above the SpO₂ target range, within the target SpO₂ range, and below the target SpO₂ range per oxygen supplementation day by all patients in that week (A)–(C), respectively, and mean desaturation events per oxygen supplementation day by all patients in that week (D). Diamond and circle-shaped dots represent unstable points (out-of-control process) and stable points, respectively. Centerline shifts conformed to standard statistical process control rules (8 points in a row). Dotted lines indicate upper and lower control limits.