QI case study: Using PDSA to improve oxygen saturation management

Managing oxygen saturation range in the preterm infant care is always a challenge, even in high resource settings.

In this activity we examine the quality improvement (QI) action taken by a hospital concerned about tightening the regulation of oxygen saturation between 90% and 95% for preterm babies in their neonatal intensive care unity (NICU) and reduce the risk for death and retinopathy of prematurity (ROP).

As you read, relate the steps to the quality of care framework that we first encountered in week 1.

Quality improvement to tighten the regulation of oxygen saturation in preterm babies

This example has been adapted and simplified from ‘Oxygen saturation histogram monitoring to reduce death or retinopathy of prematurity: a quality improvement initiative.’ J Perinatol 40, 163–169 (2020).

Quality of care framework: The first four steps
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Step 1

A hospital QI team was formed for the NICU services. The NICU manages about 200 preterm births annually.

Step 2

The QI team undertook a baseline situation assessment of 6 months of data from the oxygen saturation monitoring alarms set for all preterm babies <29 weeks gestational age. All preterm infants are fitted with a pulse oximeter.

The team found the following practice in use:

• Low level alarm set at 88% oxygen saturation (SpO2)

• Loud alarm set at 80% and at 95% SpO2

They also found that each preterm baby spent:

• 48.7% of the time within the goal of 90 – 95% SpO2

• 20.1% of the time above the goal

• 27.6% of the time below the 90% level.

The monthly death rate at the same time was 19.6%, the development of severe ROP was 15.6% and the rate of death or severe ROP was 32.1%.

Balancing oxygen delivery to preterm babies is of critical importance. We know that the risk of ROP increases with increased exposure to both high levels of oxygen (>95%) and the number of fluctuations in oxygen saturation. Mortality risk also increases when oxygen saturation levels fall below 90%.

Step 3

The QI team recognised and documented that previous Plan-Do-Study-Act (PDSA) cycles had been used to determine the limit settings for oxygen saturation alarms, improve nursing guidelines and train attending fellows to understand oxygen saturation histograms (bar graphs). These actions had led to some important improvements but more needed to be done.

Step 4

The team undertook a process flow chart analysis to evaluate:

• What was causing the fluctuations in oxygen saturation levels (both extremes of high and low oxygen readings).
• How quickly the team were able to respond to the alarms.
• The level of awareness in the team about the impact of oxygen fluctuations on preterm babies.
• How decisions were being made about the respiratory status of the baby.

Based on the analysis, along with further discussion and information, the QI team listed three ideas for change:

1. Implement a visual histogram monitoring the oxygen saturation level for each baby, using beside assessment methods, for all nursing staff and not only fellows.

2. Observe trends to identify babies in need of more or less respiratory support.

3. Improve training in understanding the histogram of changing oxygen saturation levels for all nursing care providers not only residents.

Step 5. PLAN

A small QI intervention team was formed comprising a neonatologist, two resident fellows (previously trained to read histograms) and two NICU nurses.

The team set themselves the following aim:

To reduce the monthly rate of death or severe ROP by 10% in infants <29 weeks gestational age, within 12 months.

The objectives included:

1. To train all 20 residents and nursing staff within the NICU about the importance of oxygen saturation and how to interpret histograms within the first month of the PDSA process.

2. To assess the compliance (%) and ability of nursing staff to complete and assess bedside log saturation histograms for each infant <29 weeks gestational age every six hours and to provide physicians with an update after every four histogram assessments.

3. To ensure the QI team’s two resident fellows provided monthly feedback to nursing staff on compliance rates and the use of the histogram to make clinical changes.

4. To audit fatality and severe ROP monthly rates for 12 months.

Quality of care framework: Steps 5 to 8, the Learning System – Plan, Do, Study and Act
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Activity: Critically appraise the steps taken so far

Consider the questions below and share your response to each one in the Comments.

• Do you think that the problem the QI team identified is relevant?

• What are the likely resource requirements to carry out the plan?

• The previous PDSA cycle introduced alarms. Do you think that worked or not? What are your reasons?

• Are the aim and objectives SMART?

Share your responses in the Comments. We will rejoin this case study next week and appraise the QI team’s activities through the rest of the PDSA cycles.