QI case study: Improving oxygen saturation management, part 2

In this step we return to our Quality improvement (QI) case study from week 3. This case study 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).

We left the QI team just as they had completed step 5 of the quality of care framework, to PLAN.

The plan’s aim was: ‘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 mortality and severe ROP monthly rates for 12 months.

In this activity we ask you to read how the QI team carried out steps 6 and 7 of the PDSA cycles – Do and Study – before deciding how the team should ACT, the final step of a PDSA cycle.

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

Step 6. Do

To achieve each of the objectives the following action was taken, initially for 20 infants:

• Objective 1. The NICU team undertook pre- and post-assessments to evaluate the residents’ and nurses’ understanding of the impact of fluctuating oxygen saturation levels on comorbidities and mortality. They were then trained and reassessed, first individually and then in groups, on their ability to interpret a baby’s histogram and their use of histograms to assess clinical care for the baby.

• Objective 2. Clear guidance on what was being observed was defined and used in routine histogram interpretation every six hours. This was reported to the neonatologist on duty.

• Objective 3. Data were tracked for every 30 days during the intervention period and feedback provided to the NICU team. The definitions applied were: goal oxygen saturation level (90 – 95%), below goal oxygen saturation level (90%) and above goal oxygen saturation level (>95%). The plan started with the attending fellow applying the histogram to clinical care and this was later adopted by nursing staff.

• Objective 4. All the data on mortality and severe ROP was audited at the end of the 12 months.

Step 7. Study

Each implementing team carefully followed the results of their intervention carefully across three PDSA cycles:

• The mean monthly rate of death or severe ROP before periodic histogram analysis was 32.1%. In April 2016, following the third PDSA cycle, this decreased to 18.0% which was sustained.

• The rate of severe ROP was 15.6% during the baseline period and was 5.9% throughout the initiative.

• The mean rate of any ROP was 49.0% prior to the initiative and remained at 30.0% throughout the initiative.

• The lowest rate of ROP occurred in the third PDSA cycle (21%) compared to 48.9% in the first cycle.

• Severe ROP developed in 3.4% of infants in the third PDSA cycle compared to 15.6% in the first cycle.

Step 8. Act

Activity: Critically appraise the team’s activities to achieve the change ideas and the findings from the three PDSA cycles followed

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

• Based on the results, what do you recommend for this QI initiative – to adapt the changes, adopt them or abandon them?

• Reflect back on the aim for this plan. Do you think it was achieved?

• What is your view of the different PDSA cycles that the QI team persisted with using ?

Share your answers in the Comments.