Overcoming barriers to oxygen saturation targeting.

OBJECTIVE: To reduce hyperoxia in very low birth weight infants who receive supplemental oxygen, the Children's Mercy Hospital neonatal respiratory quality improvement committee introduced the potentially better practice of oxygen saturation targeting and identified strategies to overcome barriers to implementation of this practice. METHODS: Using rapid-cycle quality improvement projects, this center adapted an oxygen saturation targeting protocol and tracked hourly oxygen saturation as measured by pulse oximetry in very low birth weight infants who received supplemental oxygen. RESULTS: The percentage of time in the range of 90% to 94% of oxygen saturation as measured by pulse oximetry increased from 20% to an average of 35% after implementation of the protocol. The percentage of time with oxygen saturation as measured by pulse oximetry >98% dropped from 30% to an average of 5% to 10%. CONCLUSIONS: A well-planned strategy for implementing oxygen saturation targeting can result in a sustained change in clinical practice as well as change in the culture of the NICU regarding the use of oxygen.

Standardizing nasal cannula oxygen administration in the neonatal intensive care unit.

OBJECTIVE: A multicycle, quality improvement method was used to standardize nasal cannula O2 administration and weaning in the NICU. METHODS: A 2-armed nasal cannula standardized order form (nasal cannula for stable O2 arm and nasal cannula for stable flow arm) was developed after review of the literature, surveying of the practice of NICU physicians and nurse practitioners, and development of consensus among these providers. Outcomes were measured by tracking the distribution of protocol arm chosen, days on O2, weeks on nasal cannula, and disposition of infants who were supported by nasal cannula. Data were collected in an SPSS statistical data set. RESULTS: Of the 90 infants evaluated, 12 were supported on the stable O2 arm and 53 on the stable flow arm for their entire nasal cannula course. Twenty-five infants switched between arms of support. Patients who were on the stable flow arm of the standard order set for their entire nasal cannula course experienced fewer O2 days but more days on nasal cannula. A subpopulation of infants were supported on nasal cannula flow 0.5 to 1.0 L, with fraction of inspired O2 of 21%. When data from the first 10 weeks of observation were compared with that of the second 10 weeks, the rate of discharge on O2 had decreased from 13 (30%) of 44 to 3 (7%) of 39. CONCLUSIONS: The multiple steps of literature review, practice surveys, and consensus-building resulted in enthusiastic reception of the nasal cannula standardized order form. The 2-armed nasal cannula protocol forced caregivers to consider which method of support was most beneficial for each infant who was on nasal cannula and allowed a subpopulation of NICU patients to be supported with a lower fraction of inspired O2 than previously used in the NICU.

Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia.

OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs. METHODS: The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback. This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management. RESULTS: These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates. CONCLUSIONS: The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.

Implementation of evidence-based potentially better practices to decrease nosocomial infections.

OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. Nosocomial infection is a significant area for improvement in most NICUs. METHODS: Six NICUs participating in the Vermont Oxford Network made clinical changes to address 3 areas of consensus: handwashing, line management, and accuracy of diagnosis. The summary statements were widely communicated. Review of the literature, internal assessments, and benchmarking visits all contributed to ideas for change. RESULTS: The principle outcome was the incidence of coagulase-negative staphylococcus bacteremia. There was an observed reduction from 24.6% in 1997 to 16.4% in 2000. CONCLUSIONS: The collaborative process for clinical quality improvement can result in effective practice changes.