784 - Staying in the Target Zone: A Quality Improvement Initiative to Achieve Oxygen Goal Saturations in Preterm Infants

Publication Number: 1760.784

Gabriela Ulloa, Weill Cornell Medicine, New York, NY, United States; Priyanka Tiwari, Weill Cornell Medicine, Williston Park, NY, United States; Sandra Diez, NYP- Weill Cornell, New York, NY, United States; Hiroko M. Yasuda, Weill Cornell Medicine, Whitestone, NY, United States; Meril Rajan, New York Presbyterian Weill Cornell, Orangeburg, NY, United States; Khemraj Ramudit, NewYork-Presbyterian Komansky Children’s Hospital, Brooklyn, NY, United States; Suzanne Handrinos, Weill Cornell Medicine, Gillette, NJ, United States; Vivien Yap, Weill Cornell Medicine, New York, NY, United States; Lauren Blatt, Weill Cornell Medicine, New York, NY, United States

Background: Oxygen is a common treatment used in preterm infants with respiratory distress syndrome. Prolonged hypoxia is associated with necrotizing enterocolitis (NEC) and increased rates of mortality. However, unrestricted use of oxygen may lead to prolonged periods of hyperoxia, which has been associated with a higher risk of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP).

Objective: The SMART aims were to increase the average percentage of time within goal oxygen saturation (SpO2) range by 20% and thereby decrease rates of BPD by 10% and decrease rates of ROP requiring treatment by 10% by May 2026 in a level IV neonatal intensive care unit.

Design/Methods: Using a quality improvement framework, a multidisciplinary team implemented SpO2 goal ranges and alarm limit parameters for patients born < 32 weeks gestational age and requiring supplemental oxygen through three Plan-Do-Study-Act (PDSA) cycles (Table 1). Data was collected from April 2024 through September 2025. Process measures included percentage of patients with correct orders for SpO2/alarm limit parameters and correct monitor alarm limits as well as average percentage of time within goal SpO2 range in accordance with our unit guidelines. Outcome measures included rates of BPD and ROP. Balancing measures included rates of NEC and mortality. Statistical process control charts were used to display and analyze data.

Results: Our interventions resulted in an improvement from 11% to 85% of patients with correct orders placed for SpO2 goal range (Figure 1). Additionally, orders for alarm limits were correctly entered 85% of the time during the intervention period. Bedside alarm limits correctly matching guidelines improved from 0% to 60%. There was a center line change from 28% to 37% for the mean percentage of time patients spent within SpO2 goal range (Figure 2). There has been no change in rates of BPD or ROP and NEC or mortality.

Conclusion(s): The increased frequency of correct orders and bedside alarm limits likely contributed to the improvement in time spent in SpO2 goal range. Macros in the electronic medical record order set and handoffs as well as staff audit with feedback were our most impactful interventions. Our group found alarm limit compliance to be challenging in patients born at earlier gestational ages, likely resulting in nursing alarm fatigue and difficulty maintaining a narrow SpO2 goal range. Next steps include setting a wider goal range for extremely premature infants, creating a nursing role to check bedside alarm limits, and adding bedside visual aids.

Table 1
PDSA cycles and interventions

Figure 1
P-chart displaying percentage of patients on supplemental oxygen with goal SpO2 order correctly matching guidelines. X-axis is time (month/year); number of patients included in parentheses. Y-axis is the percentage of patients with correct order. Arrows with PDSA cycle number indicating time of intervention. The solid line indicates the center line (CL). Dashed lines indicate upper control limit (UCL) and lower control limit (LCL).

Figure 2
X-bar S chart displaying mean percentage of time spent within goal SpO2 range for patients on supplemental oxygen and standard deviation over time. X-axis is time (month/year); number of patients included in parentheses. Y-axis is the percentage of time spent within goal SpO2 range. Arrows with PDSA cycle number indicating time of intervention. The solid line indicates the center line (CL). Dashed lines indicate upper control limit (UCL) and lower control limit (LCL).