118 - Adherence to Updated Oxygen Saturation Guidelines: Successes and Challenges of a Quality Improvement Initiative

Publication Number: 3112.118

Stephanie Martinez, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States; Heather Burgess, Regional One Health, Memphis, TN, United States; Christina Phan, Regional One Health, Bartlett, TN, United States; Bonnie Phillips, UT Medical Group, Cordova, TN, United States; Kelley Smith, Regional One Health, Memphis, TN, United States

Background: In the premature infant population, both high and low oxygen saturations are associated with morbidity. Hypoxemia events have been associated with bronchopulmonary dysplasia (Raffay et al Pediatr Res 2019, Fairchild et al Pediatr Res 2019) and adverse neurodevelopmental outcomes at 18 months (Poets et al JAMA 2015). In addition to the association of oxygen administration and retinopathy of prematurity, higher oxygen saturations have been associated with pneumonia, exacerbations of chronic lung disease, and prolonged hospitalization (STOP ROP Pediatrics 2000).
In February 2025, our division approved updated oxygen saturation goals and alarm limits for patients with varying pathologies, including infants less than 36 weeks' gestational age, with bronchopulmonary dysplasia, undergoing therapeutic hypothermia, and with congenital heart defects.

Objective: In April 2025, we started a quality improvement project focused on increasing adherence to the new alarm limits with SMART goal of achieving 80% adherence by October 2025.

Design/Methods: This quality improvement project was started in April 2025 at two neonatal intensive care units (NICUs): one Level III high risk delivery center, and one Level IV Regional Children's Hospital. Both are staffed by the same neonatologists and neonatal nurse practitioners, but separate nursing and respiratory therapy staff. We used the Institute for Healthcare Improvement Model for Improvement, including multiple Plan-Do-Study-Act cycles and analysis of systematic factors. Interventions included large- and small- group education, use of electronic medical record orders, and posted reminder cards.

Results: While both hospitals demonstrated adherence to alarm limit guidelines, the NICU in the Level IV children's hospital struggled to achieve > 75% adherence, while the Level III high-risk delivery center consistently achieved > 95% adherence.

Conclusion(s): Factors identified that led to improved success in the high-risk delivery center include unit participation in nationwide quality improvement collaborative, open-bay layout, diverse key stakeholders as members of the QI team, daily audits of adherence during beginning portions of the project, and monitors with the ability to decrease volume of alarms. Next steps include diversifying and increasing the size of the team at the children's hospital, increasing audit days, and holding meetings with the nursing Unit Council and leadership team regarding specific challenges and brainstorming solutions specifically related to alarm fatigue.

Level 3 NICU: Upper Alarm Limits Correct: P-Chart
Percentage of patients with correct upper alarm limits. Starting at week 21, audits were spaced to twice per week, widening the confidence interval.

Level 4 NICU: Upper Alarm Limits Correct: P-Chart
Percentage of patients with correct upper alarm limits. Audits were performed intermittently, approximately once per week.

Ishikawa Diagram: Factors Contributing to Difference in Success Rates
Ishikawa diagram to identify key factors that contributed to increased success in the Level 3 Neonatal Intensive Care Unit