Oxygen With Love: Reducing the Need for Laser Surgery in Preterm Infants

1. Oxygen With Love: Reducing the Need for Laser Surgery in Preterm Infants Team Members The Outstanding NICU Nursing Staff Barb Hering, RNC, MSN, & Lisa Festle, RNC, MSN NICU Education Co-Chairs Marianne Chybik, APN/CCNS, Neonatal Case Manager Elaine Trulis RN, BSN, Nurse Manager, NICU Marc Weiss, MD, Director of Neonatology Confidential: For Quality Improvement Purposes Only

2. Background: Oxygen With Love • Blindness occurs in approximately 2% of premature infants born under 1200 grams. Retinopathy of Prematurity (ROP) is a disease of the retina. ROP in VLBW infants (< 1200 grams) tends to be the most severe. It is associated with retinal scarring and detachment which can result in blindness. There is no successful treatment once the retina has been damaged. • Best practice evidence demonstrates that maintaining a targeted saturation range based on gestational age may reduce the incidence and severity of ROP • Aksie LM, Henderson-Smart DJ. Early versus late discontinuation of oxygen in preterm orlow birth weight infants; Cochrane Datatbase Syst Rev: 2001 (4) CD001076. • Chow et al. Can changes in clinical practice decrease the incidence of severe retinopathy in very low birth weight infants? Pediatrics: 2003,111: 339. • Personal communication with Dr. Goldsmith regarding his presentation entitled "Oxygen Targeting". 4th National Neonatal Nurses Meeting, October 3, 2004 • Magnet forces 6, 7, 8, 9 & 13 Confidential: For Quality Improvement Purposes Only

3. Problem statement Oxygen With Love • Retinopathy Of Prematurity (ROP) is a common complication of prematurity associated with high levels of oxygen administration. • Laser surgery is required in infants with severe ROP • 30% of infants with ROP that reached threshold and received surgery had unfavorable vision as long as 10 years later Confidential: For Quality Improvement Purposes Only

4. Contributing Causes Oxygen With Love • Higher oxygenation in the early neonatal period increases the risk for ROP, especially in the premature and/or low birth weight infant. • Fluctuation in saturations (hypoxia/hyperoxia).   • Difficulty in maintaining SaO2 within tight control at all times – intensive surveillance at bedside is required, with frequent adjustments in percentage of oxygen administered Confidential: For Quality Improvement Purposes Only

5. Aim Statement: Oxygen With Love • Decrease the incidence of severe ROP as measured by a decrease in the amount of laser ablation surgery performed in the NICU • Goal or Target:4 % or less (Vermont Oxford Network data national average 3.98%)  • Source of Goal or Target: VON data Confidential: For Quality Improvement Purposes Only

6. Solutions Implemented Oxygen With Love • 2007 - Intermittent saturation range audits • Results - Data from 9/07 audits: • MD order present 83% of time: GOAL: 100% • OWL cards present 84% of time: GOAL: 100% • Alarm limits in range 69% of time: GOAL: 85% • 2008 – Updates from NICU Education Committee • Laminate additional bedside OWL cards (supply limited/missing cards) • Every Sunday night Charge Nurse will make announcement for RN to ensure OWL card and MD order are present and reflect correct gestational age • Reaudit alarm limits, OWL cards, MD orders: in progress 02/08 • Obtain 2007 LUHS laser surgery data • Review staffing guidelines for labile patients with E. Trulis • Plot improvement on bar graph displayed in unit Confidential: For Quality Improvement Purposes Only

7. Vermont-Oxford Birth Weight Comparison Confidential: For Quality Improvement Purposes Only

8. Vermont-Oxford Gestational Age Comparison Confidential: For Quality Improvement Purposes Only

9. Vermont-Oxford Severe ROP Confidential: For Quality Improvement Purposes Only

10. Vermont-Oxford ROP Surgery Confidential: For Quality Improvement Purposes Only

11. Results:Reduction in the amount of laser surgery done in the NICU for ROP Oxygen With Love Confidential: For Quality Improvement Purposes Only

12. RESULTS Oxygen With Love • Since implementation of Seemore the OWL, the laser ablation rate for infants with severe ROP has been cut in half. • Patient benefit: • Short term – decreased length of stay, no surgery, no readmission for surgery • Long term – better eyesight Confidential: For Quality Improvement Purposes Only

13. Next Steps Oxygen With Love • Continued use of Seemore the OWL cards at each bedside • Intermittent oxygen saturation audits to monitor compliance • Continued monitoring of the laser ablation rate in the NICU • Continued comparison of LUMC NICU outcomes to those within the Vermont Oxford Network Confidential: For Quality Improvement Purposes Only