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) CD
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
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 Continued use of Seemore the OWL cards at each bedside
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