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COMMENTARY |
a Department of Pediatrics, Tulane University, New Orleans, Louisiana
b Departments of Pediatrics and Neonatology, Thomas Jefferson University and AlfredI. duPont Hospital for Children, Philadelphia, Pennsylvania
Abbreviations: ROP, retinopathy of prematurity
"Because I said so!" We have all been guilty of using this abrupt paternalistic response with our children when they question a direction. Maybe at the time we were too busy to give a full explanation, but the result may have been that the compliance was as brief as the response. Perhaps a more reasoned explanation would bring a better and more lasting result.
It is no different when we as physicians give orders to our health care team. Orders without education or explanation, especially when they differ from previously accepted norms, will result in less compliance than when the health care team is fully aware of the reasons for the changes and "buys in" to the new approach.
This principle of quality improvement is well illustrated by the use of oxygen in our neonatal intensive care units (NICUs). Bedside neonatal caregivers see oxygen as life-giving, not poisonous. Establishing new oxygen targeting for preterm infants has become a hot issue in neonatology. It is well recognized that oxygen toxicity leads to a multitude of complications, and reducing the levels and time of oxygen exposure to sick infants from the delivery room through their early intensive care course will likely reduce morbidities. However, allowing very low birth weight infants to live in previously undesirable oxygen saturation ranges may be a difficult culture to change.
The challenges of translating the concept of lower oxygen targets to practice have many obstacles. In this issue of Pediatrics, Clucas et al1 document that only 22% of their population of preterm infants had pulse oximetry alarms set in accordance with the established protocol. Even when the saturation limits are properly set, Hagadorn et al2,3 have shown previously that without a special compliance program, they were able to keep sick oxygen-dependent infants in their 14 esteemed NICUs within the targeted range only about half of the time.
Clucas et al reported that a memo sent to all staff citing the new standard for oximetry limits in the neonatal unit of the Royal Woman's Hospital resulted in a low compliance even when the nursery team knew that they were being monitored. It is unclear why the orders were not followed very often. Were the guidelines clear, well dispersed, and reinforced? Did the staff know the targets but choose to ignore them? What educational process was given to the caretakers? We know that an intensive education program for hand-washing improves compliance, but still only about half of the health care team performs this task correctly, and the education must be repeated frequently to maintain even that much compliance.4
Certainly clinical leadership should view this study with great concern. When a change in clinical culture is necessary, the process requires careful planning and execution. In the case of saturation limits, it is likely that frequent alarms may prompt a caretaker to reset limits, especially if the ordered limits target too narrow a range. It is possible that the care team ignored the guideline or that there was difficulty with the equipment. Unfortunately, the most critically ill infants, and the infants who would likely benefit most from the lower targeted saturations that Clucas et al described, are the most labile and, therefore, the most difficult to keep within range.1
In the complex NICU environment, creating a major change, such as resetting the acceptable oxygen saturation target ranges for sick neonates, involves many obstacles. Such change requires a multidisciplinary team to develop the vision and strategy, assess and eliminate roadblocks, establish a sense of urgency, and communicate the new guidelines to all parties involved. There should be short-term wins, probably with rewards, a process of assessment and quality improvement, and reinforcement until the change becomes anchored as part of the culture. The process may uncover the need for new equipment (ie, different monitors), alterations in staffing models (ie, 1:1 nursing for the smallest and more labile infants), evidence-based education for staff and/or families, etc.
There are several published demonstrations that lower oxygen targets can be achieved and resultant morbidities such as retinopathy of prematurity (ROP) can be reduced.5–7 Chow et al5 used contracts with the nursing and respiratory staffs and the establishment of the Caring Responsible Approach to Development in the Lives of Extremely Low Birth Weight Infants (CRADLE) Club to promote compliance with the new targeted ranges and achieved virtual elimination of surgical intervention for ROP in their unit over 3 years. However, no measures were made of how much time the infants spent in the targeted ranges. The Oxygen With Love (OWL) program uses an icon on each bed (an owl, recognized for wisdom and good eyesight) to remind staff of the targeted ranges to supplement unit education, which includes the parents. Monitoring targeted ranges in this unit resulted in 80% compliance with a similar reduction in ROP for inborn infants (J.P.G., unpublished data).
There is general agreement that oxygen targets for critically ill preterm infants should be lower than historic norms. Clucas and colleagues have demonstrated that the first step in achieving this change, altering the alarm limits, is difficult to achieve. Education, involvement of the entire health care team and the parents, frequent monitoring and assessment with broad-based communication, empowerment, and perseverance will be needed to reach the goal of optimal oxygen delivery for sick neonates.
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FOOTNOTES |
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Address correspondence to Jay P. Goldsmith, MD, 1625 Joseph St, New Orleans, LA 70115. E-mail: goldsmith.jay{at}gmail.com
The authors have indicated they have no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
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