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The Toxigen Initiative: Targeting Oxygen Saturation to Avoid Sequelae in Very Preterm Infants

Deuber, Charlene DNP, NNP-BC, CPNP; Abbasi, Soraya MD; Schwoebel, Ann MSN, RN; Terhaar, Mary DNSc, RN

Section Editor(s): Dowling, Donna

doi: 10.1097/ANC.0b013e31828913cc
Original Research

Supplemental oxygen plays a critical role in the care of infants born at the lower limits of viability, but not without the risk of morbidity resulting from high levels or prolonged exposure.

PURPOSE: The purpose of this quality improvement project was to reduce exposure to hyperoxia as evidenced by SpO2 values within the established target range (88%-92%) among very preterm infants (VPIs) in a level 3 neonatal intensive care unit (NICU). Reducing exposure to hyperoxia in this population of exquisitely vulnerable infants has been associated with reduced morbidity, including retinopathy of prematurity, chronic lung disease, and brain injury.

SUBJECTS: Two populations of interest were identified: VPIs receiving supplemental oxygen and NICU clinicians.

DESIGN: Interventions were employed to (1) improve knowledge regarding hyperoxia and associated outcome sequelae in an interdisciplinary sample of clinicians (pretest posttest design) and (2) reinforce content of the educational intervention by triggering caregiver behaviors to reduce time the VPIs is above target SpO2 range while receiving supplemental oxygen (cohort design).

METHODS: Retrospective chart review, baseline clinician knowledge assessment, education, posteducation assessment, collaborative rounds with regular feedback citing time VPIs spent above target oxygen saturation levels (SpO2), and evaluation of impact on time infants spent above target SpO2 range aligned with the project purpose.

OUTCOME MEASURES: Pre- and postintervention dependent variables included clinician knowledge of hyperoxia and related evidence as measured by a 24-item multiple-choice Knowledge Assessment Tool before and after attending an educational presentation. Time VPIs were exposed to hyperoxia was evaluated using SpO2 readings and calculating the percentage of time readings were above target range before and after the introduction of educational and behavioral interventions.

PRINCIPAL RESULTS: Outcome 1 was to increase knowledge about hyperoxia among clinician caregivers. Paired-samples t test showed a significant difference between preintervention and postintervention Knowledge Assessment Tool scores (P = .000). Outcome 2 measured reduction in time spent with SpO2 readings above target range. An independent-samples t test was used to compare outcomes in preintervention and postintervention VPI cohorts. Mean time spent with SpO2 greater than target range increased in the postintervention cohort, reaching statistical significance with P = .047.

CONCLUSIONS: Knowledge acquisition on the subject of hyperoxia in VPIs was achieved. Decreasing the percent time VPIs were exposed to hyperoxia was not attained. The postintervention VPI cohort spent more time above the target saturation range despite greater knowledge among clinicians.

Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia (Dr Deuber), CHOP Newborn Care at Pennsylvania Hospital and University of Pennsylvania School of Medicine (Dr Abbasi), and Neonatal Intensive Care Nursery, Pennsylvania Hospital (Ms Schwoebel), Philadelphia; and Doctor of Nursing Practice Program, School of Nursing, Johns Hopkins University, Baltimore, Maryland (Dr Terhaar).

Correspondence: Charlene Deuber, DNP, NNP-BC, CPNP, Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA 19104 (

The authors thank Annette Kirlin-Jones, MBA, RN, for assisting with scoring and unit dissemination of findings.

The authors declare no conflicts of interest.

© 2013 National Association of Neonatal Nurses