Pulse Oximetry Quality Audit
What we know: Since the 1950’s we have known that the unrestricted use of supplemental oxygen for preterm infants increases the risk for retinopathy
of prematurity, but the optimal strategy for the management of oxygen therapy remains uncertain. Recent evidence from the SUPPORT and
BOOST II trials shows that infants managed using a high oxygen saturation target (91% to 95%) as opposed to a low saturation target
(85% to 89%) were more likely to develop retinopathy of prematurity, but were less likely to die.
What we did: The Vermont Oxford Network conducted the VON Days Pulse Oximetry Audit between October 31st and November 4th, 2011 to assist teams in
understanding their own oxygen management practices and to provide a snapshot of current practices at a wide range of neonatal units.
Each participating unit chose a single day in that period to audit all infants less than 30 weeks gestation at birth on a pulse oximeter.
For each eligible infant the audit addressed the low and high ordered oxygen saturation target, the low and high pulse oximeter alarm
settings, and whether the targets and alarm settings were consistent with the unit’s own policies and guidelines.
Audit data were entered using the VON Day on-line audit tool which provided immediate feedback on the unit’s own audit results (see Manual of Operations).
What we found: Of the 150 NICUs (16% Type A, 58% Type B, 26% Type C) participating in the audit, 88% have policies or guidelines for oxygen saturation
targets and 93% for alarm limits. Only 38% of units have revised their policies or guidelines in response to the recent trial results. Audits were performed for 1814 infants
(median per center 10, range 1 to 47. The median lower and upper saturation targets for these infants were 85% (1st quartile 85%, 3rd quartile 88%) and 95%
(1st quartile 93%, 3rd quartile 99%), respectively. The median lower and upper alarm limit settings were 85% (1st quartile 83%, 3rd quartile 88%) and 100%
(1st quartile 96%, 3rd quartile 100%), respectively. The median width of the target saturation range (difference between upper and lower target) was 8%
(1st quartile 6%, 3rd quartile 12%). The median difference between the lower saturation target and the lower alarm setting was 0%
(1st quartile 0%, 3rd quartile 3%). The median difference between the upper alarm setting and the upper saturation target was 1%
(1st quartile 0%, 3rd quartile 5%). Of the 1814 audited infants only 53% had ordered saturation ranges and alarm limit settings consistent
with their own unit’s policies and guidelines.
In summary, although most units have policies and guidelines for oxygen saturation targets and alarm limits, only half of the infants under 30 weeks being monitored on the day of the audit had ordered saturation targets
and alarm limits consistent with these policies and guidelines. Furthermore, despite new evidence suggesting increased risk for death when
lower oxygen saturation targets are used, only 38% of units have changed their guidelines in response to this evidence, and half of all
infants are being managed with a lower oxygen saturation target of 85%
Next Steps: Based on the VON Day Pulse Oximetry Audit it is clear that there are opportunities to improve the
management of oxygen therapy and pulse oximetry. There is still uncertainty regarding the appropriate target saturation ranges and
alarm limits. However, we must make our best effort to translate the available evidence into action. The upcoming iNICQ will address
some of these issues and provide a platform for improving the quality of care at your center.
For more information about the 2012 iNICQ series click here.