(1337) Oxygen Toxicity Prevention in the Pediatric Intensive Care Unit: Quality Improvement Initiative

Introduction: Excessive oxygen supplementation in the pediatric intensive care unit (PICU) can lead to systemic toxicity and worsen patient outcomes. Hyperoxia, or supraphysiologic PaO2, has been associated with increased mortality in critically ill children due to the formation of reactive oxygen species (ROS) and induced inflammatory responses causing cellular apoptosis. Although guidelines recommend maintaining oxygen saturation (SpO2) below 98%, the optimal oxygen parameters remain unclear. This study aimed to reduce hyperoxia exposure among mechanically ventilated children in the Arkansas Children’s Hospital PICU.

Methods: A multidisciplinary team was formed to lead the initiative. QI methodology was used to plan and implement the initiative. After a thorough literature review and initial presentations to gauge interest, key drivers for improvement were identified. Interventions included targeted education, changes in electronic health records, and clinical decision support tools.

Interventions:

Education and Engagement: Educational modules on oxygen toxicity were added to the mandatory nursing curriculum, with periodic reminders and updates provided during PICU QI meetings.
Electronic Health Record Adjustments: Ventilator orders were modified to preselect SpO2 goals (90-97%) and allow staff to wean FiO2 to 0.21 if SpO2 was within range.
Best Practice Advisory (BPA): A BPA was created to alert staff when SpO2 was 98-100% with FiO2 > 0.21, reminding them to wean FiO2 as appropriate. Alerts were limited to once every 4 hours to prevent alarm fatigue.
Measurement:
Hyperoxia was defined as SpO2 of 98-100% with FiO2 > 0.21. Hourly SpO2-FiO2 data pairs were collected, and the hyperoxia rate was calculated and monitored monthly. Baseline data from the 12 months prior to the project were compared to post-intervention data.

Results: Following the first PDSA cycle, hyperoxia rates decreased slightly. However, after the second PDSA cycle, the hyperoxia rate dropped significantly to an average of 27% and was sustained for > 10 months, exceeding the project goal.

Conclusions: Using QI methodology, we achieved a substantial and sustained reduction in hyperoxia rates among mechanically ventilated children in the PICU, demonstrating the efficacy of electronic health record tools in improving clinical practices.