Retinopathy of Prematurity (ROP)

Using Visual Management Tools to Improve Oxygen Targeting and Reduce ROP in the Micropremie population

The Neonatal Intensive Care Unit (NICU) is a Level IV regional medical center with 108 beds both single and open bay, greater than 1200 total admissions per year with an average of 250 very low birth weight infants per year.

Prior to 2011, an oxygen saturation range of 83 to 92% was used for very premature babies. This resulted in a decreased rate of retinopathy of prematurity (ROP) and chronic lung disease (CLD). In 2011, the decision to change the oxygen saturation range to 88 to 95% was made. This was in response to studies that linked higher mortality rates to lower oxygen saturation ranges.

Registered Nurses (RN’s) and Respiratory Therapists (RT’s) caring for these infants had varied practices for managing oxygenation. This variation in practice could be attributed to lack of knowledge regarding the effects of hypoxia and hyperoxia.

A multidisciplinary team was pulled together to decide on an approach to improving compliance and standardization in practice. The team hypothesized that use of a visual management tool would assist in improving oxygen management and also prompt discussions with providers and other team members about individualizing oxygen saturation targeting. This was based on previous success of other centers that have used visual management to improve a team approach to oxygen management. The results of these efforts would have an impact on ROP and potentially CLD rates.

The multidisciplinary team also reviewed morbidity outcomes in comparison to the Vermont Oxford Network Quality (VON) an international quality improvement collaborative and registry for neonatal units. It was identified that ROP rates were higher than the other centers. Additionally, baseline data and practices including histograms, a current algorithm compared to other organizations, the VON annual report for severe ROP from 2005-2015, and the results of a Survey Monkey to assess staffs current practices and level of understanding about oxygen management were reviewed. It was determined that the use of a visual management tool, referred to as the Oxygen With Love (OWL) project, was a way to individualize oxygen target saturation and prompt discussions between the care givers in an effort to heighten awareness and understanding about the importance of oxygen management.

The goal is to reduce the rate of severe Retinopathy of Prematurity (ROP) from the current rate of 15.9% to the VON rate of 6.3% by December 2017. The intermediate goal is a 50% reduction by December 2016. Subsequently, a series of three Plan, Do, Study, Act (PDSA’s) cycles focused on Oxygen with Love (OWL) visual management were conducted January through April 2016. This intentional effort to improve the interdisciplinary approach in managing oxygen saturation in the premature infant resulting in the following interventions:

  • Adoption of the OWL cards on all infants receiving supplemental oxygen
  • Completion of the oxygen tracking tool
  • Developed and implemented communication workflow for the providers, the bedside caregivers, and for families
    • Communication standard work includes information about the card, expectations, and tracking form and was shared via an SBAR e-mailed to staff in addition to shift overview, CNS update, and provider check out rounds.

In the two quarters July 2015 through December 2015 the ROP rate was 16%. In the two quarters post PDSA intervention, July 2016 through December 2016, the rate decreased to 7.5%.


Team Members:

Amy Atwater MPA, BSN, RN
Kari Luymes RT
Denise Brown BSN, RN, CCRN,
Jennifer Teller BSN, RN, RNC-NIC
Teresa Smeckert RN, RNC-NIC
Mark Willing RRT
Krista Haines MD
Vickie Westing BSN, RN, RNC-NIC
Laurie Smith RN, RNC-NIC
Joshua Steiner BSN, RN
Kelley Romans BSN, RN, RNC-NIC
Beth Huizinga MSN, RNC-NIC
Sherri Hoard BSN, RN, RNC-NIC
Caitlin Holman BSN, RN, RNC-NIC
Barb Mcgorty RRT
Ben Doctor MD
Jeanette Prentice MD
Amy Nyberg

NOTE: OWL concept through work with VON (it was part of the Chronic Lung Disease work group) but Neo made many modifications to meet HDVCH need.