O2 range: an innovative health system implementation of nurse/respiratory therapist-driven oxygen management to achieve evidence-based goal oximetry ranges

SESSION TITLE: Pioneering Pathways to Improve Quality SESSION TYPE: Original Investigations PRESENTED ON: 10/11/2023 08:30 am - 09:30 am PURPOSE: Mounting evidence suggests that excessive use of supplemental oxygen (O2) for hospitalized patients leads to hyperoxia, a condition associated with mortality and morbidity. Despite this, at the University of Pennsylvania Health System (UPHS), clinician ordering of O2 was not consistent, O2 titration and weaning were not guideline-based, interdisciplinary clinicians experienced poor communication surrounding O2 administration, and clinicians did not adjust pulse oximetry (SpO2) goals for hypercapnic respiratory failure risk. With support from the UPHS Executive Leadership, we sought to develop and implement evidence-based “oxygen-in-range" (O2RANGE) guidelines for standardized Registered Nurse (RN)/Respiratory Therapist (RT)-driven inpatient nasal cannula O2 management. METHODS: An interdisciplinary taskforce conducted clinician surveys to understand baseline practices and literature review to determine best practices in O2 initiation, titration, and weaning. We then designed and implemented role-based educational modules, a novel algorithmic clinical decision support (CDS) tool and O2 order, and clinical pathways for O2 initiation, titration, and weaning. O2RANGE also incorporated newly published data on racial bias in oximetry. O2RANGE was pilot-tested in 2 units at 1 hospital and subsequently implemented across 5 UPHS hospitals. Quality improvement and change management principles were employed to facilitate adoption. RESULTS: Pre-pilot data from 1 unit revealed missing O2 orders for up to 14% of inpatients receiving supplemental O2. Among patients at risk for hypercapnic respiratory failure, up to 31% had inappropriate SpO2 goals ordered. Post-deployment, all hospitalized patients on nasal cannula O2 are ordered a target SpO2 of 94-98%, or 88-92% for patients at risk for hypercapnic respiratory failure. In the first 6 months across 5 UPHS hospitals, the new O2 order was placed 169,881 times across 79,516 encounters. These target SpO2 ranges were selected 153,050 (90%) and 16,355 (10%) times, respectively. Next steps include quantitative evaluation of effectiveness and patient outcome metrics, including time on supplemental O2, hypoxic/hyperoxic events, and time to documentation (expected to be available by conference). CONCLUSIONS: Interdisciplinary collaboration on range-based SpO2 goals coupled with education, just-in-time reminders, and CDS tools were deployed across 5 UPHS hospitals to aid providers in choosing appropriate SpO2 goal ranges and facilitate RN/RT-driven O2 initiation, titration, and weaning. CLINICAL IMPLICATIONS: O2RANGE is a clinically transformative solution for the complex patient safety issue of inpatient nasal cannula O2 administration. Through a standardized and evidence-based approach, these efforts aim to provide structure and ownership to healthcare teams and to reduce harm to hospitalized patients from hypoxia and hyperoxia, racial bias in oximetry, and hypercapnic risk. DISCLOSURES: No relevant relationships by Sarah D'Ambrosia No relevant relationships by Paula Gabriel No relevant relationships by Rachel Kohn No relevant relationships by Benjamin Parker No relevant relationships by Huey Pigford No relevant relationships by Sameh Saleh No relevant relationships by Rebecca Stamm No relevant relationships by Arshad Wani