Background: Evidence suggests that oxygen supplementation is only beneficial to hypoxic patients (or oxygen saturation (SPO2) < 90%) yet is commonly given to normoxemic patients despite having no clinical indication for its use. Excessive oxygen supplementation with saturations above 96% for long periods of time has also been proven to increase mortality rates when compared to more conservative oxygen utilization. These practices increase the risk of potential harm to patients. Current guidelines for oxygen supplementation have a wide variety of ideal target ranges which makes it difficult to determine best practices clinically. To develop a standardized recommendation, we evaluated the literature as well as key areas of improvement in the entire process of oxygen use and created a guideline for Medicine Units in Froedtert Hospital, a large academic medical center. The aim of this project was to reduce the percentage of patients with inappropriate utilization of oxygen by half before the start of January 2021.

Methods: Nasal cannula (NC) oxygen use data for inpatients on the Froedtert Medicine Hospitalist service was pulled weekly beginning January 2020. Patients with cystic fibrosis, pulmonary hypertension, on home oxygen, devices other than NC, or post-operative were excluded. Chart review was utilized to ensure accurate tracking of oxygen saturation levels prior to and during oxygen use, to determine whether an explanation for the use was provided, to track oxygen orders, and to remove exclusions. A multidisciplinary team was assembled to determine appropriate standards and develop a guideline for O2 use. Initiation of NC O2 with a baseline SPO2 > 92% was defined to be inappropriate and three or more consecutive SPO2 > 96% was defined as excessive supplementation. The formal dissemination of the guideline to nursing and providers was August 17, 2020. A formal Epic order was created that indicated a range of oxygen use of 92-96% saturation and implemented on December 17, 2020. Creation of magnetic placards containing guideline reminders for nursing staff were trialed in Froedtert Hospital 9NT unit starting on December 29, 2020 and fully implemented on all units starting in June of 2021.

Results: Baseline data revealed that 40% of internal medicine patients at Froedtert Hospital were inappropriately placed on oxygen supplementation. Of these instances, 71% started in the Froedtert ED with continued use when patients were transferred to the floor. 55% of all patients on NC had at least one instance of excessive oxygen supplementation recorded during their stay. Only half of all improper uses of oxygen had any stated medical reasoning and only 30% had a corresponding order. Even instances of proper oxygen use had oxygen orders only 48% of the time. After our interventions, run charts revealed statistically significant decreases in both inappropriate initiation and excessive supplementation of oxygen. Data tracking revealed modest improvement of individual floor adherence to guideline with reminder placards. Our interventions have not had any effect on increasing charting for oxygen use nor on including oxygen orders.

Conclusions: These data indicate that inappropriate oxygen initiation and excessive supplementation has significantly decreased across all internal medicine units after implementation of our interventions. Most uses are still initiated in the ED and maintained upon reaching the floor. We have improved weaning procedures and have increased the number of patients screened on room air within four hours upon arrival to the floor. Most instances of oxygen use continue to have no associated order even after we updated the Epic oxygen order. The trial placards in contrast appear to be an effective reminder to nursing staff of oxygen use and weaning procedures. Next steps include continuing to track the guideline’s long-term effect on improper oxygen utilization. Further quality improvement interventions will likely be required to reach our goal with regards to oxygen orders. The Froedtert ED has also expressed interest in carrying over the project with some adjustments to suit their needs.

IMAGE 1: Figure 1: Control chart displaying changes in improper initiation of oxygen over time. Prior to intervention, 39.2% of all NC oxygen use in either the ED or the floor was started inappropriately while patient had an SPO2>92% which is indicated by the yellow line. As of June 19, 2021, current inappropriate oxygen use is down to 26.8% (p=0.00001) with maximum improvement after modifying the standard EPIC order

IMAGE 2: Figure 2: Control chart displaying changes in maintenance of oxygen. Excessive supplementation was defined as three or more consecutive SPO2 values above 96%. At baseline, 55.6% of patients on NC while on the floor were excessively oxygenated sometime during their stay which is indicated by the yellow line. As of June 19, 2021, current over supplementation has reduced to 35.1% (p=0.00001)