Reducing Hyperoxia in the Critical Care Unit: a Quality Improvement Initiative
CCCF ePoster library. JT. 11/13/19; 283413; EP132
Ms. Julie Nardi and
Ms. Julie Nardi and
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Topic: Quality Assurance & Improvement

Nardi, Julie1;Linseman, Beth1; Bodley, Thomas2; Amaral, Andre Carlos1,2
1: Sunnybrook Health Sciences Centre, Toronto, Ontario
2: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario

Providing supra-physiologic supplemental oxygen can induce hyperoxia, which is associated with increased mortality in critically ill patients.1, 2   Despite literature supporting conservative oxygen therapy to target normoxia, 3 patients are hyperoxic 63% of the time in the Sunnybrook Critical Care Unit (CrCU).
The project aim was to reduce the percentage of CrCU patients with hyperoxemia (blood oxygen saturation greater than 97% on supplemental oxygen) by 25% between November 30, 2018 and April 30, 2019.  The primary outcome was percentage of CrCU patient days with blood oxygen saturation (SpO2) > 97% on supplemental oxygen. 
The interprofessional ICU team, including respiratory therapists, nurses, staff physicians, fellows and residents was engaged as part of this project.  An Ishikawa diagram identified primary drivers for hyperoxia such as lack of clinician awareness of the potential patient harms, and miss-understanding the relationship between arterial oxygen tension, SpO2, and systemic oxygen delivery.  Process mapping identified existing CrCU order sets as a target for improvement, including current SpO2 targets which did not have an upper limit. Interventions included a CrCU unit educational campaign and revision of existing CrCU admission order sets to adjust SpO2 targets. Five PDSA cycles were performed. Cycles one and two included quality “walk arounds” and bedside pilot testing of an upper limit SpO2 alarm. Feedback from the ICU staff prompted our third PDSA cycle utilizing a structured educational handout tool to improve knowledge about hyperoxia.  PDSA cycles four and five consisted of implementing changes to existing order sets to alter SpO2 targets (changing from SpO2 > 92% for all patients to SpO2 88-95%). We used an interrupted time-series method to analyze the changes in hyperoxia rates. Interrupted time-series control for secular trends that are a common threat to validity in before-after studies, and also provides information on the sustainability of the intervention. We coded intervention as beta1, secular trend as beta 2 and post-intervention trend as beta3.
The interrupted time-series shows an immediate effect of the intervention that led to a decrease of 8% in hyperoxia rates (beta 1 = -0.08, 95% CI: -0.16 to -0.01, p = 0.03), a constant decrease in hyperoxia rates of 3% per month after the intervention (beta 3 = -0.03, 95% CI: -0.06 to -0.00, p = 0.04), and no evidence of a secular trend (beta 2 = -0.00, 95% CI: -0.02 to 0.01, p = 0.57). Mean hyperoxia rate (SpO2 > 97% on supplemental oxygen) during the intervention was 33% vs 53% baseline (p<0.02 for Special Cause Variation using chi-square statistics for the dichotomized outcome).  The Run Chart in Figure 1 summarizes our findings.  
Hyperoxia among critically ill patients is preventable, and the incidence can be reduced through a systematic multifaceted intervention that leads to an immediate change of 8% in rates and a constant improvement of 3% per month afterwards. Given the harms of hyperoxia extend beyond critically ill patients; future work should focus on other departments such as the Emergency Room and General Wards, as well as regional dissemination to other health care institutions.



  1. Damiani E, Adrario E, Girardis M, et al. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta-analysis. Critical Care 2014:18:711.
  2. Helmerhorst H, Ross-Blom MJ, Westerloo DJ, de Jonge E. Association between arterial hyperoxia and outcome in subsets of critical illness: a systematic review, meta-analysis, and meta-regression of cohort studies. Critical Care Medicine 2015:43(7):1508-19.
  3. Chu DK, Kim LH-Y, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczekilik W, Schunemann HJ, Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018;391:1693-705.


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