Table 1

Details of Plan–Do–Study–Act (PDSA) cycles

PDSA cycleWhenPlanDoStudyAct
1
(n=30)		22 Dec 2017–5 Jan 2018Assess the feasibility of starting nasal prongs and implement oxygen policy

  • In 30 random neonates, use of nasal prongs as primary respiratory support.

  • Assess nasal injury, tolerability of prongs, difficulties in fixation, fitting, desaturations and need for switching to oxygen hood.

  • Subjective experience of mothers and nurses

  • Assess daily (1) proportion where saturation checked before starting oxygen at triage, (2) proportion on continuous and intermittent pulse oximetry, (3) proportion in whom starting and stoppage of oxygen was documented.

  • All 30 were successfully started on nasal prongs.

  • There were no nasal injuries; two neonates had mild desaturations due to dislodgement and were switched to hood.

  • Nurses and mothers were happier. They could observe the babies better.

  • Oxygen saturation recorded in all before initiating oxygen.

  • Continuous pulse oximetry could be done in 12 (40%), intermittent monitoring could be done in rest; oxygen starting and stoppage documented in all.

  • Develop SOP and train nurses in fixation of prongs.

  • Decision of starting oxygen to be taken by the triage nurse after checking saturation.

  • All neonates deemed eligible for oxygen therapy will be started on nasal prongs at 0.5–1 L/min.

  • Continuous pulse oximetry will be prioritised for babies on CPAP or who have frequent desaturations or increased work of breathing. For rest, intermittent (every 2 hours) monitoring will be done.

  • Document the start and stoppage of oxygen along with indication.

2
(n=292)		(A)
6 Jan 2018–19 Jan 2018		Universal application of adapted oxygen policy to all eligible neonates

  • Assess compliance to use of nasal prongs as in all eligible neonates.

  • Record the number of babies with nasal prongs failure due to dislodgement.

  • Record daily oxygen cylinder consumption.

  • 100% compliance to nasal prongs use as primary respiratory support.

  • Rare failures.

  • Oxygen cylinder consumption decreased.

  • Less attention to stopping oxygen.

  • Doctor to enquire the reason for continuation of oxygen during bedside rounds.

  • Nurse will document the reason for continuing oxygen.

(B)
20 Jan 2018–2 Feb 2018		All above+

  • Ongoing education and sensitisation of staff, weekly meetings and appreciating weekly champions.

  • In 2 neonates with moderate respiratory distress, hiking of respiratory support from nasal prongs to CPAP was delayed.

  • Capacity building of nurses in the identification of moderate to severe respiratory distress for timely escalation of respiratory support

(C)
3 Feb 2018–16 Feb 2018		All above+

  • Training of nurses in assessing severity of respiratory distress to identify babies needing CPAP and empowering them to initiate CPAP.

  • Daily number of babies on oxygen decreased, however number of admissions remained the same

  • Number of neonates receiving CPAP increased.

  • No change in nasal injury and mortality rates

  • Finalise modifications in oxygen policy and SOP.

  • Plan audits, feedback and refresher training

Sustenance phase
(n=1005)		21 Feb 2018–30 Sep 2018Dissemination and regular audit plan

  • Disseminate the final policy and SOP.

  • Record cylinder consumption.

  • Monthly meeting, audit, refresher training and feedback.

Monthly audits

  • Compliance with oxygen policy

  • Number of admissions, number of babies receiving oxygen, number of oxygen cylinders used.

  • Mortality.

  • CPAP, continuous positive airway pressure; SOP, standard operating procedure.