Tuesday, June 12, 2007
Whoever said you can't get too much of a good thing didn't know about neonates and oxygen. We try to keep a premature baby's oxygen saturation - the level of oxygen in their blood - in a certain range, 88% to 94% for example, because not only can too little oxygen be harmful, but also too much can be harmful, especially to the eyes and lungs. We continuously measure the oxygen saturation with a monitor and adjust the amount of oxygen we give the baby based on what the monitor tells us. If the oxygen saturation goes too high or low, an alarm on the monitor goes off to let us know so we can adjust the amount of oxygen we're giving.
Over the past several years we have learned that it's better to keep the baby's oxygen level at a lower range than previously done. We used to keep their oxygen saturations at, say, 92 to 97%, whereas now they might be kept at 88 to 94 % or maybe 85 to 92%, the level varying from NICU to NICU.
There's one problem, though. It can be tough to get the people who adjust the amount of oxygen given, primarily the nurses, to accept that too much oxygen is bad for a baby and that it really is important to keep the oxygen level from going too high. It's pretty easy to get a nurse to increase the amount of oxygen given when a baby's oxygen saturation falls to, say, 80%, but it seems harder to get them to decrease the amount of oxygen given when the saturation is, say, 98%. It's understandable; all our life we're taught how we need enough oxygen. The too much oxygen thing almost goes against our nature.
One way we try to keep the oxygen levels lower is by setting lower the level at which the monitor alarms. If we want to keep the oxygen saturation level below 92%, we would probably set the monitor so it alarms when the saturation goes above 94%. Here, too, we have a problem sometimes with getting the nurses to set the alarm at a lower level that we used to, and this bothers me some. Why do we have trouble getting some of the nursing staff to do this?
It's not because it's not explained to them. A few years ago when we decreased our suggested oxygen saturation range and monitor alarm limits we gave inservices to the nurses explaining why we were doing so, showing them the research that proved it was beneficial. Some nurses caught right on and were very conscientious in adjusting the amount of oxygen given and the alarm limits, but others didn't seem to take it too seriously. My experience is not unique, because an article in the latest Pediatrics shows that in the NICU studied the upper monitor alarm limit was set correctly only 23% of the time, with it usually being set too high.
Why, I wonder, is change so hard for some people? Change can be hard for me, too, but when it's explained to me why a change will be better, I change. Also, if a standing order or policy changes, I follow the new standing order or policy. So why don't some of the nurses follow the new policy of setting the oxygen alarm limits lower? It can drive me a little batty at times.
Please don't take this as a broadside against nurses. Some of them change admirably and want to keep up with the latest information. Also, nurses are hardly the only people who have trouble changing. I know there are some doctors who are set in their ways or are just not conscientious about making certain important changes. But still, it bugs me.
A few years ago I gave one of the inservices explaining why we now wanted to keep the oxygen levels in a baby's blood lower. One of the nurses dozed through most of my presentation, which was short and, hey, not that boring. When my inservice was done, I said,"Okay, now, let's keep those oxygen saturations in the normal range."
The nurse sniffed sarcastically. "Oh, is that what we have to do now?" like it was a totally ridiculously thing to do and a waste of her time. I wanted to kick her behind out the door. We're taking care of babies here, not making widgets, so when a change improves their care, doggone it, we'd better change.