There is strong evidence that inappropriate oxygen administration to newborns is associated with important morbidities and toxicities including increased mortality, lower Apgar scores, prolonged time to first breath, oxidative stress, organ damage and childhood cancers. The vast majority of infants at birth do not require interventions beyond initial NRP steps to support normal transition to extra-uterine life. Healthy near term and term infants often do not have transcutaneous saturations greater than 90% for five to ten minutes or longer with no ill effects. As long as the heart rate is greater than 100 bpm the infant is breathing, and there is reasonable muscle tone, there is no need to administer supplemental oxygen, even if the infant appears cyanotic. The assessment of “color” in a newborn is highly subjective, sometimes misleading, and not nearly as important as the evaluation of heart rate, breathing and muscle tone.

In our program supplemental oxygen is only administered after 90 seconds of effective airway management and ventilation, if the heart rate is < 100 and respirations are inadequate. Oxygen administration is begun in a blended fashion (going up from 21% not down from 100%) and with pulse oximetry applied to ensure that transcutaneous saturations do not rise above 95%.

Initiative Change Process:

The process of transitioning to room air resuscitation of newborns began in the NICU at Providence St Vincent Medical Center, the largest hospital with 6,000 births annually in the Providence Health & Services System in Oregon. The timeline for implementing at the seven hospital Perinatal Units was 18 months from initiation of the project and the formation of a multidisciplinary committee for the change process. Nursing, medical providers, respiratory therapy, and all the hospitals were represented in the group.

Educational requirements for the nursing staff, medical providers, and respiratory therapy were very significant. A room air resuscitation change package developed by the committee included:

§         Room Air Resuscitation (RAR) position paper

§         RAR powerpoint/HealthStream Module & post test

§         RAR practice alert

§         RAR primary reference article by Saugstad

§         Revised NRP algorithm

Challenges included:

§         Accessing clinical data in the electronic chart relative to the clinical change to monitor baseline, process and outcome measures

§         Equipment-purchase, training and competency

§         Difficulty of changing ingrained clinical practice after decades of acceptance

§         Clarifying NRP “allows” this variation in the published NRP algorithm

§         Conveying increased legal risks of continued indiscriminate oxygen use in the face of the current clinical evidence

By May of 2008 six of seven Oregon hospitals had transitioned to room air resuscitation as described above. By Spring of 2009 we should have process and outcome data to present. There are plans to export the clinical change to the rest of the Providence Health & Services System, 26 hospitals in 5 states in 2009-10.