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The neonatal intensive care unit at Johnson City Medical Center is a level III regional referral center that serves the areas of Northeast Tennessee, Southwest Virginia, and Western North Carolina.  Monitoring patient outcomes is very critical for this vulnerable patient population.  In 2006, we recognized that the number of infants experiencing retinopathy of prematurity (ROP) was much higher in our NICU than in facilities participating in the Vermont Oxford quality collaborative.  Our goal was to use published science to find a solution to this problem. 

The initial step toward a solution involved the development of a multidisciplinary team which consisted of a physician champion, a nurse practitioner, nursing, and respiratory therapy.  This team came together to explore the available research relating to all facets of ROP causation as well as research relating to any possible contributing factors.  The result of the evaluation of evidence was the creation of an ROP risk reduction strategy which addressed four major areas.  These areas included oxygen therapy, Epogen treatment protocols, iron replacement therapy, and blood transfusions. 

Oxygen therapy protocols were developed so that weaning practices and initiation of oxygen therapy were carefully regulated.  Team members were education on the premise that oxygen therapy is not a benign treatment strategy in this patient population and should be considered carefully and prudently.  Physicians also participated by evaluating their use of medications affecting the oxygen binding and carrying capacity of blood.  Changes were made to Epogen treatment strategies, iron replacement therapy and blood transfusion protocols.           

The strategy was implemented after wide-spread education and training, then compliance was evaluated by front-line team members.  What resulted from consistent implementation of current evidence-based interventions was a significant reduction in the number of infants within our NICU who experienced ROP and also a decrease in the severity of ROP when it did occur. Several activities have been done to ensure that we hold our gains.  Laminated cards have been placed at the bedside to remind nurses to keep oxygen with the normal limits.  We have provided ongoing education for new employees about ROP and ROP prevention, and we have developed monitoring tools to ensure the prevention strategies are followed.  Since July of 2008, nurses have been doing monthly rounds to assess for compliance.  July saw the worst results with a mean compliance rate of 52%.  After education and increased monitoring, compliance has increased to 100%.               

In 2006, 75% of infants weighing 501 to 1500 grams experienced some stage of ROP as opposed to the Vermont Oxford rate of 48.1%.  Infants with severe ROP in 2006 totaled 14.3% as opposed to 11.1% in the Vermont Oxford network.  Outcomes for this extremely vulnerable population have changed drastically since that time.  In 2008, only 31% of our infants experienced any stage of ROP as compared to 47.1% in Vermont Oxford.  Severe ROP dropped to 4.3% with the comparison group at 10.5%.  These results have shown how science can help find solutions for problems.