Reducing Severe Retinopathy of Prematurity in the NICU

Babies born prematurely have a greater risk of losing their vision because of several conditions that can hinder their eye development.

One of those conditions is retinopathy of prematurity (ROP), which causes underdeveloped blood vessels in a baby's retinas. ROP screenings are recommended for babies born before 31 weeks' gestation and weighing 1,500 grams (3.3 pounds) or less.

Seeing a hopeful future

Mild ROP, defined as stage 1 and 2, sometimes resolves by itself. However, stages 3 and 4 retinopathy of prematurity, known as severe ROP, are a leading cause of childhood blindness. About 1 in 820 babies with ROP will lose their vision.

But thanks to nurse researchers at Children's Hospital Colorado, families with preemies can see a more hopeful future. In 2018, the team launched a quality improvement project to reduce the rate of severe ROP in our Colorado Springs neonatal intensive care unit (NICU).

Research shows that resolving ROP without surgery whenever possible yields better overall outcomes. Surgery can increase the risk of a baby developing strong nearsightedness, cataracts and other conditions.

Finding the key

The team began by studying existing literature and inviting pediatric ocular specialist Scott Oliver, MD, to share his expertise.

Multiple risk factors can contribute to ROP, including anemia, blood transfusions, breathing difficulties and a baby's overall health. But the team discovered a simple factor that held a key to halting ROP: measuring a baby's blood oxygen using pulse oximetry.

Previous research had shown mixed results on the ideal saturation levels of blood oxygen, but new findings point to lowering the range to protect retinal blood vessels. With that goal in mind, the team developed key drivers and interventions to prevent disease progression:

• Establishing and maintaining a target pulse oximetry range, which varies based on a baby's gestational age at birth
• Setting correct pulse oximetry alarm limits
• Establishing a protocol to reduce fluctuation of oxygen saturation in a baby's blood
• Increasing ROP awareness, real-time staff education and family involvement
• Implementing audits and a task force to ensure ongoing compliance

The team grounded their project in national best practices, using a "Plan-Do-Study-Act" methodology:

• Plan: Develop a strategy to test the changes
• Do: Carry out the changes
• Study: Observe and learn from the results
• Act: Determine what modifications should be made

Clearing a major health hurdle

The interventions made an immediate, dramatic impact: The number of cases of ROP requiring laser surgery at Children's Colorado dropped 45% in 2018.

Team members are now equipped to troubleshoot the most challenging ROP cases, avoiding surgery whenever possible. That means the condition is more likely to resolve on its own, giving babies a better chance of having normal vision.

Like all preemies, ROP patients are at risk for other vision delays and conditions, such as amblyopia (lazy eye) and strabismus (eye misalignment). But by improving treatment for retinopathy of prematurity, Children's Colorado is helping its smallest patients clear a major health hurdle.

"Whenever we can prevent a baby from needing to have surgery, that's a big win," says Victoria Del Valle, a clinical nurse specialist in the NICU. "Correcting ROP as soon as possible can make a dramatic difference throughout a child's entire life."