Oxygen Stewardship in Adult Critical Care: A Quality Improvement Initiative

BACKGROUND: Oxygen therapy is commonly administered in critical care, yet patients frequently receive oxygen above recommended saturation targets. Excessive oxygen exposure may contribute to avoidable harm and unnecessary resource use. Despite guideline recommendations, reliable adherence to oxygen titration targets in routine intensive care practice remains inconsistent. AIM: To evaluate the impact of a nurse-engaged oxygen stewardship quality improvement initiative on adherence to oxygen saturation targets and oxygen consumption in an adult intensive care unit. STUDY DESIGN: A clinician-led, before-and-after quality improvement evaluation was conducted over 21 months in a mixed adult intensive care unit. The intervention integrated a standardised oxygen weaning protocol, multidisciplinary education, audit and feedback through spot checks, workflow reminders and iterative refinement informed by staff surveys and interviews. RESULTS: The proportion of patient-days outside target oxygen saturation ranges decreased from a median of 63% (IQR 57-65) pre-intervention (n = 2686 patient-days) to 20% (IQR 15-22) post-intervention (n = 5621 patient-days), with sustained improvement over 12 months. Median monthly oxygen consumption per patient-day declined significantly for conventional oxygen therapy, non-invasive ventilation and mechanical ventilation. High-flow nasal cannula therapy remained associated with higher non-compliance rates and showed no statistically significant reduction in oxygen consumption. Reductions in overall oxygen use were primarily attributable to decreased oxygen delivery during non-compliant periods, while oxygen use within target ranges remained stable. CONCLUSIONS: Embedding oxygen stewardship into routine critical care workflows was associated with sustained improvements in oxygen titration practice and reduced oxygen consumption. Behavioural reinforcement and integration into daily nursing practice were key to maintaining adherence. RELEVANCE TO CLINICAL PRACTICE: Structured oxygen stewardship initiatives can support critical care nurses in delivering guideline-adherent oxygen therapy, strengthen accountability during handovers and reduce unnecessary oxygen exposure without compromising appropriate treatment.