Preventing Oxygen    Toxicity: a whole system            approach           Prof Tony Davison       Co-Respiratory Lead Ea...
Oxygen in Hospital• 17.5% of UK hospital  patients are receiving  oxygen at any given  time•   About 18,000 people every d...
Chaos reigned until 2008  • Most patients were given too much oxygen    And there was disagreement about how much oxygen t...
UK Emergency Oxygen Guideline       published 2008                                4
Key Principles• Oxygen is a treatment for low oxygen (Hypoxemia)  (Giving oxygen does not relieve breathlessness or increa...
“They gave me a cardbecause I’m intolerantof too much oxygen.They used to whack upthe oxygen in theambulance on the wayto ...
“I think it is a good“Last time I was               thing, it stops themadmitted they didn’t           poisoning me withtu...
Implementation from Guideline to Patient                       Doctors must prescribe                             Monitori...
Oxygen prescriptionModel for oxygen section in hospital prescription charts      DRUG                      OXYGEN         ...
Online appendix of Guideline includes            implementation materials• Summary of recommendations• Sample local oxygen...
Implementation and DisseminationAdvantage of Partnership    Incorporation of Emergency Oxygen Guidelines in               ...
National Patient Safety Agency        Rapid Response Report – September 2009                           Immediate Actions  ...
Overview of results 2008-2012                      2008-Year             2008              2009             2010          ...
Drug rounds & Observation Rounds  Year           2008             2009       2010      2011            2012  Percent   of ...
Electronic Prescribing in 2012• 11 of 94 responding hospitals (12%) have  fully Electronic Prescribing in 2012  (8% in 201...
Making it happen every time• Use Admission Orders Bundles                             Admission Orders                    ...
Recent clinical evidence• Mortality in acute COPD was 9% when high  concentration oxygen was given compared with  4% morta...
Moving Forward• BTS e-learning programme• Oxygen spend down 10% - Target Chief  Executives – QIPP Programme• BTS audit giv...
What else can be done• Emergency oxygen will be taken under the  umbrella of Patient Safety in the Outcomes  Strategy( Dom...
What else can be done• Emergency oxygen should be included in the  mandatory resuscitation training• Improvement in emerge...
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Breakout 4.5 Preventing Oxygen Toxicity: a whole system approach - Prof Tony Davison

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Breakout 4.5 Preventing Oxygen Toxicity: a whole system approach - Prof Tony Davison
Co-Respiratory Lead East of England
Co-Chair and Co-author BTS Emergency Oxygen Guideline
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

Published in: Health & Medicine
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Breakout 4.5 Preventing Oxygen Toxicity: a whole system approach - Prof Tony Davison

  1. 1. Preventing Oxygen Toxicity: a whole system approach Prof Tony Davison Co-Respiratory Lead East of England Co-Chair and Co-author BTS Emergency Oxygen GuidelineOxygen is the most commonly used drug in emergency medicine• 34% of emergency ambulance patients receive oxygen• Oxygen is used in about 2 million ambulance journeys in the UK each year 1
  2. 2. Oxygen in Hospital• 17.5% of UK hospital patients are receiving oxygen at any given time• About 18,000 people every day• More than 2 million per year Oxygen saves lives but too much may cause death • Essential in severely ill patients with low blood oxygen levels • Too much oxygen may cause 2,000-4,000 avoidable deaths per year in chronic obstructive pulmonary disease flare ups • Too much oxygen is linked to increased risk of death in strokes, ICU patients and survivors of cardiac arrest 2
  3. 3. Chaos reigned until 2008 • Most patients were given too much oxygen And there was disagreement about how much oxygen to give • Oxygen was rarely prescribed 68% of UK hospital patients who were using oxygen in 2008 had no prescription and most prescriptions were incomplete • Doctors and nurses had very little knowledge about safe use of oxygen Solution – Novel Guideline• Guideline development group undertookevidence review 2003-04• Universal participation - 21 other societies andcolleges 3
  4. 4. UK Emergency Oxygen Guideline published 2008 4
  5. 5. Key Principles• Oxygen is a treatment for low oxygen (Hypoxemia) (Giving oxygen does not relieve breathlessness or increase the oxygen supply to vital organs if the patient’s oxygen level is normal to start with)• Aim for a normal oxygen saturation level for most patients (94-98%)• Aim at a lower level for (88-92%) for those at risk from higher doses of oxygen• Doctors prescribe a “target range” and nurses adjust equipment and flow rates to achieve the desired target range Oxygen Alert Card Safeguards COPD patients who are most at risk from oxygen poisoning 5
  6. 6. “They gave me a cardbecause I’m intolerantof too much oxygen.They used to whack upthe oxygen in theambulance on the wayto hospital.” 6
  7. 7. “I think it is a good“Last time I was thing, it stops themadmitted they didn’t poisoning me withturn the oxygen up too much oxygentoo high” because I mustn’t have too much.” Implementation and Dissemination from Guideline to patient• No point in having guideline recommendations if they are not implemented for patient safety• Included as integral part of guideline – this is unique 7
  8. 8. Implementation from Guideline to Patient Doctors must prescribe MonitoringNeed Local NeedOxygen TrainingPolicy Nurses must be able to change oxygen being given All patients receive correct and safe oxygen Online appendix of Guideline includes implementation materials • Summary of recommendations • Sample local oxygen policy • Patient information sheet (developed with patients) • Example of new prescription chart 8
  9. 9. Oxygen prescriptionModel for oxygen section in hospital prescription charts DRUG OXYGEN (Refer To Trust Oxygen Policy) Circle target oxygen saturation STOP DATE 88-92% 94-98% Other___ Starting device/flow rate________ PRN / Continuous Tick if saturation not indicated PHARM (Saturation is indicated in almost all cases except for palliative terminal care) SIGNATURE / PRINT NAME DATE ddmmyy Online appendix of Guideline includes implementation materials• Summary of recommendations• Sample local oxygen policy• Patient information sheet (developed with patients).• Example of new prescription chart• Example of new monitoring chart• Lecture for Doctors• Education materials for nurses – unique drop-in training 9
  10. 10. Online appendix of Guideline includes implementation materials• Summary of recommendations• Sample local oxygen policy• Patient information sheet (developed with patients).• Example of new prescription chart• Example of new monitoring chart• Lecture for Doctors• Education materials for nurses – unique drop-in trainingAll of these were piloted at Southend and/or Salford Implementation and Dissemination Oxygen Champions • Pilot sites illustrated importance of local champions BTS asked for volunteer medical and nursing/physiotherapy oxygen champions in every trust responsible for: • Introducing local oxygen policy • Organising training for nurses and doctors • Conducting audit 10
  11. 11. Implementation and DisseminationAdvantage of Partnership Incorporation of Emergency Oxygen Guidelines in other Guidelines • JRCALC (Joint Royal Colleges Ambulance Liaison Committee) Oxygen Guideline April 2009 • BTS Pneumonia Guideline 2009 • NICE Guideline for Chest Pain of Recent Onset – March 2010 • Resuscitation Council (UK) Guideline 2010 • European Resuscitation Guideline 2010 • BTS-SIGN Asthma Guideline 2011 National Patient Safety Agency Rapid Response Report – September 2009 281 reports of serious incidents involving poor oxygen management: • Caused 9 deaths • May have contributed to 35 further deaths 11
  12. 12. National Patient Safety Agency Rapid Response Report – September 2009 Immediate Actions • Oxygen must be prescribed in all situations in accordance with BTS guideline • Pulse oximetry should be available in all locations where oxygen is used • BTS Emergency Oxygen Audits Audit 1 July- July-Sept 2008 Before Guideline launch in October 2008 Audit 2 November 2009 Audit 3 Oct- Oct-November 2010 Audit 4 Aug- Aug-November 2011 Audit 5 Aug-November Aug- 2012• Oxygen champions conducted audits• Methodology- BTS online Audit tool 12
  13. 13. Overview of results 2008-2012 2008-Year 2008 2009 2010 2011 2012Hospitals 99 47 90 156 145 Wards 712 300 1,026 1919 1733Patients 14,830 7,113 22,017 41,009 38,094Percent on 17.5% 18.4% 15.5% 13.7% 14.0%Oxygen *Definition of “on oxygen” in 2008-09 included patients with a prescription who were not on oxygen at the time of audit Oxygen prescribing 2008-2011 2008- Year 2008 2009 2010 2011 2012 Target 10% 40% 41% 43% 46% Range No Written 68% 31% 44% 52% 48% Order 13
  14. 14. Drug rounds & Observation Rounds Year 2008 2009 2010 2011 2012 Percent of drug rounds on 5% 27 % 16 % 20 % 20%which oxygenwas signed for on the drug chart Percent ofobserved over expected 94 % 93 % 99 % 100 % 100% observation rounds with oximetry Implementation Audits 2009 2009 2010 2011 2012 Year Feb n=72 Nov n=61 n=51 N=127 N=95 Oxygen Policy Implemented 6% 21% 37% 89% 83% Printed Oxygen 9% 28% 51% 72% 80% Prescription O2 on Monitoring 7% 34% 33% 58% 69% Chart Nurse Training Implemented 7% 13% 18% 31% 42% Doctor training implemented 4% 10% 11% 31% 42% 14
  15. 15. Electronic Prescribing in 2012• 11 of 94 responding hospitals (12%) have fully Electronic Prescribing in 2012 (8% in 2011)• Partial Electronic Prescribing (8%) (7% in 2011)• Paper Prescribing (80%) Oxygen prescribing and documentation on drug rounds 2008 2009 2010* 2011 2012 Was UK oxygen mean 5% 27% 16% 20% 20% signed for on drug Rounds? Salford 0% 8% 63% 84% 80% *Electronic prescribing with “Admissions Order Set” was introduced at SRFT over the course of 2010 15
  16. 16. Making it happen every time• Use Admission Orders Bundles Admission Orders Choose from Medicine, Surgery or Critical Care 16
  17. 17. Recent clinical evidence• Mortality in acute COPD was 9% when high concentration oxygen was given compared with 4% mortality with controlled oxygen (target range 88-92%)1• Mortality in acute COPD was 11% when >35% oxygen was given but 7% when lower doses of oxygen were used2• Need for ventilatory support; 22% v 9%2 1. Austin MA, et al. BMJ. 2010 Oct 18;341:c5462. doi: 10.1136/bmj.c5462 2. Roberts CM et al. Thorax 2011: 66: 43 Summary • Things are getting better—but slowly • There are institutional barriers to modernisation of clinical practice • Training of health care professionals is the greatest challenge BTS Oxygen Audits are supported by NAGCAE (National Advisory Group on Clinical Audit and Enquiries) and included in Trust Quality Accounts 17
  18. 18. Moving Forward• BTS e-learning programme• Oxygen spend down 10% - Target Chief Executives – QIPP Programme• BTS audit gives results for individual wards/doctors• Review guidelines; new Paediatric section Moving Forward Overview of Emergency Oxygen produced by NHS Improvement in 2012 18
  19. 19. What else can be done• Emergency oxygen will be taken under the umbrella of Patient Safety in the Outcomes Strategy( Domain 5 )• Oxygen Toxicity should be a never event• BTS audit results should be published for each Trust. Data can drive change.• Pharmacists should be more involved in monitoring oxygen prescription and drug chart completion What else can be done• Failure to prescribe and complete the drug chart should be recorded as a critical incident• All staff should have a competency certificate for emergency oxygen• Emergency oxygen should be included in induction training for all nursing and medical staff 19
  20. 20. What else can be done• Emergency oxygen should be included in the mandatory resuscitation training• Improvement in emergency oxygen could be start up project for the Respiratory Alliance Moving Forward• Need substantial yearly improvements in use of emergency oxygen across UK Safer and better care for all patients receiving Emergency Oxygen Saving Lives 20

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