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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

Oxygen 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

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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

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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 undertook evidence review 2003-04

• Universal participation - 21 other societies and colleges

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UK Emergency Oxygen Guideline published 2008

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• Doctors prescribe a “target range” and nurses adjust equipment and flow rates to achieve the desired target range

• Aim at a lower level for (88-92%) for those at risk from higher doses of oxygen

• Aim for a normal oxygen saturation level for most patients (94-98%)

• 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)

Key Principles

Oxygen Alert Card

Safeguards COPD patients who are most at risk from oxygen poisoning

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“They gave me a card because I’m intolerant of too much oxygen. They used to whack up the oxygen in the ambulance on the way to hospital.”

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“Last time I was admitted they didn’t turn the oxygen up too high”

“I think it is a good thing, it stops them poisoning me with too much oxygen 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

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Implementation from Guideline to Patient

All patients receive correct and safe oxygen

Monitoring

Nurses must be able to change oxygen being given

Doctors must prescribe

Need Local Oxygen Policy

Need Training

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

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DRUG OXYGEN (Refer To Trust Oxygen Policy)

Circle target oxygen saturation

88-92% 94-98% Other___ STOP DATE

Starting device/flow rate________

PRN / Continuous

PHARM

(Saturation is indicated in almost all cases except for

palliative terminal care)

SIGNATURE / PRINT NAME DATE

ddmmyy

Oxygen prescriptionOxygen prescription Model for oxygen section in hospital prescription charts

Tick if saturation not indicated

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

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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

All 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

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Implementation and Dissemination

Incorporation of Emergency Oxygen Guidelines in

other Guidelines

Advantage of Partnership

• JRCALC (Joint Royal Colleges Ambulance Liaison Committee) Oxygen Guideline April 2009

• European Resuscitation Guideline 2010

• Resuscitation Council (UK) Guideline 2010

• NICE Guideline for Chest Pain of Recent Onset – March 2010

• BTS Pneumonia Guideline 2009

• 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

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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

••

Audit 1 JulyAudit 1 July--Sept 2008Sept 2008 Before Guideline launch in October 2008 Before Guideline launch in October 2008

Audit 2 Audit 2 November 2009November 2009 Audit 3Audit 3 OctOct--November 2010November 2010 Audit 4Audit 4 AugAug--November 2011November 2011

• Oxygen champions conducted audits

• Methodology- BTS online Audit tool

BTS Emergency Oxygen AuditsBTS Emergency Oxygen Audits

Audit 5 AugAudit 5 Aug--November November 20122012

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*Definition of “on oxygen” in 2008-09 included patients with a prescription who were not on oxygen at the time of audit

Year

2008

2009

2010

2011

2012

Hospitals

99

47

90

156

145

Wards

712

300

1,026

1919

1733

Patients

14,830

7,113

22,017

41,009

38,094

Percent

on

Oxygen

17.5%

18.4%

15.5%

13.7%

14.0%

Overview of results 2008Overview of results 2008--20122012

Year

2008

2009

2010

2011

2012

Target

Range

10%

40%

41%

43%

46%

No Written

Order

68%

31%

44%

52%

48%

Oxygen prescribing 2008Oxygen prescribing 2008--20112011

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Year

2008

2009

2010

2011

2012

Percent of drug

rounds on

which oxygen

was signed for

on the drug

chart

5%

27 %

16 %

20 %

20%

Percent of

observed over

expected

observation

rounds with

oximetry

94 %

93 %

99 %

100 %

100%

Drug rounds & Observation RoundsDrug rounds & Observation Rounds

Implementation AuditsImplementation Audits

Year 2009

Feb n=72

2009 Nov n=61

2010 n=51

2011 N=127

2012 N=95

Oxygen Policy

Implemented

6%

21%

37%

89%

83%

Printed

Oxygen

Prescription

9%

28%

51%

72%

80%

O2 on

Monitoring

Chart

7%

34%

33%

58%

69%

Nurse Training Implemented

7%

13%

18%

31%

42%

Doctor training implemented

4%

10%

11%

31%

42%

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Electronic Prescribing in 2012Electronic 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

oxygen

signed for

on drug

Rounds?

UK

mean

5%

27%

16%

20%

20%

Salford

0%

8%

63%

84%

80%

*Electronic prescribing with “Admissions Order Set” was introduced at SRFT over the course of 2010

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Making it happen every time

• Use Admission Orders Bundles

Admission Orders Choose from

Medicine, Surgery or Critical Care

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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

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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

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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

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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