Patient Safety Awards 2011

Improving the safety of administration of Emergency Oxygen

in adult patients across the UK

The BTS guideline for emergency oxygen use in adult patients

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

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

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

• North West oxygen guideline 2000

Time To Do SomethingKey Theme

• Safe oxygen for all patients in UK

• Solution needed to be:

»Ambitious

»Pioneering

»Multidisciplinary

Solution – Novel Guideline• Early pilots in Salford and Southend

• BTS appointed Salford and Southend Co-Chairs in 2003 to produce UK Guidance• Guideline development group undertook evidence review 2003-04• Universal participation - 21 other societies and colleges

Solution – Novel Guideline• Early pilots in Salford and Southend.

• BTS appointed Salford and Southend Co-Chairs in 2003 to produce UK Guidance.• Guideline development group undertook evidence review 2003-04• Universal participation - 21 other societies and colleges

• Draft Guideline prepared 2005-2007

• Pilot work continued in Salford/Southend

UK Emergency Oxygen Guideline published 2008

• 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

“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.”

“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

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

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 DATEddmmyy

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

Respiratory Rate, Oxygen saturation and oxygen therapy Clinical review required if saturation is outside target rangeContinuous Oxygen / PRN / Not on oxygen therapy Target range: 88-92% 94-98% Other_____

Respiratory Rate

Respiratory Rate

Oxygen Saturation %

OxygenSaturation %

OxygenDevice or Air

OxygenDevice or Air

Oxygen flow rate L/min

Oxygen flow rate L/min

Your Initials*

Your Initials*

Model for respiratory section of observation chartModel for respiratory section of observation chart

Codes for recording oxygen delivery on observation chartA Air. (Patient not requiring oxygen therapy)AX Measurement on air for a patient who is on PRN Oxygen therapyAW Measurement on air for a patient who is being weaned off oxygen but not yet discontinued on chartN Nasal CannulaeSM Simple maskV24 Venturi 24% V28 Venturi 28% V35 Venturi 35% V40 Venturi 40% V60 Venturi 60%H28 Humidified oxygen at 28% (“Quatro” or similar device) (also H 35, H40, H60)RM Reservoir MaskTM Tracheostomy MaskCP Patient on CPAP systemNIV Patient on NIV systemOTH Other device

*All changes to oxygen delivery systems must be initialled by a registered nurse or equivalent

If the patient is medically stable and in the target range on two consecutive rounds, report to a registered nurse to

consider weaning off oxygen (unless the oxygen prescription is part of a timed protocol

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

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

Launch of Guideline October 2008

• PR company helped with pre-launch information to medical press

• Editorials in journals e.g. Nursing Times, BMJ

• Letters to Chief Executives

• Oxygen champions primed: Discussion area on BTS web site

• Lectures at many National and Regional Meetings

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 AgencyRapid Response Report –

September 2009

281 reports of serious incidents involving poor oxygen management:

• Caused 9 deaths

• May have contributed to 35 further deaths

National Patient Safety AgencyRapid 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 2008 and 2010 Oxygen Audits

Hospitals Patients Wards On O2

(%)O2

Prescribed

Drug rounds signed

Oximetry

recorded

Correct delivery system

2008 99 14,830 712 17.5 32% 5% 94% 47%

2010 90 22,017 1026 15.5 56% 16% 99% 59%

Implementation AuditsFeb 2009, November 2010

Feb 2009

n=72

Oct-Nov 2010Provisional Data

n=51

Oxygen Policy in place 6% 37%

Pre-printed oxygen prescription charts

9% 51%

Pre-printed monitoring chart

7% 33%

Nurse training fully implemented

7% 18%

Doctor training fully implemented

4% 11%

Improvement in prescribing oxygen at Southend

8

87

0

10

20

30

40

50

60

70

80

90

100

Before Guideline After Guideline

Pe

rce

nta

ge

(%

)

BTS Audit supported by NCAAG

National Clinical Audit Advisory Group

• BTS Emergency Oxygen Audit is in the list of audits recommended by the NCAAG for inclusion in Quality Accounts for 2010/2011

• Hospitals’ results will be published

Moving Forward• BTS e-learning programme• Oxygen spend down 10% - Target Chief Executives – QIPP

Programme

• BTS Oxygen Champion – Yearly Prize• Refine BTS audit results so individual wards/doctors given

results

• Review guidelines; new Paediatric section

Moving Forward

• Guideline group expecting substantial yearly improvements in use of emergency oxygen across UK

Safer and better care for

all patients receiving

Emergency Oxygen

Saving Lives