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

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 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
1

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. 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
3

4. UK Emergency Oxygen Guideline
published 2008
4

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. “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.”
6

7. “I think it is a good
“Last time I was thing, it stops them
admitted they didn’t poisoning me with
turn the oxygen up too much oxygen
too 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
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8. Implementation from Guideline to Patient
Doctors must prescribe
Monitoring
Need Local Need
Oxygen Training
Policy
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. Oxygen prescription
Model 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. 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
10

11. Implementation and Dissemination
Advantage 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
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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. Overview of results 2008-2012
2008-
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 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
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14. Drug rounds & Observation Rounds
Year 2008 2009 2010 2011 2012
Percent
of drug
rounds on 5% 27 % 16 % 20 % 20%
which oxygen
was signed for
on the drug
chart
Percent of
observed 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. 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. Making it happen every time
• Use Admission Orders Bundles
Admission Orders
Choose from
Medicine,
Surgery or
Critical Care
16

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. 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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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
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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
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