Oxygen Prescription Research Articles

M26 Teaching students to prescribe oxygen safely: the impact of an e-Learning module and BTS oxygen prescription section on oxygen prescribing by medical students taking Final MBBS examinations

Introduction and ObjectivesNational audits show oxygen prescribing is not consistently safe, despite BTS Emergency Oxygen Guidelines. We previouslyidentified that medical students were unable to safely prescribe oxygen at final MBBS...

P67 Electronic prescribing alerts significantly increase oxygen prescribing

Introduction In 2011, the number of patients using oxygen without a prescription within a teaching hospital in the West Midlands was higher than the national average (local 11.3% vs national 7.1%). Following this, an electronic alert was incorporated into a bespoke prescribing system to remind doctors to prescribe oxygen. This alert was triggered whenever the oxygen saturations of a patient were recorded on supplemental oxygen without an oxygen prescription. Method Data was collected using the standard BTS oxygen prescribing audit proforma in October 2011 and October 2012. In 2012, 215 patients from six medical and respiratory wards were included; 40 were on supplemental oxygen. We used Fisher exact test to analyse our data. Results The number of patients using oxygen with a valid prescription increased significantly from 42.9% in 2011 to 72.5% in 2012 (p = 0.023). The national average for oxygen prescriptions in 2012 was 52.3%. Oxygen is being signed for on drug round s more often, 64.1% of the time compared with 13.5% the previous year. Despite the number of oxygen prescriptions increasing significantly, the proportion of patients with saturations in their target range actually decreased. Conclusions The number of oxygen prescriptions have increased significantly with the introduction of an electronic alert system. Potential development s for the future would include an automatic prescription with ‘opt out’ facility and an alert for nursing staff when oxygen saturations are out of range to allow better titration of oxygen. This study shows that use of information technology and prescribing alerts and reminders can have a significant effect on number of prescriptions. What remains to be seen is if this will have an effect on patient outcomes. References O9Driscoll BR et al . BTS guideline for emergency oxygen use in adult patients., Thorax . 2008 Oct;63 Suppl 6:vi1–68 O9Driscoll BR Emergency oxygen use. 2012 BMJ ;345:e6856. Brent Mollon et al. Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials. BMC Medical Informatics and Decision Making 2009, 9 :11

P64 The impact of simple interventions on oxygen prescribing and monitoring: Audit of oxygen management in Central London Teaching Hospital

IntroductionOxygen is one of the most commonly used drugs, but one of the most poorly prescribed. National BTS audits show many patients receive oxygen without prescription1. Local historical data showed...

M29 National Early Warning Score (NEWS): Is it bad news for our patients?

Background Titrated oxygen has been shown to significantly reduce mortality in patients presenting with acute exacerbations of chronic obstructive pulmonary disease (COPD) 1 . All patients at risk of type 2 respiratory failure (T2RF) should be administered oxygen in accordance with British Thoracic Society Guidelines. However, the NEWS system proposed by the Royal College of Physicians makes no allowance for patients at risk of T2RF and may lead to potential over oxygenation in this group of patients 2 . Objective To assess the use of the NEWS in patients with T2RF in our district general hospital and to assess the safety of a modified system. Methods Patients were selected from the Medical Admissions Unit. Inclusion criteria were oxygen prescription or oxygen in situ . Data were collected over 5 consecutive days. Conventional NEWS for these patients were compared with a system currently being piloted at Salford Royal Foundation Trust with modified oxygen saturation levels (SpO2) for patients at risk of T2RF (Table 1) Results 69 patients were assessed. 32% (22/69) had risk factors for T2RF. 21 had COPD and one had sleep apnoea. 55% (12/22) had oxygen saturations in their target range or were above target saturations but on air. 32% (7/22) were on oxygen and had saturations above 92%. 14% (3/22) had saturations below 88%. 73% (16/22) of at risk patients had their scores altered when using the Salford EWS system. 69% (11/16) of these patients had their scores reduced. 4 patient’s scores were reduced by 3, 4 were reduced by 2 and 3 were reduced by 1. 31% (5/16) of patient’s scores were increased. 4 scores were increased by 2 and 1 increased by 1. The score differences were due to over oxygenation. Conclusions The current NEWS system appears to increase the risk of over oxygenation in patients at risk of T2RF. Using a modified score for patients at risk of T2RF will reduces this risk. With thanks Ronan O’Driscoll, Salford Foundation Trust for use of the modified Salford NEWS chart

P65 Why has emergency oxygen administration failed to improve despite ‘best practice’ interventions?

Introduction and ObjectivesDespite instigating all operational and educational recommendations in the BTS Emergency Oxygen Guideline (local policy, standardised prescription and bedside documentation and training) our performance in the BTS annual...

Learning safe practice by improving care: student-led intervention on oxygen prescribing in a respiratory ward

The primary aim of this intervention was to improve oxygen prescribing in accordance with the 2008 British Thoracic Society guidelines for the prescription of emergency oxygen in adults. Eight final year medical students reviewed the drug charts of all patients admitted to the respiratory ward on a daily basis in order to collect data on five audit questions: (1) Has oxygen (O2) been prescribed? (2) Has an O2 target saturation level been indicated? (3) Has O2 been prescribed as an 'as required' (PRN) or 'continuous therapy'? (4) Has the prescription been signed? (5) Has O2 been signed for in every drug round since the original prescription? Following an initial audit cycle an educational poster was distributed to all clinical staff via email and hard copies of the poster were placed strategically throughout the ward before its effectiveness was measured. During the pre-intervention phase, compliance with all five measures varied from 0 to 25%. There was an increase in the variation in compliance after the poster intervention to 14-44%; however, this masked better overall compliance with all five investigative questions with figures of 44%, 39% and 42% being recorded in three of the four post-intervention days. Overall there was increased compliance with four of the five audit questions. Indeed compliance with question 3 rose from 14% to 83%. The poster intervention was marginally effective while also showing that students can improve prescribing in a clinical setting.

The acute prescription of oxygen in orthopaedic trauma patients

In trauma and orthopaedic surgery high flow oxygen can save lives by preventing severe hypoxaemia. Conversely, excessive oxygen can cause harm, and inadequate monitoring of its use has been reported in both pre-hospital and hospital audits. In 2008 the British Thoracic Society published guidelines on the use of emergency oxygen in adults. Data were collected before, 3 months after and 12 months after the introduction of an oxygen prescription chart and education of junior doctors and ward staff. A total of 84 patients were recorded in the first study, 76 in the second and 72 in the third. After education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments correctly prescribed increased from 10/84 (12%) to 56/76 patients (74%, P<0.001) at 3 months. Twelve months after education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments prescribed decreased to 37/72 (51%, P<0.001). Education and the use of oxygen prescribing charts significantly improved the prescription of oxygen. The effect of the intervention fell at 12 months, suggesting poor sustainability. Continued education and feedback to ward staff is vital to maintain change and improve sustainability.

Effect of ambulatory oxygen on exertional dyspnea in IPF patients without resting hypoxemia

The effects of ambulatory oxygen for idiopathic pulmonary fibrosis (IPF) patients without resting hypoxemia have not been elucidated. The purpose of this study was to assess the effect of ambulatory oxygen on dyspnea in IPF patients without resting hypoxemia but with desaturation on exertion. This was a double-blind, placebo-controlled, randomized crossover trial of ambulatory oxygen versus ambulatory air. Patients with IPF who had a partial pressure of arterial oxygen (PaO2) between 60mm Hg and 80mm Hg at rest, and desaturation of 88% or less in a room-air 6-min walk test were eligible. Patients underwent a standardized 6-min walk test and a 6-min free walk test under each ambulatory gas. Oxygen and air were provided at 4L/min intranasally. Dyspnea was evaluated immediately, 1, and 2min after the tests. Twenty patients (16 men), with a mean age of 73.5 (SD 4.1) years, % predicted forced vital capacity (FVC) of 71.0 (13.3) %, % predicted diffusion capacity for carbon monoxide (DLco) of 57.0 (13.3) %, and PaO2 of 72.5 (5.4) mm Hg were recruited. No significant differences in dyspnea were observed between ambulatory oxygen and air at each time point. However, some patients showed improvement in dyspnea with oxygen on an individual basis. Since oxygen provides no additional benefit over air in terms of exertional dyspnea for IPF patients without resting hypoxemia, routine prescription of ambulatory oxygen is not recommended. However, assessment on an individual basis is necessary. Trial registration. UMIN Clinical Trial Registry; No.:UMIN000005098; URL:http://www.umin.ac.jp/ctr/.

G157 OXYGEN PRESCRIBING FOR INPATIENTS IN THE UK

BackgroundGuidance from the British Thoracic Society, National Patient Safety Agency and British National Formulary advises that oxygen should be treated like other drugs in terms of appropriate prescribing and monitoring....

Oxygen therapy in patients with chest pain of acute onset: single centre audit experience

Although oxygen therapy has been commonly used in the treatment of acute coronary syndromes, evidence shows that oxygen administration is not always beneficial to patients with acute chest pain and in certain circumstances may, in fact, be harmful. Hence, several national and international organizations have issued guidelines restricting its use to hypoxic patients only. To audit and change the inappropriate practice of administering oxygen therapy indiscriminately to patients with acute chest pain. Emergency department, coronary care unit and heart assessment centre in a large teaching hospital. The authors identified 100 patients who presented with acute chest pain and collected data on oxygen prescription, administration and documentation from clinical notes and observation charts. Only 71% of patients in a hospital setting were correctly assessed for requiring oxygen therapy. After introducing local guidelines and a series of lectures, this rose to 94%. A third audit showed sustained change, with 96% of patients being appropriately assessed for needing oxygen therapy. The introduction of local guidelines and a series of lectures improved handling of oxygen in patients presenting with acute chest pain.

300 Outpatient oxygen prescription in All Wales Adult Cystic Fibrosis Centre: Getting closer to the truth

300 Outpatient oxygen prescription in All Wales Adult Cystic Fibrosis Centre: Getting closer to the truth

P238 Competence in, and Safety of, Oxygen Prescribing by Medical Students Taking Final MBBS as Assessed by Objective Structured Clinical Examination

Introduction and ObjectivesNational audits show oxygen prescribing is still not consistently safe and appropriate, despite the 2008 BTS Emergency Oxygen Guidelines. The aim of this study was to assess whether...

P47 Post-Operative Oxygen Saturation, Prescribing & Administration in Patients Undergoing Elective Orthopaedic Surgery

IntroductionThere is increasing interest in maximising perioperative care of surgical patients, including response to oxygen desaturation which may occur in association with anaesthesia, analgesic/sedative drugs, and/or indicate pathology. There is...

P44 How Long is short term Oxygen Therapy? Home Oxygen Prescriptions Post Hospitalisation

Introduction Long-term oxygen therapy (LTOT) has been shown to improve survival in some patients with chronic obstructive pulmonary disease (COPD); generalisation to other groups of hypoxic patients is less clear. The British Thoracic Society recommend LTOT should be prescribed to hypoxic patients after appropriate assessment during a period of clinical stability.¹ In practise LTOT is frequently prescribed following hospitalisation. This form of oxygen therapy has been termed short-term oxygen therapy (STOT). We sought to audit our practise of prescribing home oxygen therapy to hypoxic patients following hospital admission with an exacerbation of a respiratory disorder. Method We performed a retrospective case note audit of 30 patients [13 male] commenced on home oxygen therapy at discharge over a 6 month period recording patient demographics, smoking status, underlying diagnosis, compliance with BTS oxygen prescribing guidelines and the outcome of follow-up. Results The mean age was 71 years (48–91yrs); 17% current smokers, 73% ex-smokers. COPD was the most common diagnosis in 80% (24/30); the mean FEV1 1.1L (52% predicted). No definitive diagnosis was documented in 10% (3/30) with 10% diagnosed with sarcoidosis, idiopathic pulmonary fibrosis or lung cancer. 64% (19/30) of patients met BTS LTOT criteria, (80% (19/24) with COPD), 33% (10/30) did not and 3% (1/30) were prescribed palliative oxygen. 93% of patients (27/29) were followed up at 3 months. The mean oxygen flow rate required was 1.4L/min; oxygen flow rate was altered in 63%. The overwhelming majority of our patients, 90% (26/29), continued with LTOT after reassessment at 3 months and 79% (23/29) at 6 months. Conclusion Our audit shows that the majority of patients commenced on oxygen therapy post hospitalisation met the criteria for LTOT and continued to require oxygen at 3 and 6 months; this is a higher figure than quoted in the majority of the literature. This suggests our patients are presenting late with underlying chronic lung disease; we need to strive to identify these patients earlier. There is still a lack of evidence-based guidelines for STOT and further research in this area is needed. References BTS Home Oxygen Service in England and Wales. January 2006.

1628 Oxygen Prescribing and Saturation Targeting in Neonatal Intensive Care

BackgroundMany newborns require oxygen; this should be prescribed as with other medical gases. In babies due to the risks from both hypoxia and hyperoxia oxygen saturation targeting to provide optimal...

Oxygen use for chest pain in coronary care units across the UK

To quantify the adherence to national guidance for the use of oxygen in patients presenting with chest pain to coronary care units (CCUs) across the UK. Prospective survey. A total of 307 hospitals were contacted by telephone between August 2010 and October 2010. Of these, 48 had no CCUs, 10 units refused to take part and 18 hospitals were contacted on 2 occasions but were unable to provide the information due to paucity of time owing to heavy clinical workload. Overall 231 hospitals participated in the audit questionnaire. A total of 30% of the units used oxygen titrated to saturations in accordance with national guidelines. There was no difference between units that had on-site availability of percutaneous coronary intervention and those that did not. Those hospitals where there was a policy for routine oxygen prescription were as unlikely to comply with the guidelines on oxygen use as hospitals where oxygen was not routinely prescribed. Only one-third of CCUs in the UK reported adherence to guidelines with regards to oxygen delivery in patients presenting with chest pain. Despite this figure seeming rather low, this is consistent with practice through a range of specialties and guidelines. The evidence base for the oxygen guidance remains insecure. Additional research is required but in the meantime we recommend oxygen is prescribed according to current guidelines.

Multicentre audit of inpatient management of acute exacerbations of chronic obstructive pulmonary disease: comparison with clinical guidelines

Chronic obstructive pulmonary disease (COPD) exacerbations are a major cause of hospital admission and clinical guidelines for optimised management are available. However, few data assessing concordance with these guidelines are available. We aimed to identify gaps and document variability in clinical practices for COPD admissions. Medical records of all admissions over a 3-month period as COPD with non-catastrophic or severe comorbidities or complications at eight acute-care hospitals within the Hunter New England region were retrospectively audited. Mean (SD) length of stay was 6.3 (6.1) days for 221 admissions with mean age of 71 (10), 53% female and 34% current smokers. Spirometry was performed in 34% of admissions with a wide inter-hospital range (4-58%, P < 0.0001): mean FEV1 was 36% (18) predicted. Arterial blood gases were performed on admission in 54% of cases (range 0-85%, P < 0.0001). Parenteral steroids were used in 82% of admissions, antibiotics in 87% and oxygen therapy during admission in 79% (with oxygen prescription in only 3% of these). Bronchodilator therapy was converted from nebuliser to an inhaler device in 51% of cases early in admission at 1.6 (1.7) days. Only 22% of patients were referred to pulmonary rehabilitation (inter-hospital range of 0-50%, P = 0.002). Re-admission within 28 days was higher in rural hospitals compared with metropolitan (27% vs 7%, P < 0.0001). We identified gaps in best practice service provision associated with wide inter-hospital variations, indicating disparity in access to services throughout the region.

Oxygen therapy multicentric study—A nationwide audit to oxygen therapy procedures in Internal Medicine wards

Oxygen therapy is a common and important treatment in Internal Medicine wards, however, several studies report that it is not provided accordingly with the best of care. The goal of this work was to evaluate oxygen therapy procedures in Portuguese Internal Medicine wards, comparing them to the standards established by the British Thoracic Society (BTS) in its consensus statement “BTS guideline for emergency oxygen use in adult patients”.Between September 3rd and 23rd 2010, each one of the 24 enrolled hospitals audited the oxygen therapy procedures for one randomly chosen day. All Internal Medicine inpatients under oxygen therapy or with oxygen prescription were included. Data was collected regarding oxygen prescription, administration and monitoring.Of the 1549 inpatients, 773 met inclusion criteria. There was an oxygen prescription in 93.4%. Most prescriptions were by a fixed dose (82.4%), but only 11.6% of those stated all the required parameters. Absence of oxygen therapy duration and monitoring were the most frequent errors.Oxygen was administered to only 77.0% of the patients with fixed dose prescriptions. FiO2 or flow rate and the delivery device were the same as prescribed in 70.9 and 89.2% of the patients, respectively. Out of the 127 patients with oxygen therapy prescriptions by target SatO2 range, 82.7% were on the prescribed SatO2 objective range.Several errors were found in oxygen therapy procedures, particularly regarding fixed dose prescriptions, jeopardizing the patients. Although recommended by BTS, oxygen therapy prescriptions by target SatO2 range are still a minority.

An audit of the prescribing, administering and monitoring of oxygen therapy within a hospice

BackgroundFollowing the publication of the Executive Summary of the British Thoracic Society Guideline for Emergency Oxygen Use in Adult Patients 2008, a local hospice guideline for the prescribing and use...

Estudo multicêntrico de oxigenoterapia – uma auditoria nacional aos procedimentos de oxigenoterapia em enfermarias de medicina interna

Oxygen therapy is a common and important treatment in Internal Medicine wards, however, several studies report that it isn’t provided accordingly with the best of care. The goal of this work is to evaluate oxygen therapy procedures in Portuguese Internal Medicine wards, comparing them to the standards established by the British Thoracic Society (BTS) in its consensus statement “BTS guideline for emergency oxygen use in adult patients”.Between September 3rd and 23rd 2010, each one of the 24 enrolled hospitals audited the oxygen therapy procedures for one randomly chosen day. All Internal Medicine inpatients under oxygen therapy or with oxygen prescription were included. Data was collected regarding oxygen prescription, administration and monitoring.Of the 1549 inpatients, 773 met inclusion criteria. There was an oxygen prescription in 93,4%. Most prescriptions were by a fixed dose (82,4%), but only 11,6% of those stated all the required parameters. Absence of oxygen therapy duration and monitoring were the most frequent errors.Oxygen was administered to only 77,0% of the patients with fixed dose prescriptions. FiO2 or flow rate and the delivery device were the same as prescribed in 70,9 and 89,2% of the patients, respectively. Out of the 127 patients with oxygen therapy prescriptions by target SatO2 range, 82,7% were on the prescribed SatO2 objective range.Several errors were found in oxygen therapy procedures, particularly regarding fixed dose prescriptions, jeopardizing the patients. Although recommended by BTS, oxygen therapy prescriptions by target SatO2 range are still a minority.