Oxygen therapy administration Policy and Guidelines: the administration of short burst, sustained (medium term) and emergency

oxygen to adults in hospital

Reference Number:

7017

Author & Title:

Julian Hunt, Consultant Nurse Critical Care Corporate

Responsible Directorate:

Review Date:

December 2013

Ratified by (committee):

Clinical Governance Committee

Date Ratified:

December 2010

Version:

1.0

Related Procedural Documents

Policy and Guidelines for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults The Nursing Care And Management Of Adults With Tracheostomies Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults Resuscitation policy Medical Gas Pipeline System Operational Policy Medical equipment policy

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Index:
1. 2. 3. 4. 5. Introduction __________________________________________________________ 4 Purpose of this policy ___________________________________________________ 4 Definitions ___________________________________________________________ 4 Aims and Objectives of this policy _________________________________________ 5 Responsibilities _______________________________________________________ 5 5.1 5.2 5.3 5.4 5.5 6. 7. Medical staff and non-medical prescribers_______________________________ 5 Nursing staff ______________________________________________________ 6 Critical Care Outreach / Medical Nurse Practitioners / Night Nurse Practitioners _ 6 Ward managers / Clinical support staff _________________________________ 6 Critical Care Outreach / Clinical educators / Clinical Skills Trainers ___________ 6

Monitoring Compliance _________________________________________________ 7 Summary Oxygen Administration protocol___________________________________ 8 Saturation higher than target specified or >98% for an extended period of time. _______ 9 Saturation lower than target specified ________________________________________ 9

8. Prescribing, administering and monitoring oxygen _____________________________ 10 8.1 8.2 8.3 8.4 8.5 Identifying appropriate target saturations _______________________________ 10 Indicating oxygen target saturation range on the Vital Signs Chart ___________ 10 Personnel who may administer oxygen ________________________________ 11 Monitoring and recording oxygen _____________________________________ 11 Emergency situations ______________________________________________ 12

8.6 Exclusions to targeted oxygen saturation range prescription, monitoring and delivery of oxygen ______________________________________________________ 12 8.7 8.8 8.9 9. 9.1 11. 12. 13. 14. 15. 16. Specialist areas __________________________________________________ 13 Indications ______________________________________________________ 13 Contra-indications ________________________________________________ 13 Oxygen administration and carbon dioxide retention ______________________ 13 Peri-operative and immediately post-operatively ___________________________ 15 Nebulised therapy and oxygen_________________________________________ 15 Normal Oxygen saturations ___________________________________________ 15 Humidification______________________________________________________ 16 Training __________________________________________________________ 16 Health and Safety Issues _____________________________________________ 17
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Cautions ____________________________________________________________ 13

10.Transfer and transportation of patients receiving oxygen ________________________ 14

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17. 18.

References and Further Reading_______________________________________ 17 Acknowledgements _________________________________________________ 18

Appendix 1: Consultation Schedule __________________________________________ 19 Appendix 2: Ward equipment list for oxygen masks and delivery systems _____________ 20 Appendix 3: Oxygen escalator ______________________________________________ 21 Appendix 4: Patients who may have hypoxic drive _______________________________ 22 Appendix 5: Adult vital signs chart target saturation range________________________ 23 Appendix 6: Oxygen administration devices (expanded oxygen escalator)_____________ 24 Appendix 7: Humidification _________________________________________________ 29 Appendix 8: BOC Oxygen cylinder sizes and capacities ___________________________ 30 Appendix 9: Sample oxygen prescriptions______________________________________ 30 Equality Impact Assessment Tool ____________________________________________ 31 Consultation Checklist _____________________________________________________ 32 Ratification Check List _____________________________________________________ 33

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1.

Introduction

This policy and guidelines applies to all clinical staff of the Royal United Hospital Bath NHS Trust who use oxygen therapy in the care of patients. The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However oxygen should be regarded as a drug (British National Formulary, 2010) and therefore requires prescribing in all but emergency situations. Failure to administer oxygen appropriately can result in serious harm to the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the Healthcare Professionals role.

2.

Purpose of this policy

Maintaining best practice and high quality patient care The purpose of this policy is to ensure that high quality care is delivered to patients with regard to the administration of oxygen to and the appropriate monitoring of patients receiving oxygen. The purpose of the policy and guideline is: To maintain a standard of care that is consistent with current best practice, (ODriscoll et al., 2008). Broad consistency with British Thoracic Society guidelines Meeting the recommendations of the National Patient Safety Agency in the clinical management of patients receiving oxygen therapy This is a clinical policy and does not relate to the infrastructure of providing oxygen which is managed in accordance with Health Technical Memoranda HTM02 as described in the Trust Medical Gas Pipeline Systems operational policy

3.

Definitions

Administration of short- burst, medium term (and emergency) oxygen to adults on general wards For the purpose of this policy and guideline medium term oxygen is to be distinguished from domiciliary oxygen and short burst oxygen therapy, although many of the principles applied here can be generalised to those other instances. This policy and guidelines document relates to oxygen given within hospital and not domiciliary oxygen. Domiciliary oxygen is oxygen provided in the home by cylinder or concentrator for continuous or intermittent use.

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Short burst oxygen therapy is that provided at home or in hospital for administration for a few minutes to support patients who have hypoxia related breathlessness related to chronic lung pathology or to support patients having severe cluster headaches. The policy and guideline is applicable to adults only, but many of the principles here apply to childrens care, particularly children over eight years of age.

4.

Aims and Objectives of this policy

The aim of this guideline is to ensure that: All patients who require supplementary oxygen therapy receive therapy that is appropriate to their clinical condition and in line with national guidance (BTS Guideline; Thorax, 2008). Oxygen will be prescribed according to a target saturation range. The system of prescribing target saturation aims to achieve a specified outcome, rather than specifying the oxygen delivery method alone. Those who administer oxygen therapy will monitor the patient and keep within the target saturation range, unless local guidelines dictate otherwise. In a medical emergency high concentration oxygen is administered by staff who are trained in its use, and that the patient receives expert review immediately. This policy and guideline does include the control of oxygen cylinders ensuring that adequate availability of medical gas cylinders is maintained.

5.

Responsibilities

All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. This policy applies to all members of staff who are involved in any aspect of the development and use of procedure development. Key organisational duties are identified as follows: 5.1 Medical staff and non-medical prescribers To ensure that oxygen therapy is safely and appropriately used without unnecessary risk to patients. This is achieved by: Ensuring that oxygen therapy is prescribed (on the Medicines Administration Record (See Appendix 9); Ensuring that oxygen target saturation ranges are identified for each patient on admission to hospital (on the vital signs assessment chart); Ensuring that oxygen therapy is routinely reviewed and incorporated into clinical management plans.

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5.2 Nursing staff To ensure that oxygen therapy is safely and appropriately used without unnecessary risk to patients. This is achieved by: Checking the oxygen prescription and delivery system on every drug administration round and ensuring that the Medicines Administration Record (drug chart) for each patient receiving oxygen is completed; Ensuring that oxygen delivery is managed in a way that is appropriate to the clinical needs of the patient; Ensuring that patients on oxygen therapy receive observations of vital signs that are appropriate to their clinical needs; Ensuring that patients receiving oxygen have the dose adjusted to meet the prescribed oxygen target saturation range; Ensuring that high concentration oxygen is appropriately administered to patients in the event of a medical emergency and whilst medical help is being sought. (This may be necessary in the absence of a prescription or medical instruction for the administration of oxygen). 5.3 Critical Care Outreach / Medical Nurse Practitioners / Night Nurse Practitioners To ensure that oxygen therapy is safely and appropriately used without unnecessary risk to patients. This is achieved by: Providing support to ward staff in the selection, setting up and delivery of appropriate oxygen therapy; Review of patients who are profoundly hypoxic when asked to do so by ward staff; Contribution to the training and education of staff who use oxygen therapy in their clinical practice. 5.4 Ward managers / Clinical support staff To ensure that appropriate equipment for the administration of oxygen is available for use in all general wards and clinical areas. Maintain logistics function in storage and supply of materials for a range of oxygen delivery systems (Appendix 2 provides a list of required oxygen and humidification equipment for ward use); Some specialist areas will provide logistical support for particular items required for oxygen therapy that may not be available locally and are not routinely used; To ensure that availability of pulse oximeters is consistent with the demand for their use.

Ward managers should ensure that all staff who are directly involved with the handling and administration of oxygen equipment in use have attended medical gas training 5.5 Critical Care Outreach / Clinical educators / Clinical Skills Trainers To facilitate the training of all staff ,in the selection and use of an appropriate range of equipment for the administration of oxygen for use in all general wards and clinical areas.
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Teaching the use of high concentration oxygen in clinical emergencies; Teaching staff who use oxygen therapy equipment how to select and use it safely and appropriately Contributing to the maintenance of training records.

6.

Monitoring Compliance

The use of medical equipment relating to oxygen therapy will be monitored as identified within the medical Equipment policy. All incident reports relating to oxygen therapy will be reviewed by the Medicines Advisory Group (MAG), at least quarterly, in order to identify themes and trends and propose appropriate risk reduction measures to prevent reoccurrence and improve patient safety.

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7.

Summary Oxygen Administration protocol

RATIONALE Oxygen should be regarded as a drug and should be prescribed. BTS National guidelines (2008). British National Formulary (2010).

ACTION All patients requiring oxygen therapy will have a prescription for oxygen therapy recorded on the patients drug prescription chart. N.B exceptions-emergency situations The prescription will refer to a target saturation range that will be identified by the clinician prescribing the oxygen in accordance with the Trust's oxygen guideline

Certain groups of patients require different target ranges for their oxygen saturation. Certain groups of patients are at risk of hyperoxaemia, particularly patients with COPD. This includes patients who have had recent Myocardial Infarction (MI) or stroke The drug chart should be signed at every drug To ensure that the patient is receiving oxygen if round prescribed and to consider weaning and discontinuation in consultation with parent medical team To identify if oxygen therapy is maintaining the Once oxygen is in situ the nurse will monitor target saturation or if an increase or decrease observations in line with the Policy and Guidelines for Vital Signs Assessment (VSA) in oxygen therapy is required and the use of Early Warning Scoring (EWS) in Adults. All patients should have their oxygen saturation observed for at least five minutes after starting oxygen therapy. If a patient is receiving intermittent therapy they may be monitored at least 8 hourly. To provide an accurate record and allow trends The oxygen delivery device and oxygen flow rate (or oxygen percentage delivered) should in oxygen therapy and saturation levels to be identified. be recorded on the vital signs chart and care plan Oxygen saturations must always be To identify early signs of clinical deterioration, interpreted alongside the patients clinical e.g. elevated respiratory rate. status incorporating the Early Warning Score. Oxygen saturations are not a component of the EWS. If the patients oxygen saturation falls outside To maintain the saturation in the desired range. of the target range change of position, deep breathing and coughing or other clinical instruction should be considered before adjusting oxygen therapy. The saturation should be monitored continuously for at least 5 minutes after any increase or decrease in oxygen dose to ensure that the patient achieves the desired saturation range.

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Saturation higher than target specified or >98% for an extended period of time. Step down oxygen therapy as per guidance for delivery Consider discontinuation of oxygen therapy Saturation lower than target specified Check all elements of oxygen delivery system for faults or errors. Ensure that pulse oximetry signal is reliable and accurate. Step up oxygen therapy as per oxygen escalator (Appendix 3) Any sudden fall in oxygen saturation should lead to clinical evaluation and in most cases measurement of blood gases Monitor EWS and respiratory rate for further clinical signs of deterioration Other instructions relating to position change, physiotherapy or encouraged cough may be required before oxygen delivery is increased

The patient will require weaning down from current oxygen delivery system. The patients clinical condition may have improved negating the need for supplementary oxygen In most instances a fall in oxygen saturation is due to deterioration of the patient however equipment faults should be checked for (including water traps) Note that with some very sick patients pulse oximetry may not be possible. Many of these patients are likely to be managed as a medical emergency. To assess the patients response to oxygen increase, and ensure that PaCO2 has not risen to an unacceptable level, or pH dropped to an unacceptable level and to screen for the cause of deteriorating oxygen level (e.g. pneumonia, heart failure etc). Some patients may experience transient mucus plugging leading to hypoxia which can be improved by manoeuvres other than simply increasing oxygen concentration. (The change may be made in stable patients due to patient preference or comfort).

Saturation within target specified Continue with oxygen therapy, and monitor patient to identify appropriate time for stepping down therapy, once clinical condition allows A change in delivery device (without an increase in O2 therapy) does not require review by the medical team. Oxygen delivery methods The oxygen escalator should be used to identify a suitable method for oxygen delivery Humidification needs must be assessed regularly in keeping with individual needs and at least every 24 hours.

The oxygen delivery device needs to be matched to an individuals clinical needs e.g. humidification.

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8. Prescribing, administering and monitoring oxygen

8.1 Identifying appropriate target saturations Oxygen should be prescribed to achieve a target saturation of 94-98% for most acutely unwell patients or 88-92% for those at risk of hypercapnic respiratory failure (Appendices 4 and 9) Hypoxic drive refers to the stimulus to breathe for some patients being the lack of oxygen. For patients who do rely on hypoxic drive as their stimulus to breathe, overoxygenation can have severe and potentially fatal outcomes. The groups of conditions which patients who may have hypoxic drive are: Chronic hypoxic lung disease Chronic Obstructive Pulmonary Disease (COPD) Severe Chronic Asthma Bronchiectasis / Cystic fibrosis Chest wall disease Kyphoscoliosis Thoracoplasty Neuromuscular disease Obesity hypoventilation

For patients with these conditions a target oxygen saturation range of 88-92% is recommended. For most other conditions a target saturation range of 94-98% is recommended. There are rare clinical indications where a higher saturation target saturation is required e.g. carbon monoxide poisoning. It is not routine to aim for target saturations of 100% (The implication of doing so is that most patients will receive too much oxygen). For patients who have had a myocardial infarction or a stroke, and are not in the process of immediate resuscitation, a different target saturation range may be appropriate. In the absence of conditions that may cause hypoxic drive normal BTS target saturations are currently recommended with the lower end of the target saturation range desirable. Supplemental oxygen is not recommended unless the patient is hypoxic (saturations less than 95%). National Collaborating Centre for Chronic Conditions (2008); Weston (2010); Wijesinghe (2009). 8.2 Indicating oxygen target saturation range on the Vital Signs Chart An oxygen section on the vital signs chart has been designed to assist administration of oxygen (Appendix 5). The need for supplemental oxygen therapy should form part of the management plan for a patient and be documented in the plan along with the appropriate target saturation range.
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8.3 Personnel who may administer oxygen Once the target saturation has been identified and prescribed, guidance regarding the most appropriate delivery system to reach and maintain the prescribed saturation is provided for those administering oxygen in Appendix 6. Any registered nurse, doctor, or physiotherapist, or other professional or nonprofessional staff who have received training in the use of oxygen and been deemed competent within their normal area of working can administer oxygen therapy according to these guidelines. All staff who are directly involved with the handling and administration of oxygen equipment in use must attend medical gas training. Oxygen administration must not be delayed and needs to be instituted as soon as it is clinically indicated. 8.4 Monitoring and recording oxygen The patient's oxygen saturation and oxygen delivery system should be recorded on the vital signs chart alongside other physiological variables. All patients receiving oxygen therapy should have regular pulse oximetry measurements. All recordings of oxygen saturation should be associated with respiratory rate recording at the same time (NCEPOD, 2005).The frequency of oximetry measurements will depend on the condition being treated and the stability of the patient. Critically ill patients should have their oxygen saturations monitored continuously and recorded with a frequency appropriate to their physiological condition. Patients with mild breathlessness due to a stable condition will need less frequent monitoring. Oxygen therapy should be increased if the saturation is below the desired range and decreased if the saturation is above the desired range (and eventually discontinued as the patient recovers, usually in consultation with parent medical team). Any sudden fall in oxygen saturation should lead to clinical evaluation of the patient and in most cases, measurement of blood gases. A baseline blood gas should be taken for all patients with oxygen saturation on air of below 94%. Do not stop oxygen therapy in order to carry out blood gas sampling, unless it is part of a documented plan for patients under the direct care of respiratory physicians. Patients should be monitored accurately for signs of improvement or deterioration. Nurses should also monitor skin colour for peripheral or central cyanosis and respiratory rate. Patients with noisy or laboured breathing or respiratory rate of less than 8 or more than 25 should be reported immediately to the duty doctor, regardless of oxygen saturations.

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8.5 Emergency situations In an emergency situation an oxygen prescription is not required. Oxygen should be given to the patient immediately without a formal prescription or drug order but documented later in the patients clinical record. All peri-arrest patients and patients who acutely become critically ill, should be given high concentration oxygen (15 litres per minute via a reservoir bag mask) whilst awaiting immediate medical review. Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients pending the results of urgent blood gas results after which these patients may need oxygen therapy set to appropriate target oxygen saturation range as part of their continuing medical management plan. If the patient has severe hypoxaemia and / or hypercapnia with respiratory acidosis then non-invasive ventilation with closely regulated and monitored oxygen therapy may be required. All patients who have had a cardiac or respiratory arrest should have high concentration oxygen provided along with basic or advanced life support. A subsequent written record must be made of what oxygen therapy has been given to every patient along with the recording of all other emergency treatment. Any registered nurse, allied health professional or doctor can commence oxygen therapy in an emergency. Some non-professional staff who have received specific training may also commence oxygen in a medical emergency. Medical, nursing and allied health professional students can commence oxygen therapy in an emergency under supervision. 8.6 Exclusions to targeted oxygen saturation range prescription, monitoring and delivery of oxygen Patients receiving oxygen as part of the management of a medical emergency (until a definitive management plan which includes oxygenation is produced). Patients admitted to critical care unit (intensive and high dependency care); Operating theatres or PACU where specific oxygen instructions are provided by intensivists / anaesthetists. Patients receiving oxygen as part of palliative care or patients on the end of life care pathway (in which case, the prescriber should write target saturations not indicated in the text section of the vital signs chart and cross through the oxygen prescription area of the chart (Note vital signs are no longer recorded for a patient on an end of life pathway). Patients admitted who are normally on long term oxygen therapy (continuous, nocturnal or short-burst) where specific individual instructions for oxygenation and target saturation range may be required.

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8.7 Specialist areas This policy is for general use within general wards and departments and for transfer between departments. Patients transferring from specialist areas must be transferred with a prescription for their oxygen therapy based on target saturation range, if there is a clinical indication for ongoing oxygen therapy. 8.8 Indications The rationale for oxygen therapy is prevention of cellular hypoxia, caused by hypoxaemia (low PaO2), and thus prevention of potentially irreversible damage to vital organs. Therefore the most common reasons for oxygen therapy to be initiated are: Acute hypoxaemia (for example pneumonia, shock, asthma, heart failure, pulmonary embolus) Ischaemia (for example myocardial infarction, but only if associated with hypoxaemia (abnormally high levels may be harmful to patients with ischaemic heart disease and stroke). Abnormalities in quantity, or type of haemoglobin (for example acute gastro-intestinal blood loss or carbon monoxide poisoning; sickle cell crisis). Other indications include: Pneumothorax oxygen may increase the rate of resolution of pneumothorax in patients for whom a chest drain is not indicated. Pneumocephalus high flow oxygen may increase the resolution of pneumocephalus in patients with a basal skull fracture (Note: Mask Continuous Positive Airway Pressure [ CPAP] is contra-indicated) Post operative state general anaesthesia can lead to decrease in functional residual capacity with in the lungs (especially following thoracic orabdominal surgery) resulting in hypoxaemia (Ferguson 1999). There is some evidence to suggest a decreased incidence of post-operative wound infections with short-term oxygen therapy following bowel surgery. 8.9 Contra-indications There are no absolute contraindications to oxygen therapy in hospital if indications are judged to be present. The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest possible FiO2. Supplemental O2 should be administered with caution in patients suffering from paraquat poisoning (BNF 2010) and with acid inhalation or previous bleomycin lung injury.

9.

Cautions

9.1 Oxygen administration and carbon dioxide retention In patients with chronic carbon dioxide retention, oxygen administration may cause further increases in carbon dioxide and respiratory acidosis. This may occur in patients with COPD, neuromuscular disorders, morbid obesity or musculoskeletal disorders. There are several factors which lead to the rise in CO2 with oxygen therapy in patients with hypercapnic respiratory failure (Appendix 4).
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9.2

Other precautions/Hazards/Complications of oxygen therapy Drying of nasal and pharyngeal mucosa Oxygen toxicity Absorption atelectasis Skin irritation Fire hazard Potentially inadequate flow resulting in lower FiO2 than intended due to high inspiratory demand or inappropriate oxygen delivery device or equipment faults.

10.Transfer and transportation of patients receiving oxygen

Patients who are transferred from one area to another must have clear documentation of their ongoing oxygen requirements and documentation of their oxygen saturation. If a patient transfers from an area not utilising the target saturation system their oxygen should be administered as per the transferring areas prescription until the patient is reviewed and transferred over to the target saturation scheme, which should occur as soon as possible. Recommended target saturation range should be prescribed before transfer. Patients requiring oxygen therapy whilst being transferred from one area to another should be accompanied by a trained member of the nursing staff wherever possible. If this does not occur, clear instructions must be provided for personnel involved in the transfer of the patient, which must include delivery device and flow rate and recommended target oxygen saturation range. Patients being transferred on oxygen therapy must have their oxygen requirement calculated and a check made to ensure that sufficient oxygen is available for the transfer. If the oxygen delivery device is changed for transfer, its suitability and effectiveness must be checked with pulse oximetry before transfer. As a general principle for patients being transferred on oxygen therapy, supply should be provided from a wall outlet rather than a cylinder if a patient is required to wait in a particular area for treatment investigation. Cylinders should only be used if there is no piped oxygen available. If a patient is transferred on a different oxygen delivery system from that which was being used in the ward or department, then oxygen saturation should be checked for five minutes before transfer is made. Patients with unstable respiratory condition may require a longer period of monitoring before transfer

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For specific guidelines for transferring a patient who requires high flow oxygen see the Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults

11. Peri-operative and immediately post-operatively

The usual procedure for prescribing oxygen therapy in these areas should be adhered to, using a suitable target saturation range. If a patient is transferred to the ward, if oxygen therapy is to be continued, it should be prescribed using the target saturation scheme.

12. Nebulised therapy and oxygen

When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure, it should be driven by compressed air. If necessary, supplementary oxygen should be given concurrently by nasal prongs at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other specified target range. All patients requiring 35% - 50% oxygen therapy should have their nebulised therapy driven by oxygen at a flow rate of 4 - 6 litres/minute and should receive continuous pulse oximetry for at least the duration of the nebuliser treatment. Patients receiving oxygen via Aquapak, or high flow venturi at greater than 40% or high-flow should have a nebulised drug administered using a T piece added to the circuit. The driving gas should be oxygen or air (compressor or wall supply) according to the level of hypoxia of the patient and the patients oxygen requirement. Pulse oximetry should be used for the first five minutes of any addition of a nebuliser, as this constitutes a change in oxygen delivery. If a patient is requiring oxygen via a reservoir bag mask and needs a nebuliser the nebulised drug may be given using a nebuliser and mouthpiece in addition to the high concentration oxygen. The nebuliser should be driven by air or oxygen as appropriate. Expert help may be required for profoundly hypoxic patients. Such help may be sought from the medical team, critical care outreach or Night Nurse Practitioner. Where for example a patient is receiving oxygen via a reservoir bag mask at 15 litres a minute and remains hypoxic, help my be required to administer prescribed nebulised drug treatment. Delivery of nebuliser using a mouthpiece along with a reservoir bag mask may be possible.

13. Normal Oxygen saturations

In adults less than 70 years of age at rest at sea level 96% - 98% when awake.
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Adults aged 70 and above at rest at sea level greater than 94% when awake. Patients of all ages may have transient dips of saturation to 84% during sleep.

14. Humidification
Humidification may be required for some patient groups, especially neck-breathing patients and those who have difficulty in clearing airway secretions or mucus (See Appendix 7). If the flow rate exceeds 4 litres per minute for several days where nasal cannulae or Hudson mask are used Tracheostomy or laryngectomy patients (neck-breathing patients) (heated humidification required for minimum 36 hours for fresh tracheostomies or laryngectomies (See Tracheostomy policy) Cystic Fibrosis patients Bronchiectasis patients Patients with a chest infection retaining secretions Patients ventilated invasively (i.e. via tracheal tube) Humidification is not routinely required for non-invasively ventilated patient. Expert help should be sought as use of humidification can influence ventilator efficiency or safety. Humidification is not routinely required in the Emergency Department unless there is a delayed transfer beyond four hours.

15. Training
All health care professionals administering oxygen therapy should must attend medical gas training. All staff administering oxygen need to understand the use of oxygen administration systems and be trained in the use of the oxygen equipment being used. Staff prescribing oxygen therapy should have received training in the possible causes of hypoxic drive and identification of safe and appropriate target saturation range. Staff must refer to the Mandatory Training Matrix, available on the intranet at http://webserver.ruhbath.swest.nhs.uk/development/mandatory/documents/matrix_roles.xlsi, to identify what training in relation to administering oxygen is relevant for their role. The Mandatory Training Matrix identifies when training needs to be undertaken, the method of delivery and frequency of the training. The Mandatory Training policy identifies how training non-attendance will be followed up and managed and is available on the intranet at http://webserver.ruhDocument name: Oxygen therapy administration Policy and Guidelines Issue date: Page 16 of 33 Ref.: Status: V2

bath.swest.nhs.uk/staff_resources/governance/policies/documents/non_clinical_polic ies/black_hr/HR_148_Mandatory_training_policy.pdf

16. Health and Safety Issues

Oxygen supports combustion and may be stored under high pressures. Therefore there is potential for injury. All gas supply wall outlets or terminal units (including oxygen) must be appropriately labelled. Connexion and disconnexion of Schrder valves must be done with firm grip of equipment to avoid accidental pressure forcing tubing to propel away from the valve port. Potential for injury exists if care is not taken. No sources of ignition should be used near oxygen ports (in use or not) unless there has been a risk assessment. This includes electric hair dryers. Oxygen delivery systems should be disconnected from patients and held away during emergency defibrillation, unless the breathing circuit is a completely sealed one. Oxygen cylinders are heavy. Appropriate manual handling techniques should be employed Oxygen cylinders should be well secured when used, particularly for the transport of patients. Oils, greases and creams should not be used on oxygen cylinders or equipment connections as there is a risk of explosion and fire if they come into contact with oxygen. Oxygen cylinder regulators should not be changed in patient clinical areas. All staff should have appropriate training that is appropriate for their role in oxygen use.

17. References and Further Reading

British National Formulary (2010). BMA and RPS Publishing Group. (http://bnf.org. Last accessed 4th November 2010) British Oxygen Corporation (2005). Medical Cylinder Data. BOC National Committee of Enquiry into Patient Outcome and Death. (2005). An Acute Problem. NCEPOD
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National Patient Safety Agency (2009). Oxygen Safety in Hospitals. Rapid Response report from reporting to learning NPSA/2009/RRR006 ODriscoll B, Howard L, Davison A. (2008) BTS guideline for emergency oxygen use in adult patients. Thorax; 63: Supplement VI. Stroke Oxygen Study (unpublished) Protocol summary: A multi-centre, prospective, randomised, open, blinded-endpoint study to assess whether routine oxygen treatment in the first 72 hours after a stroke improves long-term outcome Weston C. (2010). Oxygen therapy in acute myocardial infarction too much of a good thing? [editorial]. The Cochrane Library 2010 (16 June). http://www.thecochranelibrary.com/details/editorial/742329/Oxygen-therapy-inacute-myocardial-infarction--too-much-of-a-good-thing--by-Dr-C.html (accessed 4 November 2010). Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M, Beasley R. (2009). Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart 95(3):198202.

18. Acknowledgements
The appendix on humidification was produced by Kerry Joyce, and Gail Jones (Physiotherapists at the Royal United Hospital as well as the author) Consent for use of photographs from Louise Barton and Lauren Hunt Some photographs borrowed from BTS guideline online materials The example of local oxygen policy from http://www.brit-thoracic.org.uk/clinicalinformation/emergency-oxygen/emergency-oxygen-use-in-adult-patients.aspx was used as a basis for this guideline.

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Appendix 1: Consultation Schedule

Name and Title of Individual Francesca Thompson, Director of Nursing Resuscitation / Clinical skills team Jerry Nolan, Consultant intensivist Kim Gupta, Consultant Intensivist Critical Care Outreach nurses Band seven nurses (Critical Care) Consultant Physicians, Respiratory Ward Issy Wyber, Pharmacist Susie Slade, Ward Manager Respiratory Ward Mark Mallett, Acute Care Consultant Geoff Allen Julie Blackman, Clinical Skills training manager Medical Nurse Practitioners Tim Craft, Medical Director Robin Fackrell, Consultant, Older Persons Unit Helen Jeffcoat, Ward Manager MAU Alexandra Lucas, Philip Kaye, Consultant ED Night Nurse Practitioners Andrew Padkin, Consultant Intensivist Kevin Roles, Ward Manager SAU Judith Rollason, Respiratory Nurse Specialist Mark Grover, Respiratory Nurse Specialist Antoni Salamon, Surgical Nurse Practitioner Clare Taylor, Consultant ED Dominic Williamson, Consultant ED Gerrit Van Rensberg, Acute Care Consultant Alison Harries, Claire Fullbrook-Scanlon, Nurse Consultant Stroke Regina Brophy, Principal Pharmacist Andy House, Head of Estates Date Consulted 27th July 2010 27thJuly 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 August 2010 27th July 2010 27th July 2010 November 2010

Name of Committee Critical Care Delivery Group Medicines Advisory Group Medical Gas Committee Operational Governance Committee Clinical Governance Committee

Date of Committee 27th July 2010 27th July 2010 December 2010

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Appendix 2: Ward equipment list for oxygen masks and delivery systems
All general wards where acutely unwell patients are admitted should have access to the following range of equipment (Stock levels need to be determined locally and where appropriate there should be sharing arrangements between wards to ensure that access to the following is possible). Where there are long term requirements for some equipment temporary stock for individual wards may be required. Disposable equipment Hudson masks (simple masks) Nasal cannulas Reservoir Bag Masks Aerosol masks Aerosol tubing 7mm Green bubble tubing Venturi valves 24% Venturi valves 28% Venturi valves 35% Venturi valves 40% Nebulisers Nebuliser T pieces Nebuliser mouthpieces Aquapak water (500 and 1000 mls) Aquapak venturi connectors High Flow and Continuous Positive Airway Pressure (CPAP) equipment High flow and CPAP equipment is not for routine use on general wards. Outside specialist areas it should only be used as a bridge to transfer based on clinical need, with expert support. It may be obtained (with expertise) from the following areas or teams: Critical Care Nursing Outreach (Bleep 7719) Night Nurse Practitioners (Bleep 7428 or 7429) Critical Care Unit (ITU & HDU) (Extension 5010) Respiratory Ward (Extension 4405) Medical Assessment Unit (Extension 1214) Coronary Care Unit (Extension 5012) Tracheostomy masks and Aquapak heaters These may be obtained from the following areas or teams: Critical Care Nursing Outreach (Bleep 7719) Night Nurse Practitioners (Bleep 7428 or 7429) Head and Neck Nurses (Bleep 7169) Critical Care Unit (ITU & HDU) (Extension 5010) Waterhouse Ward (Extension 4425)
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Appendix 3: Oxygen escalator

(RBM = Reservoir bag mask; NASAL CAN = nasal cannulae)

Oxygen delivery systems deliver either a measure of oxygen in litres per minute or an oxygen concentration expressed as a percentage See Appendix 6 for more information about different types of oxygen delivery device.

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Appendix 4: Patients who may have hypoxic drive

Patients who may have hypoxic drive and normally require oxygen titrated to an oxygen saturation target range of 88 92% are people with the following conditions: Chronic hypoxic lung disease COPD Severe Chronic Asthma Bronchiectasis / Cystic Fibrosis Chest wall disease Kyphoscoliosis Thoracoplasty Neuromuscular disease Obesity hypoventilation

Consider also, patients with a significant smoking history.

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Appendix 5: Adult vital signs chart target saturation range

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Appendix 6: Oxygen administration devices (expanded oxygen escalator)

Nasal cannulae These are the most commonly used means of giving oxygen therapy as they are comfortable and well tolerated and allow patients to communicate, eat, drink, wear glasses and read without too much difficulty. These deliver a low to moderate concentration of oxygen, and can be used to deliver oxygen up to 5 litres per minute. They are described as a variable performance system which means that it is not possible to be precise about the exact concentration of oxygen given, so the oxygen given is recorded in litres per minute. They are widely used for people who cannot (or will not) tolerate a mask, or as an adjunct if the patient is too hypoxic on a mask alone. Mouth breathers will get less oxygen support than patients who are breathing at least in part through their nose. If a patient has a blocked nose, the percentage of oxygen delivered may be much reduced. They should be used with caution if the patient is confused and should not be used for patients emerging from anaesthesia due to the risk of strangulation.

Hudson mask (also known as simple oxygen mask) This is a plastic mask with several small vent holes on each side. It is attached to the oxygen supply using 7 mm oxygen tubing. It is a variable performance mask which is generally used with 3 to 5 litres of oxygen per minute where it will deliver up to 35 - 40%%. No humidification is required or should be added. This type of mask is generally used for patients emerging from anaesthesia and for a few hours post-operatively. It is suitable for use overnight for a post-operative patient with no complicating lung disease. It is not recommended for sustained use, and is inappropriate for continued use in a patient with a lung disease. It is used for short burst oxygen therapy, e.g. a patient who s prescribed oxygen for a few minutes after exertion to ease hypoxic breathlessness in chronic lung disease. If the flow is set too low (less than three litres per minute of oxygen) the mask may contribute to re-breathing which will allow a patient to retain carbon dioxide.

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Venturi mask In this Trust venturi masks are provided as a range of different venturi valves that are designed to fit onto a standard aerosol mask. A venturi is a simple design of valve that uses oxygen supplied through a port which allows room air to be drawn in. This generates a rate of flow which may in some situations approach the patients peak inspiratory flow. The advantage of this type of mask is that it delivers a precise percentage of oxygen at high rates (at least for low oxygen concentrations). On the side of each rating of venturi valve is printed or embossed the flow rate that is required to maintain the stated oxygen concentration (see below). If a patient is tachypnoeic it is advisable to increase the flow rate above that indicated on the valve but note that this will not increase the oxygen concentration). Although there are venturi valves that can deliver 60% oxygen, the need for humidification is increased as the oxygen concentration increases and an Aquapak (which is an adjustable venturi system) is recommended. The mask is suitable for patients who require low to moderate oxygen concentration, and who are unable to manage with nasal cannulae. Venturi valve rating and colour coding Valve rating Colour 24% Blue 28% White 35% Yellow 40% Red The green 60% venturi valve is not recommended for use as humidification is inadequate for a venturi valve of this rating.

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Aquapak This device is a disposable adjustable venturi valve which is used with aerosol tubing and an aerosol mask. It has a bottle of water that connects to the bottom of the device and it attaches to an oxygen flow meter to regulate the oxygen flow. It is possible to add an optional heater which turns this cold-nebulised system into a heated humidifier.

The system is set by adjusting the oxygen flow rate and by rotating the adjustable collar on the device. This allows delivery of oxygen between 24% and 98% of oxygen into the aerosol tubing to the patient. This system uses an aerosol mask with 22mm aerosol (Elephant) tubing. Although Aquapak bottles do have a connector for 7mm oxygen (green bubble) tubing, this should not be used (it only exists because the company have not changed their manufacturing process in line with current good practice). Humidification is only achieved by using aerosol tubing and ensuring that its length is around 1.5 metres. This system is useful for controlled oxygen in a patient with the specific need for added moisture at low oxygen percentages (40% and less). The system is recommended for all patients requiring greater than 40% oxygen for more than three hours provided that good oxygen saturations can be maintained. The system can deliver oxygen concentrations of up to 98%. (This does not mean that the inspired concentration is actually 98% because with Aquapak flow may not match demand), but where a patient has low saturations these may be improved by increasing the flow of the oxygen above 10 litres.
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Above 80% oxygen concentration, if oxygen saturations cannot be maintained within the targeted range, then oxygen via high flow circuit should be considered. A reservoir bag mask may improve oxygenation while this is being arranged. If an aquapak is used for humidification and water traps are used to capture condensed water from the aerosol tubing between humidifier and patient, care must be taken to ensure that the trap is well positioned and emptied frequently. If it is allowed to overfill then intermittent or complete interruption of delivered oxygen is possible.

Reservoir bag mask

This is a mask that is designed to provide high concentrations of oxygen for short periods. At 15 litres per minute the system will deliver about 90% oxygen; at 10 litres per minute the system will deliver about 70% oxygen. In the immediate and acute situation the flow of gas can be titrated over whatever range (up to 15 litres) that is required to achieve a target saturation. This type of mask is a variable performance mask and should be used for no longer than three hours. Long term use leads to complications associated with dry lung tissue (i.e. reduced ciliary action, sputum retention, mucus plugging and desiccation of lung tissue). An alternative for longer-term use would be an Aquapak system or if that proves inadequate an adjustable venturi and high flow system. If a patient remains so hypoxic that they still require this system after three hours, then they need a medical review and a suitable treatment plan.

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High Flow Oxygen and Continuous Positive Airway Pressure (CPAP) This circuitry is not routinely available on general wards. It is used in the Emergency Department, Coronary Care, Respiratory ward and the Medical Assessment Unit, as well as Critical Care (ITU & HDU). Critical Care Outreach will establish patients on high flow and provide support in its use on general wards or establish CPAP as a bridge to transfer to a more suitable clinical area. HIGH FLOW (ADJUSTABLE VENTURI) WITH HEATED WIRE HUMIDIFIER AND AEROSOL MASK

Continuous Positive Airway Pressure by face mask

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Appendix 7: Humidification

Humidification assessment
Assessment No sputum No chest signs Comments Low or no oxygen requirement Target saturation range achieved with <40% oxygen or 4l (via nasal cannulae or Hudson mask) Comfortable respiratory pattern Respiratory rate less than 20 (or normal for that individual) Chest clear on auscultation Suggested humidification None required

Loose sputum No increased oxygen requirement Loose sputum Increased oxygen requirement Chest signs Thick sputum No increased oxygen requirement Thick sputum Increased oxygen requirement Retained secretions With chest signs Increased work of breathing Probable increased oxygen requirement or at least a tendency to desaturate Increased respiratory rate

None required

Aquapak humidification

Saline nebulisers Consider Aquapak humidification Aquapak Consider saline nebulisers Aquapak Saline nebulisers Consider humidifier heater for Aquapak Consider heated wire humidification Consider expert help
JH July 2010

Note on humidification for Non-Invasive Ventilation and Continuous Positive Airway Pressure (CPAP) systems: For non-invasive ventilation, Bi-level Posiitve Airway Pressure (BiPAP) humidification is not routinely required as usually oxygen concentrations are not high and NIV machines use room air (which contains some moisture) and the upper respiratory tract is intact. Added humidification for non-invasive ventilators requires expert advice and care and is unlikely to be used in the ward setting. Humidification is not routinely used in the emergency department setting, even for mask CPAP, but it will need to be instituted if therapy continues on the ward usually the Medical Assessment Unit (MAU), Respiratory ward or the Coronary care Unit (CCU). Humidification is not routinely required for short burst CPAP which is usually managed by physiotherapists.

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Appendix 8: BOC Oxygen cylinder sizes and capacities

Cylinder size AZ C AD CD DD PD RD D E AF DF F HX ZX G J Capacity in litres 170 170 400 460 460 300 460 340 680 1360 1360 1360 2300 3040 3400 6800

Appendix 9: Sample oxygen prescriptions

If preferred the starting oxygen device and flow rate may be specified as an additional instruction. Note: Oxygen prescription pre-printed on chart will be implemented in the future.
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Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval Initial Screening Policy, service, strategy, procedure or function: Lead (e.g. Director, Manager, Clinician): Person responsible for the assessment: Name: Julian Hunt Job Title: Consultant Nurse Is this a new or existing policy, service strategy, procedure or function? New Who is the policy/service strategy, procedure or function aimed at? Patients Staff: involved in the administration of oxygen therapy to patients Are any of the following groups adversely affected by the policy? If yes is this high, medium or low impact (see attached notes): Group Affected? Impact Disabled people: No Low Race, ethnicity & nationality No Low Male/Female/transgender: No Low Age, young or older people: No Low Sexual orientation: No Low Religion, belief and faith: No Low If the answer is yes to any of these proceed to full assessment. This applies whether the impact assessment is high, medium or low. If the answer is no to all categories, the assessment is now complete 1. Does the policy, service strategy, procedure or function include measures which promote equality? 2. If yes, what are these measures? No Policy and guidelines Julian Hunt

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Consultation Checklist
Author; attach this to each copy of the policy being sent to a meeting for comment. Dear Chairman Please would you disseminate this document for comment at your next meeting and return any amendments/comments to: Julian Hunt, Consultant Nurse Critical Care Title of meeting: Operational Governance Committee Date of meeting: Policy Title and Reference: Oxygen Policy and Guidelines: the administration of short burst, sustained (medium term) and emergency oxygen to adults in hospital Name of author: Julian Hunt Are there any elements of this policy which present operational issues that require further discussion? If yes, please provide a contact name for the author. Does the document include a training plan? Does the document include relevant references? Are up to date National Guidelines included? If you are the appropriate forum, have the necessary resources been agreed to implement this document? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed in the document? Other comments from meeting. What are the cost implications of implementing this document? Equipment Staffing (additional) Training Other Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No Yes / No Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A

Are there any other department affected? Document endorsed without further comment? Further amendments to document suggested? Name of Chair: Carol Peden

Signature: ____________________________________ Date: __________________

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Ratification Check List

Author; attach this to each copy of the policy being sent to a Committee for final ratification. Dear Chairman Please would you review this document at your next meeting and agree final approval and organisational ratification. Title of meeting: Date of meeting: Title and Reference of document: Oxygen Policy and Guidelines: the administration of short burst, sustained (medium term) and emergency oxygen to adults in hospital Name of author: Julian Hunt, Consultant Nurse Critical Care Clinical Governance Committee

Are there any elements of this policy which present operational issues that require further discussion? If yes, please provide a contact name for the author. Does the document include a training plan? Is the policy referenced? Are up to date National Guidelines included? If you are the appropriate forum, have the necessary resources been agreed to implement this document? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? What are the cost implications of implementing this policy? Equipment Staffing (additional) Training Other

Yes

No

N/A

Yes Yes Yes Yes Yes Yes

No No No No No No

N/A N/A N/A N/A N/A N/A

Yes Yes Yes Yes Yes Yes

No No No No No No

N/A N/A N/A N/A

Document endorsed without further comment? Further amendments to document suggested? Name of Chair: Michael Earp

Signature: ________________________________ Date: ________________________

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