Emergency oxygen

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oxygen

Oxygen therapy and prescription for paediatric inpatients

Oxygen is regarded as a medicine and therefore cannot be administered by nursing staff without a prescription. This is a legal requirement.

 

Background
BTS Guidelines – 2008
BTS guidelines for emergency oxygen use in adults indicate that oxygen for inpatients must be prescribed and monitoring of therapy must be formally documented. There are currently no parallel guidelines for the management of emergency oxygen therapy in children, but these are in the process of being developed.
The adult guideline provides guidance on the following principles:
• Defining target oxygen saturations for different patient groups
• Prescribing oxygen
• Monitoring and altering oxygen therapy accordingly

National Patient Safety Agency
Rapid Response Report – September 2009
The NPSA received 281 reports of serious incidents related to inappropriate administration and management of oxygen. Of these incidents, poor oxygen management appears to have caused nine patient deaths and may have contributed to a further 35 deaths.
Common themes identified from the review of these incidents
• Prescribing: failure to or wrongly prescribed
• Monitoring: patients not monitored, abnormal oxygen saturation levels not acted upon
• Administration: confusion of oxygen with medical compressed air, incorrect flow rates, inadvertent
• Equipment: empty cylinders, faulty and missing equipment
• Disconnection of supply
NPSA recommendations for every institution
• NPSA briefing sheets highlighting actions to minimise risks of oxygen therapy are immediately made available to all relevant staff.
• The use of oxygen cylinders is minimised
• Where the use of oxygen cylinders is unavoidable robust systems are in place to ensure reliable and adequate supplies, including checking and stocktaking of cylinders.
• The risks of confusing oxygen and medical compressed air are assessed and action plans developed
• Oxygen is prescribed in all situations in accordance with BTS guidelines (but note these do not cover critical care or children less than 16 years).
• In an emergency, oxygen should always be given immediately and documented later.
• Pulse oximetry is available in all locations where oxygen is used.
• A multidisciplinary group responsible for reviewing oxygen-related incidents, developing a local oxygen policy and a training programme.

University Hospital of Wales
UHW have implemented the following strategies to date
• Minimal oxygen cylinder use hospital wide.
• Governance strategies where use of oxygen cylinders is unavoidable hospital wide
• Education programme in adult services.
• Mandatory prescription of oxygen in adult services using drug chart sticker.
• Doctor and nurses training programme for effective prescription and monitoring of oxygen therapy in adult services.
• System of oxygen therapy governance for monitoring of oxygen related incidents.

Paediatric Addendum

This document is produced by a multidisciplinary paediatric team involved in implementing parallel changes to oxygen therapy in paediatric inpatients at the University hospital of Wales. The majority of oxygen related incidents reported to the NPSA are likely to have occurred in adult patients with chronic disease, where excessive oxygen therapy can be dangerous as it may affect the patient’s respiratory drive. This is less of an issue in paediatric patients. The adult BTS guidelines are not directly applicable to paediatric patients.
This paediatric addendum has concentrated on implementing safe prescription, monitoring and titration of oxygen therapy in paediatric inpatients. It will need to be reviewed with reference to the BTS guidelines for the emergency management of oxygen therapy in children, when this document has been published.

Oxygen therapy in children
Children are given oxygen in hospital in the following situations
• The majority of children admitted to hospital acutely who require oxygen have a lower respiratory infection or asthma.
• Systemically unwell children (e.g. DKA, sepsis, trauma) are given oxygen in the emergency situation as per APLS guidelines.
• Children with a chronic oxygen requirement including chronic lung disease of prematurity, pulmonary hypertension or end-stage cystic fibrosis are often admitted to hospital either routinely or when unwell. These patients will have a predefined range within which the oxygen saturations should be maintained.

Target oxygen saturations
Oxygen is delivered to children to achieve specific target oxygen saturations and these will differ depending on the indications for oxygen therapy.
• Oxygen saturations for healthy children with an intercurrent illness should be >92%.
• Oxygen saturations for children with chronic lung disease of prematurity should be between 91-94%.
• Oxygen saturations for children with or at risk of pulmonary hypertension should be >95%
• Children with congenital heart disease and blood mixing may have low oxygen saturations at baseline, and advice should be sought from the cardiology team with regard to target saturations in these patients.

A flow sheet for acute oxygen management can be found here

Oxygen delivery systems
Oxygen is delivered to children on the ward through many different interfaces. These include nasal cannulae, facemask, headbox oxygen, non-rebreathe mask, CPAP, SIPAP, BIPAP, and high flow humidified oxygen systems (vapotherm, Optiflow). It is important to realise that for almost all of these systems, the amount of oxygen delivered to the lungs cannot be quantified as these are open systems where the patient can in-train surrounding air into the oxygen supply being delivered. This is called uncontrolled oxygen therapy. The exception is headbox oxygen where the %FiO2 in the child’s immediate environment can be accurately controlled. This is an example of controlled oxygen therapy.

Guidance on delivery systems is provided here

Is giving oxygen safe?
In adults with chronic respiratory disease and CO2 retention, respiratory drive may be dependant on hypoxia. Giving oxygen to these patients may cause CO2 narcosis.
These adult patients are managed with regular blood gases and lower target oxygen saturations. Children with chronic respiratory disease may also have CO2 retention. In theory, they may also be at risk of CO2 narcosis but this is extremely rare in the paediatric population. Particular attention should be paid to children with chronic lung disease of prematurity, end stage cystic fibrosis, neuromuscular weakness and obesity when prescribing oxygen. If in doubt talk to your consultant.

Emergency oxygen
In any emergency, oxygen may still be administered without a prescription. The prescription will need to be written retrospectively and should be done as soon as is possible.

 

Prescribing oxygen
Oxygen is regarded as a medicine and therefore cannot be administered by nursing staff without a prescription. This is a legal requirement.

Because children are generally managed with uncontrolled oxygen therapy, prescription of oxygen needs to relate to target oxygen saturations rather the amount of oxygen to supply.

The oxygen prescription chart has been designed to accommodate the following needs:

  • Formalise oxygen delivery
  • Maintain adequate flexibility so that nurses can continue to titrate oxygen appropriately without the restriction of needing to modify the prescription many times a day.
  • Set the upper limit to the amount of oxygen that may be delivered before repeat medical reassessment is indicated. These limits are designed to precipitate a request for further medical consultation before oxygen therapy can be escalated.
  • The oxygen chart must be able to accommodate multiple modifications in oxygen prescription in keeping with the changing condition of the child

The oxygen prescription is explicit in the following

  • Target oxygen saturation
  • Mode of oxygen delivery
  • A range in the amount of oxygen that may be safely delivered to achieve the desired oxygen saturations.

 

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Oxygen monitoring by nursing staff
The sticker will fit into a single prescription compartment on the existing drug charts

Drug chart
• Nurses should use the time grid on the drug chart to sign for the oxygen prescription once / shift

Observation chart
• A minimum of 4 hourly observations should be carried out. Observations should include respiratory rate, oxygen saturations, level of oxygen administered and mode of oxygen delivery.

Titrating oxygen therapy
• Nurses should always administer the minimum oxygen possible to achieve the desired oxygen saturations.
• Oxygen saturations should be monitored and documented for 5 mins at every change
• If oxygen delivered reaches upper extreme of range, nurses should request a medical review.

Stopping oxygen therapy
• Oxygen therapy may be discontinued when oxygen saturations have been stable on mimimal oxygen therapy for two consecutive observations.
• Note: Oxygen may still be required at night and with feeding

How to stop oxygen therapy
• Stop oxygen & monitor oxygen sats for 5 minutes.
• If stable, continue to monitor in air for 1 hour
• If saturation falls, then re-start oxygen
• If saturations remain stable at one hour, stay in air
• Document the changes you make
• Doctor should review and cross off oxygen on drug chart