Emergency Oxygen Professor Thida Win 10/03/2015SCN Emergency Oxygen Event.

SCN Emergency Oxygen Event

Emergency Oxygen

Professor Thida Win

10/03/2015

SCN emergency Oxygen Event

Why Important

• Oxygen is the main ‘‘fuel’’ of the cells and it is essential for humans to maintain a safe level of oxygen in the bloodstream

• Oxygen is the most commonly use drug in emergency situation

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• 34% of emergency ambulance patients receive oxygen1

• ~14% of UK hospital patients were on oxygen during BTS audits

• Approx 2-4 million people per year in UK


too much of a good thing!

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Human experiments found evidence of “leaky airways” in healthy subjects after inhaling 30% oxygen for 45 hours

Griffith DE et al Am Rev Respir Disease 1986 ; 134: 233-237

Risks of hyperoxaemia

SCN emergency Oxygen Event10/38/2015

• JL Smith J Physiology 1899 Vol 24 p19-35


BTS Oxygen guideline

• Strategy 2005• Guideline 2008• Due to update this year

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Audit 1 July-Sept 2008 Before Guideline launch in October 2008 Audit 2 November 2009Audit 3 Oct-November 2010Audit 4 Aug-November 2011

• Oxygen champions conducted audits

• Methodology- BTS online Audit tool

BTS Emergency Oxygen Audits

Audit 5 Aug-November 2012

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*Definition of “on oxygen” in 2008-09 included patients with a prescription who were not on oxygen at the time of audit

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

Oxygen

17.5%

18.4%

15.5%

13.7% 14.0%

Overview of results 2008-2012

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Prescription of oxygen

32% of patients who were using oxygen had some sort of written order for oxygen use in 2008

69% in 2009 (47 Trusts)

56% in 2010 (90 Trusts)

48% in 2011 (156 Trusts)

52% in 2012 (145 Trusts) Possible selection bias in earlier audits (more medical wards)

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Year 2008 2009 2010 2011 2012

PercentOn oxygen

17.5% 18.4% 15.5% 13.7% 14.0%

TargetRange

10% 40% 41% 43% 46%

No Written Order

68% 31% 44% 52% 48%

Percent of all hospital patients on oxygen with no written

order

11.9% 5.7% 6.8% 7.1% 6.7%

Oxygen prescribing 2008-2011

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Year 2008 2009 2010 2011 2012

Percentof drug

rounds on which oxygen was signed for

on the drug chart

5% 27 % 16 % 20 % 20%

Percent of expected

observation rounds with

oximetry

94 % 93 % 99 % 100 % 100%

Drug rounds & Observation Rounds

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Observations Rounds for 2483 patients on Oxygen with a Target Range 2012

• 57% of patients within the target range• 31% of patients outside the target range 10% not possible to judge due to use of NEWS chart

Below

Target RangeAbove

Target RangeBy 1% 3% 6%

By 2% 3% 7%

By >2% 3% 9%*

Total 9% Below target range

22% Above target range

*It is not possible to be more than 2% above target range if the patient’s target range is 94-98%. Therefore, all patients who are more than 2% above target must be at risk of hypercapnic respiratory failure.10/38/2015


Implementation Audits

Year 2009

Feb n=72

2009Nov n=61

2010 n=51

2011N=127

2012N=95

Oxygen PolicyImplemented 6% 21% 37% 89% 83%

PrintedOxygen

Prescription9% 28% 51% 72% 80%

O2 on Monitoring

Chart7% 34% 33% 58% 69%

Nurse TrainingImplemented 7% 13% 18% 31% 42%

Doctor training implemented 4% 10% 11% 31% 42%

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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

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EOE BTS Oxygen Audit

• Audit Period: 15 August - 15 November 2012• Oxygen delivery and management of acutely

ill patients, was published in October 2008.• 18 Trusts in EOE• 2 did not participate• 3 did not answer• 13 included in survey, but 1 have incomplete

data

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The Guideline’s key recommendations

• Oxygen therapy should be adjusted to achieve target saturations rather than giving a fixed dose to all patients with the same disease

• Oxygen will require a prescription in all situations except for the immediate management of critical illness

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Basildon &

Thurro

ckPAH

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

Southen

dN&N

Ipswich

West

Suffolk

0

5

10

15

20

25

30

35

40

% of patients on Oxygen

% of patients on Oxygen

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94-98%

Basildon &

Thurro

ck

Ipswich

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

Southen

dPAH

West

Suffolk

N&N0

20

40

60

80

100

120

Series1Number of patients using oxygen with a prescrip-tion with a target range94-98%

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BTS 55%

SCN emergency Oxygen EventBasi

ldon & Th

urrock

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

L&D

N&NPAH

Southen

d

Ipswich

West

Suffolk

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Number of patients using oxygen with a prescription with target range

88-92%

Number of patients using oxygen with a prescrip-tion with target range88-92%

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BTS – 45%


Above the target

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Basildon &

Thurro

ck

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

L&D

N&NPAH

Southen

d

Ipswich

West

Suffolk

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Number of patients with SpO2 above target range by 1%?Number of patients with SpO2 above target range by 2%?Number of patients with SpO2 above target range by more than 2%?total belwo


Below target range

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Basildon &

Thurro

ck

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

L&D

N&NPAH

Southen

d

Ipswich

West

Suffolk

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Number of patients with SpO2 above target range by 1%?Number of patients with SpO2 above target range by 2%?Number of patients with SpO2 above target range by more than 2%?total belwo


Above and below range

Basildon &

Thurro

ck

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

L&D

N&NPAH

Southen

d

Ipswich

West

Suffolk

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

total belwototal above

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BTS, Above 23%, below 9%


Observation and range

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Basildon &

Thurro

ck

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

L&D

N&NPAH

Southen

d

Ipswich

West

Suffolk

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Number of patients with SpO2 within target range at last assessment?total out of range

BTS 64% in range


Observation rounds

Basildon &

Thurro

ck

Addenbro

okes

Colchest

er

ENHHT

Hinchingb

rooke

James

Paget

L&D

N&NPAH

Southen

d

Ipswich

West

Suffolk

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

140.00%

Number of patients currently using oxygen with no prescription or bedside order.% of observations to rounds

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Summary

• 7-34% of patients were on Oxygen• Majority with higher target range, however,

surprisingly big number with lower target range (except southend)

• Significant number without prescription• Significant number without signature• More Above the range than below

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Limitations..

• No data for education• No data for Observation Chart• No data for organisational factor• No data on Ambulance• No data on harm• Data Long time ago- a lot moved on• Cross section data of given time

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Since....• Unify drug chart• New Observation Chart• Different pathway progress• Acute Chest team/ Chest specialist in MAU• Electronic prescription• Care Bundle

– Pneumonia– COPD

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More Evidence

• Risk to COPD patients50 years or anectotes, now good evidence

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•Mortality in acute COPD was 9% V 4% when high concentration oxygen was compared with controlled oxygen (target 88-92%)1

•Mortality in acute COPD was 11% V 7% comparing >35% oxygen with lower doses2 •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


Other at Risk• Other hypercapnia risk, such as Morbid

Obesity, Muscle disease, Scoliosis etc

• Myocardial Infarction

• Stroke

• Post Resuscitation

• Ventilated ICU Patients

• Traumatic Brain Injury 10/38/2015


Oxygen is medicine

• If it is used properly it is beneficial and safe

• Giving too much or too little oxygen may cause harm

• Giving oxygen to those who do not need it may cause harm

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AIMS of today...

• Re enthuse oxygen Champions• Re publish what’s out there• Re member oxygen guideline• Re mind oxygen Audit• Re emphasize importance of education• Re organise oxygen group • Re energise all enthusiastic colleagues

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Emergency Oxygen Professor Thida Win 10/03/2015SCN Emergency Oxygen Event.

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