Oxygen prescription and administration in Adults.doc

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Policy for the prescription and administration ofOxygen in Adults

Reference Number 3.60

Version 1

Name of responsible (ratifying) committee Formulary and Medicines Group

Date ratified 02.03.2010

Document Manager (job title) Dr Sudheer Alapati: Consultant Respiratory Physician

Date issued 11.03.2010

Review date 18/09/2010

Electronic location Corporate Policies

Related Procedural DocumentsSee section 15. References and AssociatedDocumentation

Key Words (to aid with searching)Normal oxygen saturation ranges; oxygen therapy;Humidification; Nebulised therapy; oxygen; prescriptionand administration; Oxygen; Adults

Oxygen prescription and administration in Adults. Issue 1. 11.03.2010 Page 1 of 32(Review date: 18/09/2010) 19/06/2013


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CONTENTS

QUICK REFERENCE GUIDEPage 3

1. Introduction2. Purpose3. Scope

4. Definitions5. Normal oxygen saturation ranges6. Indications7. Contra indications8. Cautions9. Process10. Transfer and transportation of patients receiving oxygen therapy11. Peri-operatively and immediately post operatively12. Nebulised therapy and oxygen13. Humidification14. Training requirements, monitoring compliance with, and effectiveness of

Procedural documents15. References and Associated documentation16. Health and Safety

Appendices

A) Table 1 Critical illnesses requiring high levels of supplemental oxygenB) Table 2 Serious illnesses requiring moderate levels of supplemental oxygen if the

patient is hypoxaemicC) Table 3 COPD and other conditions requiring controlled or low-dose oxygen therapyD) Table 4 Conditions for which patients should be monitored closely oxygen therapy is

not required unless the patient is hypoxaemic

E) Figure 1 Oxygen prescription for acutely hypoxaemic patients in hospitalF) Example of Oxygen prescription chartG) Administering acute oxygen therapyH) Equipment used in the delivery of oxygenI) Flow Chart for oxygen administrationJ) Personnel who may administer oxygenK) Example of bedside observation chart and codes for oxygen deliveryL) Example of nebuliser prescription chartM) Monitoring of patientsN) HumidificationO) Health and safetyP) Oxygen Administration protocol (and weaning protocol)



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QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust proceduraldocuments.

For quick reference the guide below is a summary of actions required. This does not negate the needfor the document author and others involved in the process to be aware of and follow the detail of thispolicy.

1. Oxygen is a drug and therefore requires prescribing in all but emergency situations

2. In the emergency situation oxygen prescription is not required. Oxygen should be given to thepatient immediately without a formal prescription or drug order but documented later in thepatients record.

3. Oxygen will be prescribed according to a target saturation range. The system of prescribingtarget saturation aims to achieve a specified outcome, rather than specifying the oxygendelivery method alone

4. Take special care as there are air outlets which may be mistaken for oxygen outlets

5. Oxygen should be prescribed to achieve a target saturation of 94-98% for most acutely unwellpatients or 88 92% for those at risk of hypercapnic respiratory failure.

6. The patient's oxygen saturation and oxygen delivery system should be recorded on Vital PACor the bedside observation chart (if VitalPAC unavailable) alongside other physiologicalvariables as shown in Appendix K

7. Oxygen therapy should be increased if the saturation is below the desired range anddecreased if the saturation is above the desired range (and eventually discontinued as thepatient recovers). See Appendix I for more details

8. Patients requiring oxygen therapy whilst being transferred from one area to another should beaccompanied by a trained member of nursing staff wherever possible. If this does not occur,clear instructions must be provided for personnel involved in the transfer of the patient andthe oxygen prescription chart must accompany the patient.

9. When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure(see section 8.1), it should be driven by compressed air. If necessary as decided by thedoctor, supplementary oxygen should be given concurrently by nasal prongs at 1-4 litres perminute to maintain an oxygen saturation of 88-92% or other specified target rangedocumented on oxygen/nebuliser prescription chart.



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1.INTRODUCTION

The administration of supplemental oxygen is an essential element of appropriate management for awide range of clinical conditions; howeveroxygen is a drug and therefore requires prescribing inall but emergency situations. Failure to administer oxygen appropriately can result in serious harmto the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integralcomponent of the Healthcare Professionals role.

2.PURPOSE

The aim of this policy 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 oxygendelivery method alone.

Those who administer oxygen therapy will monitor the patient and keep within the target

saturation range

3.SCOPE

This policy is for use within general wards and departments caring for adult patients. Wherespecific clinical guidelines are required for oxygen administration within specialist areas (CriticalCare, Respiratory High Care), they must be approved via the appropriate clinical governance forum.They should reflect wherever possible the principles within this policy.

Patients transferring from specialist areas must be transferred with a prescription for their oxygentherapy utilising target saturation, if the clinical indication is ongoing. If a patient transfers from anarea not utilising the target saturation system, their oxygen should be administered as per thetransferring areas prescription until the patient is reviewed and transferred over to the targetsaturation scheme, which should occur as soon as possible.

In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that itmay not be possible to adhere to all aspects of this document. In such circumstances, staffshould take advice from their manager and all possible action must be taken to maintain ongoingpatient and staff safety

4. DEFINITIONS

PaO2 Partialpressure of oxygen

FiO2 Fractional concentration of inspired oxygen

CO2 Carbon dioxide

BTS British Thoracic Society

EWS Early Warning Score

O2 Oxygen

ABG arterial blood gases

CaO2 oxygen content of blood

COPD Chronic Obstructive Pulmonary Disease



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PCO2 carbon dioxide tension

PaCO2 arterial carbon dioxide tension

PACO2 alveolar carbon dioxide tension

PaO2 arterial oxygen tension

PACO2 alveolar oxygen tension

PO2 oxygen tension

SaO2 arterial oxygen saturation

SpO2 arterial oxygen satuation measured by pulse oximetry

5. NORMAL OXYGEN SATURATIONS

In adults less than 70 years of age when awake at rest and at sea level: 96% - 98%.

Aged 70 and above when awake at rest and at sea level: greater than 94%.

NB: Patients of all ages may have transient dips of saturation to 84% during sleep.

6. 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 (e.g. pneumonia, shock, asthma, heart failure, pulmonary embolus)

Ischaemia (e.g. myocardial infarction, but only if associated with hypoxaemia (abnormally high

levels may be harmful to patients with ischaemic heart disease and stroke).

Abnormalities in quality or type of haemoglobin (e.g. acute Gastrointestinal blood loss or carbon

monoxide poisoning).

Other indications include:

Pneumothorax Oxygen may increase the rate of resolution of pneumothorax in patients for

whom a chest drain is not indicated.

Post operative state (general anaesthesia can lead to decrease in functional

residual capacity with in the lungs (especially following thoracic or abdominalsurgery) resulting in hypoxaemia (Ferguson 1999). There is some evidence tosuggest a decreased incidence of postoperative wound infections with short-term oxygen therapyfollowing bowel surgery.



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7. CONTRA-INDICATIONS

There are no absolute contraindications to oxygen therapy if indications are judged to be

present. The goal of oxygen therapy is to achieve adequate tissue oxygenation using thelowest possible FiO2.

Supplemental Oxygen should be administered with caution in patients suffering from paraquat

poisoning and with acid inhalation (seek specialist advice from the UK National PoisonsInformation Service) or previous bleomycin lung injury.

8. CAUTIONS

8.1 Oxygen administration and carbon dioxide retention

In patients with chronic carbon dioxide (CO2) retention, oxygen administration may cause furtherincreases 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, and

details are in the BTS guideline available at:

http://www.brit-thoracic.org.uk/ClinicalInformation/EmergencyOxygen

8.2 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 highinspiratory demand or inappropriate oxygen delivery device or equipment faults

8.3 Take special care, as there are air outlets that may be mistaken for oxygen outlets

9.PROCESS

9.1 Prescribing, administering and monitoring oxygen

a) Identifying appropriate target saturations

Guidance on identifying appropriate saturations for patients is provided for the medical staff

and other prescribers in Appendices A-E (table 1-4 and figure 1 in the guideline).

In summary 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.

b) Prescribing oxygen on the drug chart

An oxygen prescription chart has been designed to assist prescription and administration. Oxygenshould be prescribed in the designated section of the hospital prescription card (Appendix F) and the

appropriate target saturation should be circled on the chart (or if target saturations are not indicatedthe relevant box should be ticked to highlight the oxygen is given for palliation).

c) Administering oxygen



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Once the target saturation has been identified and prescribed, guidance regarding the mostappropriate delivery system to reach and maintain the prescribed saturation is provided for thoseadministering oxygen in Appendix G, H, I. Personnel who may administer oxygen is shown inAppendix J.

d) Monitoring and recording oxygen

All patients should have their oxygen saturation observed for at least 5 minutes after starting

oxygen therapy. The patient's oxygen saturation and oxygen delivery system should berecorded on Vital PAC or the bedside observation chart (if Vital PAC unavailable) alongsideother physiological variables as shown in Appendix K. This appendix also specifies the codesfor oxygen delivery devices to be recorded on the observation chart. Patients should thus bemonitored as specified in Appendix M.

All patients on oxygen therapy should have regular pulse oximetry measurements as decided

by the prescriber. The frequency of oximetry measurements will depend on the conditionbeing treated and the stability of the patient. Critically ill patients should have their oxygen

saturations monitored continuously and recorded every few minutes whereas patients withmild breathlessness due to a stable condition will need less frequent monitoring as specifiedin Appendix M

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 thepatient recovers). See Appendix I for more details

Any sudden fall in oxygen saturation should be referred to the doctor and lead to clinical

evaluation of the patient and in most cases, measurement of blood gases.

Patients on oxygen should have their saturations recorded at the appropriate frequency for

their level of severity of illness. This will be dictated by the Trusts vital signs escalationprotocol. (See Appendix M).

Patients should be monitored accurately for signs of improvement or deterioration. Nurses

should also monitor skin colour for peripheral cyanosis and respiratory rate. Oxygensaturations of less than 90%(unless it is with in the prescribed target range for patients at riskof CO2 retention), with or without oxygen, noisy or laboured breathing or respiratory rate ofless than 8 or more than 25 should be reported immediately to the medical team, according tothe Early Warning Score (EWS) protocol.

9.2 Emergency situations

In the emergency situation oxygen prescription is not required. Oxygen should be given

to the patient immediately without a formal prescription or drug order but documented later inthe patients record.

All peri-arrest and critically ill patients should be given 100% oxygen (15 l/min reservoir mask)

whilst awaiting immediate medical review. Patients with COPD and other risk factors forhypercapnia who develop critical illness should have the same initial target saturations asother critically ill patients pending the results of urgent blood gas results after which thesepatients may need controlled oxygen therapy or supported ventilation if there is severehypoxaemia and/or hypercapnia with respiratory acidosis.

All patients who have had a cardiac or respiratory arrest should have 100% oxygen provided

along with basic/advanced life support.



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A subsequent written record must be made of what oxygen therapy has been given to every

patient alongside the recording of all other emergency treatment.

Any qualified nurse/ health professional can commence oxygen therapy in an emergency

situation as indicated in the management of the acutely unwell patient.



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9.3 Exclusions

Patients admitted to specialist areas with a specialised oxygen prescribing policy (see section

3 of this policy document)

Patients receiving oxygen as part of palliative care or patients on the end of life care pathway

(in which case, the prescriber should tick the box target saturations not indicated on the drugchart).

Patients attending Long Term Oxygen Therapy assessment.

Peri-operatively and up to 2 hrs post operatively.

10.TRANSFER AND TRANSPORTATION OF PATIENTS RECEIVING OXYGEN THERAPY

Patients who are transferred from one area to another must have clear documentation of theirongoing oxygen requirements and documentation of their oxygen saturation. If a patient transfersfrom an area not utilising the target saturation system (see specialist areas above) their oxygen

should be administered as per the transferring areas prescription until the patient is reviewed andtransferred over to the target saturation scheme by the doctor, which should occur as soon aspossible.

Patients requiring oxygen therapy whilst being transferred from one area to another should beaccompanied by a trained member of nursing staff wherever possible. If this does not occur, clearinstructions must be provided for personnel involved in the transfer of the patient and the oxygenprescription chart must accompany the patient.

11. PERI-OPERATIVE AND IMMEDIATELY POST OPERATIVELY

The usual procedure for prescribing oxygen therapy in these areas should be adhered to, utilising thetarget saturation. If a patient is transferred back to the ward on oxygen therapy and is not on thetarget saturation system, the need for ongoing oxygen therapy should be reviewed as soon aspossible. If oxygen therapy is to be continued, it should be prescribed using the target saturationscheme unless there is an alternative time-limited instruction which is part of the Trusts Post-Operative care policy for selected patients.

12. NEBULISED THERAPY AND OXYGEN

When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure (seesection 8.1), it should be driven by compressed air. If necessary as decided by the doctor,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 documented onoxygen/nebuliser prescription chart.

All patients requiring 35% or greater oxygen therapy should have their nebulised therapy driven byoxygen at a flow rate of greater than 6 litres/minute as prescribed by the doctor. (See Appendix L Example of trust nebuliser prescription chart)

13. HUMIDIFICATION

Humidification may be required for some patient groups, especially neck-breathing patients andthose who have difficulty in clearing airway secretions or mucus. See Appendix N.

14. TRAINING REQUIREMENTS, MONITORING COMPLIANCE WITH, AND THEEFFECTIVENESS OF PROCEDURAL DOCUMENTS



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All nurses, nursing assistants and other healthcare professionals involved in prescribing oradministrating oxygen should be taught on the oxygen policy. Teaching aides are available onwww.brit-thoracic.org/emergencyoxygen. A record of all those who have been taught will be kept.

All doctors should be taught about the oxygen policy. Teaching aids are available on the BTSwebsite. Audits will be performed in all clinical areas. Audit proformas are available on the BTSwebsite. The hospital will participate in the national audits organised by the BTS.

The BTS has appointed oxygen champions in all Trusts to help introduce the Guideline.Dr. S. Alapati, Professor Gary Smith and Chris Fehrenbach are the Oxygen Champions atPortsmouth Hospital NHS Trust.

15. REFERENCES AND ASSOCIATED DOCUMENTATION

ODriscoll B R, Howard L S, Davison A G. BTS guideline for emergency oxygen use in adult

patients. Thorax 2008; 63: Supplement VI.

Summary guideline for prescribing oxygen emergency oxygen in hospital.

Available on BTS website:www.brit-thoracic.org.uk/emergencyoxygen/

Summary of prescription, administration and discontinuation of oxygen therapy.

Available on BTS website:www.brit-thoracic.org.uk/emergencyoxygen/

16. HEALTH AND SAFETY ISSUES ARE COVERED IN APPENDIX (O).

APPENDICES (including those reproduced from BTS Oxygen Guidance)

http://www.brit-thoracic.org/emergencyoxygenhttp://www.brit-thoracic.org.uk/emergencyoxygen/http://www.brit-thoracic.org.uk/emergencyoxygen/http://www.brit-thoracic.org.uk/emergencyoxygen/http://www.brit-thoracic.org.uk/emergencyoxygen/http://www.brit-thoracic.org/emergencyoxygenhttp://www.brit-thoracic.org.uk/emergencyoxygen/http://www.brit-thoracic.org.uk/emergencyoxygen/


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Appendix (A) Table 1 Critical illnesses requiring high levels of supplemental oxygen



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Appendix (B) Table 2 Serious illnesses requiring moderate levels ofsupplemental oxygen if thepatient is hypoxaemic



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Appendix (C) Table 3 COPD and other conditions requiring controlled or low-doseoxygen



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Appendix (D) Table 4 Conditions for which patients should be monitored closelybut oxygen therapy is not required unless the patient is hypoxaemic.



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Appendix (E) Chart 1 Oxygen prescription for acutely hypoxaemic patients



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Appendix (G) ADMINISTERING ACUTE OXYGEN THERAPY

ACTION RATIONALE

1. Ensure patency of airway To promote effective oxygenation

2. The type of delivery system used will To provide accurate oxygen deliverydepend on the needs and comfort of It to the patient. Most stable patients preferthe patient. It is the nurses role to assess nasal cannulae to masks.the patient and use the prescribed system.

3. Ensure oxygen is prescribed on To ensure a complete record isprescription chart. maintained and expedite patientIn emergency situations any trained nurse treatment.Can administer oxygen (Madon) The exception to this action would be

. during an emergency situation whereIn these cases the doctor must review the resuscitation guideline should bethe patients condition within the stated followed.time and prescribe oxygen accordingly.

4. Ensure that the oxygen dose is clearly In accordance with the the Policy for prescription and

If nasal cannula administration of oxygen in adults

or reservoir masks are being usedcheck that the flow rate is clearlyindicated.

5. Inform patient and or relative/ carer of Oxygen supports combustion thereforethe combustibility of oxygen there is always a danger of fire

when oxygen is being used.

6. Show and explain the oxygen delivery To obtain consent and cooperation.system to the patient. Give the patientthe information sheet about oxygen.

7. Assemble the oxygen delivery system To ensure oxygen is given as prescribed.carefully as shown in Appendix (H).

8. Attach oxygen delivery system to To ensure oxygen supply is readyoxygen source.

9. Attach oxygen delivery system to patient For oxygen to be administered toaccording to manufacturers instructions. patient.

10. Turn on oxygen flow in accordance To administer correct % of oxygen.with prescription and manufacturersinstruction.

11. Ensure patient has either a drink or To prevent drying or the oral mucosa.a mouthwash within reach.

12. Clean oxygen mask as required with To minimise risk of infectiongeneral purpose detergent and dry

thoroughly needed. Discard systems (Single patient device)after use.



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Appendix (H)

EQUIPMENT USED IN THE DELIVERY OF OXYGEN (Choose the appropriatedelivery device)

1. Oxygen source (piped or cylinder)2. Flow meter3. Saturation monitor4. Oxygen Delivery system - (see appendix j for advice on use of each device);

A) Nasal cannula

DEVICE DESCRIPTION PURPOSE

Nasal Cannulae Nasal cannulae consist ofpair of tubes about 2cm long,each projecting into thenostril and stemming from a

tube which passes over theears and which is thus self-retaining.

Uncontrolled oxygentherapy

Cannulae are preferred tomasks by most patients.They have the advantage ofnot interfering with feeding

and are not as inconvenientas masks during coughingand sneezing.It is not advisable to assumewhat percent oxygen (FI02)the patient is receivingaccording to the Litresdelivered but this is notimportant if the patient is inthe correct target range.

ACTION RATIONALE

1. (When using nasal cannula).Position the tips of the cannula in the

patients nose so that the tips do notextend more than 1.5cm into the nose.

Overlong tubing is uncomfortable, which maymake the patient reject the procedure. Sore

nasal mucosa can result from pressure orfriction of tubing that is too long.

2. Place tubing over the ears and under thechin as shown above. Educate patient reprevention of pressure areas on the backof the ear.

To allow optimum comfort for the patient.To prevent pressure sores.

3. Adjust flow rate, usually 2-4 l/min but mayvary from 1-6 l/min in some circumstances.

Set the flow rate to achieve the desired targetoxygen saturation.



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B) Fixed performance mask (Venturi mask and valve)


Venturi mask A mask incorporating adevice to enable a fixed

concentration of oxygen to bedelivered independent ofpatient factors or fit to theface or flow rate. Oxygen isforced out through a smallhole causing a Venturi effectwhich enables air to mix withoxygen.

Controlled oxygen therapy

This is a high performanceoxygen mask designed to

deliver a specified oxygenconcentration regardless ofbreathing rate or tidalvolume.

Venturi devices come indifferent colours for %

Blue = 24%White = 28%Yellow = 35%Red = 40%Green = 60%

ACTION RATIONALE

1. (When using Venturi mask)Connect the mask to the appropriateVenturi barrel attached firmly into themask inlet.

To ensure that patient receives the correctconcentration of oxygen

2. Fasten oxygen tubing securely. Correctly secured tubing is comfortable andprevents displacement of mask/cannulae.

3. Assess the patients condition andfunctioning of equipment at regular intervalsaccording to care plan.

To ensure patients safety and that oxygen isbeing administered as prescribed.

4. Adjust flow rate. The minimum flow rate isindicated on the mask or packet. The flowshould be doubled if the patient has arespiratory rate above 30 per minute.

Higher flows are required for patients withrapid respiration and high inspiratory flowrates. This does not affect the concentrationof oxygen but allows the gas flow rate tomatch the patients breathing pattern.



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C) Simple facemask (variable flow)

DEVICE DESCRIPTION

Mask has a soft plasticface piece, vent holes

are provided to allowair to escape.Maximum 50%-60% at15ltrs/minute flow.

PURPOSEThis is a variableperformance device. Theoxygen concentrationdelivered will be influenced

by:

a. the oxygen flow rate( litresper minute) used, leakagebetween the mask and face;

Simple face maskVariable Percentage(Delivers unpredictableconcentrations that vary with flowrate)

Nasal cannulae should be used formost patients who require mediumdose oxygen but a simple facemask may be used due to patientpreference or if the nose is blocked

Uncontrolled Oxygentherapy

b. the patients tidal volumeand breathing rate.

NOT to be used for CO2retaining patients.

ACTION RATIONALE

(If using simple face mask) Gently placemask over the patients face, position thestrap behind the head or the loops over

the ears then carefully pull both endsthrough the front of the mask untilsecure.

Ensure a comfortable fit and delivery ofprescribed oxygen is maintained.

Check that strap is not across ears and ifnecessary insert padding between the strapand head.

Adjust the oxygen flow rate. Must never bebelow 5L/min

To prevent irritation.

Flows below 5L/m do not give enoughoxygen and may cause increased resistanceto breathing and may also cause CO2 re-breathing due to the small mask size.



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D) Reservoir mask (non re-breathe mask)


Reservoir Mask(Non-rebreathe Mask)

Mask has a soft plastic facepiece with flap-valve exhalationports which may be removed foremergency air-intake. There isalso a one-way valve between

the face mask and reservoirbag.

Uncontrolled oxygen therapy

In non re-breathing systemsthe oxygen may be storedin the reservoir bag duringexhalation by means of aone-way valve. High

concentrations of oxygen80-90% can be achieved atrelatively low flow rates.

NOT to be used for C02retaining patients exceptin life-threateningemergencies such ascardiac arrest or majortrauma.

ACTION RATIONALE

1. (Non Rebreathe Reservoir Mask)

Ensure the reservoir bag is inflatedbefore placing mask on patient, this canbe maintained by using 10-15 litres ofoxygen per min.

To ensure the optimal flow ofoxygen to the patient.

2. Adjust the oxygen flow to theprescribed rate.

Inadequate flow rates may resultin administration of inadequateoxygen concentration to thepatient.

In disposable reservoir, oxygen flows directly into the mask during inspiration and into thereservoir bag during exhalation. All exhaled air is vented through a port in the mask and a one-way valve between the bag and mask, which prevents re-breathing.



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E) Tracheostomy mask for patients with tracheostomy or laryngectomy

DEVICE DESCRIPTION

Mask designed for

neck breathingpatients. Fitscomfortably overtracheostomy ortracheotomy.Exhalation port on frontof mask.

PURPOSEThis is a variableperformance device forpatients with tracheostomy or

tracheotomy. The oxygenconcentration delivered willbe influenced by:a. the oxygen flow rate( litresper minute) used.b. the patients tidal volumeand breathing rate.

Tracheostomy maskVariable Percentage(Delivers unpredictableconcentrations that vary with flow

rate)

Uncontrolled Oxygentherapy

Use cautiously at low flowrates in CO2 retainingpatients as there may be

no alternative.

ACTION RATIONALE

Gently place mask over the patientsairway, position the strap behind thehead then carefully pull both endsthrough the front of the mask untilsecure.

Ensure a comfortable fit and delivery ofprescribed oxygen is maintained.

Adjust the oxygen flow rate toachieve the desired targetsaturation range. Start at 4 l/minand adjust the flow up or downas necessary to achieve the desiredoxygen saturation range.

To ensure that the correct amount of oxygenis given to keep the patient in the targetrange.



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F) Oxygen Flow Meter

DEVICE

DESCRIPTION

Device to allow the

patient to receive anaccurate flow ofoxygen, usuallybetween 2 and 15litres per minute.

May be wall-mounted or on acylinder.

Take specialcare asthere are airoutletswhich maybe mistakenfor oxygenoutlets.

PURPOSETo ensure that the patient receives thecorrect amount of oxygen.

3

2

1

3

2

1

Correct Setting for 2 l/min

Oxygen flow meterDelivers oxygen to the patient.

ACTION RATIONALE

Attach the oxygen tubing to the

nozzle on the flow meter.

Turn the finger-valve to obtain thedesired flow rate. The CENTRE of theball shows the correct flow rate. Thediagram shows the correct setting todeliver 2 l/min.

To ensure that the patient receives the correct amount ofoxygen.



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Appendix (I) Flow chart for oxygen administration on general wards in hospitals



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Appendix (J)

PERSONNEL WHO MAY ADMINISTER OXYGEN

Any qualified nurse, doctor, RSCN, RN or physiotherapist. Any appropriately registeredhealthcare professionals in accordance with policy for administration of medicines.



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Appendix (K) Bedside Observation Chart

The oxygen delivery device and flow rate should be recorded alongside thesaturation on VitalPAC, or if VitalPAC is unavailable, on the bedside observation chart



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Appendix (L) Example of Nebuliser Prescription Chart



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Appendix (M) Monitoring of patients on Oxygen

Escalation protocol for VitalPAC

EWSMinimum interval betweenobservation setsA

Escalation

Recorders (e.g. nurse, HCA) action Doctors action

0 6 hourlyB Nil

1 6 hourlyB Nil

2 4 hourly Inform nurse in charge of patients care

3 4 hourlyRegistered nurse to inform doctor (FY2 orSHO)

Doctor to see patient within2hrs

4 1 hourly

Registered nurse to inform doctor (FY2 or

SHO)Consider use of continuous patientmonitoring

Doctor to see patient within30 minutes

Dr to discuss patient with SpR + outreach teamCConsider use of continuous patient monitoring

>5 30 mins

Registered nurse to inform doctor (SpR)Consider use of continuous patientmonitoring

Doctor to see patient within15 minutesDr to discuss patient with Consultant + outreach teamC orICUConsider use of continuous patient monitoring

Colour coding represents NICE/DoH levels of escalation (see DoH document Competencies for Recognising and Responding to Acutely Ill Patients inHospital, 2009)

A This time interval also represents the minimum time between charting observations in VitalPAC. Where a patient is being continuouslymonitored using electronic technology, a full set of vital signs data must be entered into VitalPAC using the minimum interval algorithm (e.g.,for a patient with a previous EWS = 4, data from a continuous device must be entered each hour).

B can be moved to 12 hourly once there have been a) 2 consecutive EWS values of 0; b) two consecutive values of 1, or c) an EWS of 1 followedby an EWS of 0

C after 2200 hrs, call ICU (ext 5752)

* EWS of 3 comes from a single physiological parameter (e.g., pulse)

At all levels of EWS, but particularly at levels of 4 and above, clinical staff should consider the appropriateness of referral for higher care (e.g., HDU or ICUcare) + DNAR decisions.The first vital signs observation set must be undertaken within 15 minutes of arriving in a new clinical area.Before transferring a patient, the nurse responsible should check that there is a set of observations on VitalPAC or a paper chart, done in the hourbefore transfer.

Any patient with EWS >4 should not be transferred until the actions listed in the Trust Transfer [draft] protocol have been followed, it has been explicitlyagreed that patient can be transferred and the receiving team + outreach team is aware of the patient.



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Appendix (N) HUMIDIFICATION

This should only be used if specifically requested by the doctor or physiotherapist inthe following circumstances.

1. If the flow rate exceeds 4 litres per minute for several days2. Tracheotomy or tracheostomy patients (neck-breathing patients)3. Cystic Fibrosis patients

4. Bronchiectasis patients5. Patients with a chest infection retaining secretions

Can be given by warm or cold humidifier systems(Warm humidifier systems are mainly used in critical care areas)



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Appendix (O)

HEALTH AND SAFETY

1. Inform patients and carers aboutthe combustibility of oxygen

Oxygen supports combustion, there.is alwaysa danger of fire when oxygen is being used.

2. Oxygen should be stored in anarea designated as no smoking.

3. Electrical appliances should bekept at least five feet away from thesource of oxygen.

Oxygen can be potentially dangerous when incontact with sources of ignition andflammable material.

4. Avoid grease or oil coming intocontact with apparatus.

5. Store unused cylinders in a drywell ventilated place.



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Appendix (P) -Summary Oxygen Administration protocol (and weaning protocol)

ACTION RATIONALE

All patients requiring oxygen therapy willhave a prescription for oxygen therapyrecorded on the patients oxygenprescription chart. N.B exceptions- seeemergency situations (8.2)

Oxygen is a drug and should be prescribed. BTSNational guidelines (2008). British NationalFormulary available at www.bnf.org

The prescription will incorporate a targetsaturation that will be identified by theclinician prescribing the oxygen inaccordance with the Trust's oxygenguideline

Certain groups of patients require different targetranges for their oxygen saturation, see Tables 1-4.Certain groups of patients are at risk ofhyperoxaemia, particularly patients with COPD.

The prescription will incorporate an initialstarting dose (i.e. delivery device and flowrate)

To provide the nurses with guidance for theappropriate starting point for the oxygen deliverysystem and flow rate

The drug chart should be signed at everydrug round

To ensure that the patient is receiving oxygen ifprescribed and to consider weaning anddiscontinuation

Once oxygen is in situ the nurse/ trainedHCSW will monitor observations in linewith trust policy. All patients should havetheir oxygen saturation observed for atleast five minutes after starting oxygentherapy. If a patient is receivingintermittent therapy they may be monitoredat least 8 hourly.

To identify if oxygen therapy is maintaining thetarget saturation or if an increase or decrease inoxygen therapy is required

The oxygen delivery device and oxygenflow rate should be recorded alongside theoxygen saturation on VitalPAC, or ifVitalPAC is unavailable, on the bedside

observation chart

To provide an accurate record and allow trendsin oxygen therapy and saturation levels to beidentified.

Oxygen saturations must always beinterpreted alongside the patients clinicalstatus incorporating the Early WarningScore (EWS)

To identify early signs of clinical deterioration,e.g. elevated respiratory rate

If the patient falls outside of the targetsaturation range, the oxygen therapy willbe adjusted accordingly by the nurselooking after the patientThe saturation should be monitoredcontinuously for at least 5 minutes afterany increase or decrease in oxygen doseto ensure that the patient acheives thedesired saturation range.

To maintain the saturation in the desired range.

Saturation higher than target specifiedor >98% for an extended period oftime.

Step down oxygen therapy as per

guidance for delivery

The patient will require weaning down fromcurrent oxygen delivery system.See Appendix (I)

Consider discontinuation of oxygen

therapy

The patients clinical condition may haveimproved negating the need for supplementary

oxygen



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Saturation lower than target specified

Check all elements of oxygen delivery

system for faults or errors.

In most instances a fall in oxygen saturation isdue to deterioration of the patient howeverequipment faults should be checked for.

Step up oxygen therapy as per

protocols in appendix (I). Any suddenfall in oxygen saturation should lead toclinical evaluation and in most casesmeasurement of blood gases

To assess the patients response to oxygen

increase, and ensure that PaCO2 has not risen toan unacceptable level, or Ph dropped to anunacceptable level and to screen for the cause ofdeteriorating oxygen level (e.g. pneumonia, heartfailure etc)

Monitor Early Warning Score (EWS)

and respiratory rate for further clinicalsigns of deterioration

Patient safety

Saturation within target specified

Continue with oxygen therapy, and

monitor patient to identify appropriate

time for stepping down therapy, onceclinical condition allows

A change in delivery device (without an

increase in O2 therapy) does notrequire review by the medical team.

(The change may be made in stable patients dueto patient preference or comfort).

Oxygen delivery methods

The Trusts recommended delivery deviceswill be utilised to ensure astandardised approach to oxygendelivery, see Appendix (H)

Previous audits have demonstrated widevariations in delivery devices across clinicalareas, potentially increasing the risk of adverseincidents