emergency oxygen professor thida win 10/03/2015scn emergency oxygen event
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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
SCN emergency Oxygen Event
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
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• JL Smith J Physiology 1899 Vol 24 p19-35
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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
SCN emergency Oxygen Event
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%
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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
SCN emergency Oxygen Event
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
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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%
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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
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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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SCN emergency Oxygen Event
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
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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
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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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