Download Oxygen Equipment Used by Patients/Residents

Corporate Policy & Procedures
Oxygen Equipment Used by
Patients/Residents/Clients on
Pass
Approved by:
Vice President Operations, Rural Health Services
Manual
Number: VII-B-130
Date Approved
April 19, 2012
Date Effective
May 15, 2012
Next Review (3 years from Effective Date)
May 2015
Purpose
This document provides guidance for ensuring timely and appropriate instruction and
disclosure of risk factors to patients/residents/clients/caregivers when oxygen equipment
is used for patients/residents/clients on pass.
Policy
Statement
Covenant Health qualified staff will provide instruction to patients/residents/clients/
caregivers and other staff when a patient/resident/client that uses oxygen goes off-site
(eg. pass, family moving resident to another site).
Applicability
This policy and procedure applies to all Covenant Health facilities, staff, physicians,
volunteers, students and any other persons acting on behalf of Covenant Health.
Responsibility Covenant Health Respiratory (where available) and Nursing personnel are responsible for
ensuring that proper instruction and documentation is provided to
patients/residents/clients and caregivers.
Covenant Health staff and volunteers providing transport and care to a patient/resident/
client off-site are responsible for ensuring they are provided with instruction on the safe
handling, care and use of oxygen equipment.
Principles
Covenant Health believes it is important for patients/residents/clients to be as mobile as
possible and to provide oxygen supplies to assist with mobility in all communities.
Procedure
1.
Review patient care order written by physician or nurse practitioner.
2.
Ensure oxygen equipment care and instructions are provided to
patients/residents/ clients/caregiver(s).
3.
Document actions in the patient care record.
4.
Place signed original copies of Oxygen Day/Overnight Pass (Appendix A),
Oxygen Safety Precautions Patient Information Sheet (Appendix B), Informed
Consent (Appendix C), and Indemnity & Waiver (Appendix D) form in patient care
record.
5.
Provide copy of above documents to the patient/resident/client/caregiver(s).
6.
For patients who go on frequent passes (eg. Palliative Care patients), Respiratory
(where available) or Nursing staff shall;
•
•
reinforce oxygen safety precautions and instructions;
as appropriate, provide the patient with copies of Oxygen Day/Overnight Pass
(Appendix A), and Oxygen Safety Precautions Patient Information Sheet
(Appendix B). This is especially important if the instructions have changed
Oxygen Equipment Used by Patients/Residents/Clients on Pass
•
•
7.
Definitions
Date Effective
May 15, 2012
Policy No.
VII-B-130
Page 2 of 7
(eg. oxygen flow rate has increased/decreased);
have the patient re-sign and date the original Informed Consent (Appendix C),
and Indemnity and Waiver (Appendix D) “ forms; and
document actions and teaching in the patient care record.
The signed “Informed Consent” and “Indemnity and Waiver” forms remains valid
for the duration of the patient’s current admission. Notwithstanding the foregoing,
if the circumstances have changed in the intervening period, for example, the
patient is leaving on pass with a different care provider, new forms must be
obtained.
Qualified staff member refers to a Registered Respiratory Therapist, Registered Nurse,
Registered Psychiatric Nurse, Licensed Practical Nurse or another designation approved
by the Facility.
•
Related
Documents
Guidelines for Patients/Residents/Clients Using Oxygen on pass from Rural
Sites/Sectors.
Other documents:
• Oxygen Day/Overnight Pass (Appendix A).
• Oxygen Safety Precautions Patient Information Sheet (Appendix B).
• Informed Consent (Appendix C).
Indemnity and Waiver (Appendix D).
Revisions
N/A
Oxygen Equipment Used by Patients/Residents/Clients on Pass
Date Effective
May 15, 2012
Policy No.
VII-B-130
Page 3 of 7
Guidelines for Patients / Residents / Clients Using
Oxygen on Pass from Rural Sites / Sectors
1
Requests for portable liquid oxygen or oxygen concentrator for patients on overnight pass are to
be submitted to the Nurse in Charge or Respiratory Department.
2
Requests are granted as availability of equipment and safety permits.
3
The Facility supplies patients/residents/clients on overnight pass with a portable carrier if
applicable. Exchange or refilling arrangements are made through the Nurse in Charge or
Respiratory Department.
4
The physician/nurse practitioner writes an order for a patient pass indicating length of time and
rate of flow and/or oxygen saturation.
5
Nursing staff will receive training as per site practice on:
a) the handling of cylinders and/or portable liquid oxygen systems
b) exchanging oxygen cylinders and/or refilling the liquid oxygen carriers.
6
Nurse in Charge, Respiratory staff or designate will provide instruction on:
a) Oxygen carriers – safe transport in a vehicle, wheelchair, stretcher or when walking.
b) Content Indicators: how to check the amount of oxygen in a canister
c) Flow rate
d) Refills – ensures patients on extended pass are informed where canisters can be refilled.
e) Determination of the length of time the patient/resident/client can be away based on the
flow rate of oxygen required
f) Use, care and safe transport of equipment such as:
• Inform patient/resident/client where canister can be refilled
• Oxygen flow meter
• Oxygen delivery device (eg. nasal cannula, simple face mask)
• Portable oxygen source (eg. oxygen cylinder or concentrator)
g) Who/where to call should any problems occur. If the problem cannot be resolved and the
patient/resident/client becomes short of breath or distressed, he/she is instructed to call
911.
Documentation
• Patient care record
• Oxygen day/overnight pass information package completed and a copy kept by the
patient/resident/client with the original in patient/resident/client record.
• Site Equipment loan/rental documentation addressing replacement costs if
equipment is lost or damaged and the equipment count.
Oxygen Equipment Used by Patients/Residents/Clients on Pass
Date Effective
May 15, 2012
Policy No.
VII-B-130
Page 4 of 7
APPENDIX A
OXYGEN DAY/OVERNIGHT PASS
Facility:
________________________
CALL 911 IN THE EVENT OF AN EMERGENCY AND ADVISE THE OPERATOR YOU ARE A
PATIENT/CLIENT OR RESIDENT, ON A PASS, FROM THE ABOVE NAMED FACILITY.
Destination:
Address: _______________
Phone: (Home)
__________ (Cell/Work) ____________
Method of Transportation: ___________________________
Date/Time Leaving Facility: ___________________________
Date/Time Returning: ___________________________
Oxygen Flow Rate: ___________liter/min @ rest ____________ liter/min On Exertion
Type of Oxygen Source: _______________________________
Expected time Oxygen Source Will Last: _________________
___
CHECK LIST TO BE COMPLETED BY THERAPIST WITH PATIENT/CAREGIVER
Respiratory Therapist or Qualified Staff Member Verbalizes and Demonstrates all Systems
Patient/Caregiver Understands Instructions and Repeats Demonstration as required
ˆ Fire Prevention
ˆ How to set and check correct liter flow.
ˆ How to check the pressure gauge.
ˆ Storage and transportation.
ˆ How to attach cannula and tubing,
ˆ How to test the oxygen flow by placing the cannula into a cup of water
ˆ “No Smoking” sign provided
ˆ Review Oxygen Safety Precautions Document
ˆ Oxygen Day or Overnight Pass
ˆ Oxygen Safety Precautions Patient Information Sheet
ˆ Informed Consent
ˆ Indemnity & Waiver
Signature of Respiratory Therapist
or Qualified Staff Member
Signature of Patient /Caregiver
CHECK LIST COMPLETED BY RESPIRATORY THERAPIST or QUALIFIED STAFF MEMBER
ON _______________
________________________(Date)
Oxygen Equipment Used by Patients/Residents/Clients on Pass
Date Effective
May 15, 2012
Policy No.
VII-B-130
Page 5 of 7
APPENDIX B
OXYGEN SAFETY PRECAUTIONS
PATIENT INFORMATION SHEET
Properly handled and under supervision of a physician, oxygen is considered a safe drug.
Oxygen is a non-flammable gas, however it does support combustion. Any material that will burn in air
will ignite more readily and burn rapidly in an oxygen-enriched environment.
DO NOT
Do not use or store oxygen within three meters (ten feet) of an open flame or any
strong heat sources, i.e. spark or friction-generating equipment, stoves, fireplaces, gas
pilot lights, candles, radiators, heat ducts, steam pipes and barbeques.
Do not allow smoking, open flames or candles in a home or vehicle where oxygen is in
use.
Do not store in confined spaces, i.e. closets, automobile trunks.
Do not lubricate oxygen equipment. Oil and grease, including petroleum jelly
(Vaseline), ignite very easily.
Do not use aerosol sprays in the vicinity of oxygen equipment.
DO
Do ensure that oxygen cylinders are secured when they are being transported in a
vehicle. They can be secured with a seat belt or rubber bungee cords.
Do keep a flashlight with extra batteries available in case of a power outage.
Do return to the facility if your oxygen is running low and will not last the expected time.
For a medical emergency, call 911.
Take a direct route – no intermediate stops. Avoid routes with heavy traffic.
For a medical emergency, call 911.
Patient/Client/Resident/Caregiver Signature
Witness Signature
________________________
Print Name of Patient/Client/Resident/Caregiver
Print Name of Witness
PATIENT/CAREGIVER ACKNOWLEDGES REVIEW AND RECEIPT OF OXYGEN SAFETY PRECAUTIONS.
Oxygen Equipment Used by Patients/Residents/Clients on Pass
Date Effective
May 15, 2012
Policy No.
VII-B-130
Page 6 of 7
APPENDIX C
INFORMED CONSENT
I __________________________________ understand the need for
oxygen, the contents of the attached Oxygen Safety Precautions Patient
Information Sheet, how to safely use and transport the equipment
provided, including that safe operation requires that:
•
•
•
•
Smoking or any open flame is not allowed within 3 meters (10
feet) of the oxygen and that no oil or grease products are to be
used near oxygen.
I must follow the safety guidelines outlined to me in the Oxygen Safety
Precautions Patient Information Sheet given to me.
It is my responsibility to ensure that no untrained persons operate the
equipment.
I have been advised that if I need emergency medical assistance, I
must call 911 or contact Respiratory Therapy or Qualified Staff
Member at:
_______________________
Site Name
_________________
Phone Number
Date: __________________
______________________
Patient/Client/Resident/Caregiver
Signature
_______________________
Signature of Respiratory
Therapist or Qualified Staff
Member
________________________
Patient/Client/Resident/Caregiver
Printed Name
_______________________
Printed Name of Respiratory
Therapist or Qualified Staff
Member
Oxygen Equipment Used by Patients/Residents/Clients on Pass
Date Effective
May 15, 2012
Policy No.
VII-B-130
Page 7 of 7
APPENDIX D
INDEMNITY AND WAIVER
In consideration of being allowed to take the appropriate portable
oxygen source from the Facility, I ________________________
(print name) acknowledge and agree that Covenant Health and
its relevant Respiratory Department or Nursing Unit assume no
responsibility or liability for any loss, damage or injury including
death to anyone resulting from the use or the transportation of
oxygen source. I agree that I am responsible for the oxygen
delivery device while it is being used or transported. I agree to
defend, indemnify and hold harmless Covenant Health and its
relevant Respiratory Department or Nursing Unit for any loss,
damage or injury including death to anyone resulting from the
use or transportation of the portable oxygen source, unless
caused by the negligence of Covenant Health or its relevant
Respiratory Therapy Department or Nursing Unit.
Date: ________________
_____________________
_______________________
Patient/Client/Resident/Caregiver
Signature
Signature of Respiratory
Therapist or Qualified Staff
Member
_____________________
_______________________
Patient/ Client/Resident Caregiver
Printed Name
Printed Name of Respiratory
Therapist or Qualified Staff
Member