Download Implementation and Dissemination from Guideline to Patient

Patient Safety Awards 2011
Improving the safety
of administration of
Emergency Oxygen
in adult patients
across the UK
The BTS guideline for emergency
oxygen use in adult patients
Oxygen is the most
commonly used drug
in emergency medicine
• 34% of emergency ambulance
patients receive oxygen
• Oxygen is used in about 2
million ambulance journeys in
the UK each year
Oxygen in Hospital
• 17.5% of UK
hospital patients are
receiving oxygen at
any given time
• About 18,000 people every day
• More than 2 million per year
Oxygen saves lives but too
much may cause death
• Essential in severely ill patients with low
blood oxygen levels
• Too much oxygen may cause 2,000-4,000
avoidable deaths per year in chronic
obstructive pulmonary disease flare ups
• Too much oxygen is linked to increased
risk of death in strokes, ICU patients and
survivors of cardiac arrest
Chaos reigned until 2008
• Most patients were given too much oxygen
And there was disagreement about how much oxygen to give
• Oxygen was rarely prescribed
68% of UK hospital patients who were using oxygen in 2008 had no
prescription and most prescriptions were incomplete
• Doctors and nurses had very little
knowledge about safe use of oxygen
• North West oxygen guideline 2000
Time To Do Something
Key Theme
• Safe oxygen for all patients in UK
• Solution needed to be:
»Ambitious
»Pioneering
»Multidisciplinary
Solution – Novel Guideline
• Early pilots in Salford and Southend
• BTS appointed Salford and Southend CoChairs in 2003 to produce UK Guidance
• Guideline development group undertook
evidence review 2003-04
• Universal participation - 21 other societies
and colleges
Solution – Novel Guideline
• Early pilots in Salford and Southend.
• BTS appointed Salford and Southend CoChairs in 2003 to produce UK Guidance.
• Guideline development group undertook
evidence review 2003-04
• Universal participation - 21 other societies
and colleges
• Draft Guideline prepared 2005-2007
• Pilot work continued in Salford/Southend
UK Emergency Oxygen
Guideline published 2008
Key Principles
• Oxygen is a treatment for low oxygen (Hypoxemia)
(Giving oxygen does not relieve breathlessness or increase the oxygen supply to
vital organs if the patient’s oxygen level is normal to start with)
• Aim for a normal oxygen saturation level for
most patients (94-98%)
• Aim at a lower level for (88-92%) for those at
risk from higher doses of oxygen
• Doctors prescribe a “target range” and nurses
adjust equipment and flow rates to achieve the
desired target range
Oxygen Alert Card
Safeguards COPD
patients who are most
at risk from oxygen
poisoning
“They gave me a card
because I’m intolerant
of too much oxygen.
They used to whack
up the oxygen in the
ambulance on the
way to hospital.”
“Last time I was
admitted they didn’t
turn the oxygen up
too high”
“I think it is a good
thing, it stops
them poisoning
me with too much
oxygen because I
mustn’t have too
much.”
Implementation and
Dissemination from Guideline
to patient
• No point in having guideline
recommendations if they are not
implemented for patient safety
• Included as integral part of
guideline – this is unique
Implementation from Guideline to Patient
Doctors must prescribe
Monitoring
Need
Local
Oxygen
Policy
Need
Training
Nurses must be able to change oxygen being given
All patients receive correct and safe oxygen
Online appendix of Guideline includes
implementation materials
• Summary of recommendations
• Sample local oxygen policy
• Patient information sheet (developed with patients)
• Example of new prescription chart
Oxygen prescription
Model for oxygen section in hospital prescription charts
DRUG
OXYGEN
(Refer To Trust Oxygen Policy)
STOP DATE
Circle target oxygen saturation
88-92%
94-98%
Other___
Starting device/flow rate________
PRN / Continuous
Tick if saturation not indicated
PHARM
(Saturation is indicated in almost all cases except for
palliative terminal care)
SIGNATURE / PRINT NAME
DATE
ddmmyy
Online appendix of Guideline includes
implementation materials
• Summary of recommendations
• Sample local oxygen policy
• Patient information sheet (developed with patients).
• Example of new prescription chart
• Example of new monitoring chart
Model for respiratory section of observation chart
Respiratory Rate, Oxygen saturation and oxygen therapy
Clinical review required if saturation is outside target range
Continuous Oxygen / PRN / Not on oxygen therapy
Other_____
Target range:
88-92%
94-98%
Respiratory
Rate
Respiratory
Rate
Oxygen
Saturation %
Oxygen
Saturation %
Oxygen
Device or Air
Oxygen
Device or Air
Oxygen flow
rate L/min
Oxygen flow
rate L/min
Your
Initials*
Your
Initials*
Codes for recording oxygen delivery on observation chart
A
Air. (Patient not requiring oxygen therapy)
AX Measurement on air for a patient who is on PRN Oxygen therapy
AW Measurement on air for a patient who is being weaned off oxygen but not yet discontinued on chart
N
Nasal Cannulae
SM Simple mask
V24 Venturi 24% V28 Venturi 28% V35 Venturi 35% V40 Venturi 40% V60 Venturi 60%
H28 Humidified oxygen at 28% (“Quatro” or similar device) (also H 35, H40, H60)
RM Reservoir Mask
TM Tracheostomy Mask
*All changes to oxygen delivery systems must be initialled by a registered nurse or
equivalent
CP Patient on CPAP system
NIV Patient on NIV system
If the patient is medically stable and in the target range on two consecutive rounds, report to
a registered nurse to
OTH Other device
consider weaning off oxygen (unless the oxygen prescription is part of a timed protocol
Online appendix of Guideline includes
implementation materials
• Summary of recommendations
• Sample local oxygen policy
• Patient information sheet (developed with patients).
• Example of new prescription chart
• Example of new monitoring chart
• Lecture for Doctors
• Education materials for nurses
– unique drop-in training
Online appendix of Guideline includes
implementation materials
• Summary of recommendations
• Sample local oxygen policy
• Patient information sheet (developed with patients).
• Example of new prescription chart
• Example of new monitoring chart
• Lecture for Doctors
• Education materials for nurses
– unique drop-in training
All of these were piloted at Southend and/or Salford
Implementation and Dissemination
Oxygen Champions
• Pilot sites illustrated importance of local
champions
BTS asked for volunteer medical and
nursing/physiotherapy oxygen champions in
every trust responsible for:
• Introducing local oxygen policy
• Organising training for nurses and doctors
• Conducting audit
Launch of Guideline
October 2008
• PR company helped with pre-launch information to
medical press
• Editorials in journals e.g. Nursing Times, BMJ
• Letters to Chief Executives
• Oxygen champions primed: Discussion area on
BTS web site
• Lectures at many National and Regional Meetings
Implementation and Dissemination
Advantage of Partnership
Incorporation of Emergency Oxygen Guidelines
in other Guidelines
• JRCALC (Joint Royal Colleges Ambulance Liaison
Committee) Oxygen Guideline April 2009
• BTS Pneumonia Guideline 2009
• NICE Guideline for Chest Pain of Recent Onset –
March 2010
• Resuscitation Council (UK) Guideline 2010
• European Resuscitation Guideline 2010
• BTS-SIGN Asthma Guideline 2011
National Patient Safety Agency
Rapid Response Report –
September 2009
281 reports of serious incidents
involving poor oxygen management:
• Caused 9 deaths
• May have contributed to 35
further deaths
National Patient Safety Agency
Rapid Response Report –
September 2009
Immediate Actions
• Oxygen must be prescribed in all
situations in accordance with BTS
guideline
• Pulse oximetry should be available in all
locations where oxygen is used
BTS 2008 and 2010 Oxygen
Audits
Hospitals Patients
Wards
On O2
(%)
O2
Drug
Prescribed rounds
signed
Oximetry
recorded
Correct
delivery
system
2008
99
14,830
712
17.5
32%
5%
94%
47%
2010
90
22,017 1026
15.5
56%
16%
99%
59%
Implementation Audits
Feb 2009, November 2010
Feb 2009
n=72
Oct-Nov 2010
Provisional Data
n=51
Oxygen Policy in place
6%
37%
Pre-printed oxygen
prescription charts
9%
51%
Pre-printed monitoring
chart
7%
33%
Nurse training fully
implemented
7%
18%
Doctor training fully
implemented
4%
11%
Improvement in prescribing oxygen
at Southend
100
87
Percentage (%)
90
80
70
60
50
40
30
20
10
8
0
Before Guideline
After Guideline
BTS Audit supported by NCAAG
National Clinical Audit Advisory Group
• BTS Emergency Oxygen Audit is in
the list of audits recommended by
the NCAAG for inclusion in Quality
Accounts for 2010/2011
• Hospitals’ results will be published
Moving Forward
• BTS e-learning programme
• Oxygen spend down 10% - Target Chief
Executives – QIPP Programme
• BTS Oxygen Champion – Yearly Prize
• Refine BTS audit results so individual
wards/doctors given results
• Review guidelines; new Paediatric section
Moving Forward
• Guideline group expecting substantial yearly
improvements in use of emergency oxygen across UK
Safer and better care for
all patients receiving
Emergency Oxygen
Saving Lives