Standard Operating Procedure for
Administration and use of Emergency and Non-Emergency Oxygen in
Lincolnshire Community Health Services Community Hospitals
Reference No:
G_CS_24
Version:
2
Ratified by:
LCHS Trust Board
Date ratified:
14th March 2017
Name of originator/author:
Jill Anderson /Jo Stones/ Michelle Webb
Name of responsible
committee/individual:
Quality Scrutiny Group
Date Approved by
committee/individual:
16th February 2017
Date issued:
March 2017
Review date:
February 2019
Target audience:
Registered Ward Staff
Distributed via:
Website
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
Standard Operating Procedure for the
Administration and use of Emergency and Non-Emergency Oxygen in
Lincolnshire Community Health Services Community Hospitals
Version Control Sheet
Version
Section/Para/
Appendix
Version/Description
of Amendments
1
2.1 and 8.2
Amendments from
previous document
Date
Author/Amended by
January 2016
Karen Cox, Sue
Macleod
1.1
Extension agreed
May 2016
Audit Committee
1.2
Extension agreed
October 2016
Corporate Assurance
Team
2
Full Review and
Update
February 2017
QSG
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5
6
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Copyright © 2017 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be
reproduced in whole or in part without the permission of the copyright owner.
2
Lincolnshire Community Health Services NHS Trust
Administration and use of Emergency and Non-Emergency Oxygen in
Lincolnshire Community Health Services Community Hospitals
Standard Operating Procedure Statement
Background
The purpose of this guidance is to provide a unified
clinical approach to the administration and care of
patients requiring supplemental oxygen therapy and to
ensure that oxygen is prescribed safely and appropriately
with appropriate monitoring and equipment in place.
Statement
A concise and full standard operating procedure will help
to provide all Ward staff with the knowledge and skills to
monitor the use of oxygen therapy
Responsibilities
All employees on the Wards and Urgent Care Services
will have the responsibility to follow the guidance.
Authors of the guidance will have the responsibility to
undertake appropriate consultation during development
of the guidance, and any subsequent amendments.
Training
Matrons / Clinical Leads have a responsibility to ensure
all Registered Ward staff are aware of the guidance and
have access to appropriate training.
Registered Ward Staff have responsibility to ensure all
new staff are included in this process at induction.
Dissemination
Via e-mail.
Introduction at staff meetings.
On induction of new staff.
Standard operating procedure files.
Resource implication
The operating procedure has been developed to provide
a framework / guidance for staff who are working in the
Community Hospitals / Urgent care services to ensure
safe, appropriate management of oxygen therapy.
Consultation
North East Business Unit Clinical Governance Meeting
Quality Scrutiny Group
All Adult Business Units
Respiratory Team
3
Lincolnshire Community Health Services NHS Trust
Administration and use of Emergency and Non-Emergency Oxygen in
Lincolnshire Community Health Services Community Hospitals
Contents
Section
i
ii
1
2
3
4
4
4.1
4.2
4.3
5
6
7
Part One
8
Fig. 1
Fig 2.
Fig 3.
Fig 4.
Part Two
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Appendix
1
Appendix
2
Version control sheet
Operating procedure statement
Introduction.
Aims and Objectives
Scope
Roles and Responsibilities
Indications’ for prescribed Oxygen in LCHS Community Hospitals
General Managers and Heads of Clinical Services
Practitioners
All Clinical professionals
Review
Evidence Base
Risk Management
Administration of Emergency Oxygen
Emergency situations
Critical illness requiring high levels of supplemental oxygen.
Maintaining oxygen saturation levels
Serious illness requiring moderate levels of supplemental oxygen if the patient is
hypoxaemic
COPD and other conditions requiring controlled or low dose oxygen therapy
Administration of Non-Emergency Oxygen
Indications for prescribing Oxygen in LCHS Community Hospitals
Assessing and Monitoring Inpatients Patients Requiring Oxygen Therapy
Identifying appropriate target saturations
Contra-indications
Prescribing oxygen
Types of equipment to administer oxygen therapy
Administering Oxygen
Nebulised therapy and oxygen
Humidification
Prescribing and Monitoring
Transfer and Transportation of patients receiving oxygen
Weaning and Discontinuation
Infection Prevention and Control
Training
Monitoring and recording Oxygen
Summary Oxygen Administration protocol (and weaning protocol)
Audit
Oxygen Devices
References
CHS 78 Administer Oxygen Safely and Effectively (Skills for Health
Competencies)
Oxygen Audit in Community Hospitals NPSA/2009/RRR006
Equality Impact Assessment
Audit and Monitoring
Page
2
3
5
5
6
7
8
9
10
11
12
13
14
15
16
14
17
18
23
24
26
30
32
4
1
Introduction
1.1
The administration of supplemental oxygen is an essential element of appropriate
management for a wide range of clinical conditions; however oxygen is a drug and
therefore requires prescribing in all but emergency situations. Failure to administer
oxygen appropriately can result in serious harm to the patient. The safe implementation
of oxygen therapy with appropriate monitoring is an integral component of the clinician’s
role.
1.2
Oxygen is a colourless, odourless and tasteless gas which makes up 21% of the
atmosphere. Within all community hospitals there are two varieties of oxygen
administration namely piped and portable cylinders. Both of these systems are
supported by portering staff from within the facilities team, who have a day to day
responsibility for changing cylinders, monitoring usage and availability of supplies. They
also order replacement stock.
2
Aims and Objectives
2.1
The aim of this standard operating procedure (sop) is to provide a unified clinical
approach to the administration and care of patients requiring oxygen therapy, within
LCHS community hospitals. The use of supplementary oxygen is considered to be a
medicine and should be managed in the same way as all other medicines in its method
of administration.



All patients who require emergency / supplementary oxygen therapy receive
therapy that is appropriate to their clinical condition and in line with national
guidance (British Thoracic Society 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 oxygen delivery method alone.
Those who administer oxygen therapy will monitor the patient and keep within
the target saturation range.
2.2
This sop outlines the administration and use of oxygen within community hospitals and
Urgent Care services. The clinical steps which should be taken by registered clinicians
before administering oxygen to patients. It also outlines equipment which should be
used to administer oxygen therapy and the roles and responsibilities of staff caring for
patients receiving oxygen. Where appropriate, it should be read in conjunction with
Policy for Use of Pulse Oximetry in Adults (P_CIG_09).
3
Scope
3.1
Minimum standards expected from clinical professionals in the administration of
emergency and non-emergency oxygen, are provided.
3.2
This sop applies to all areas within the Community Hospitals and Urgent Care Services
of Lincolnshire Community Health Care Services NHS Trust where oxygen is
administered. Responsibility lies with registered healthcare professionals who in order
to administer oxygen safely must understand:





The indications for oxygen
The hazards associated with oxygen therapy
Oxygen and humidification systems in use
Potential side effects of usage
Safe storage of Oxygen
5


4
How to initiate home Oxygen therapy
The referral process for the Community Respiratory Team
Roles and Responsibilities
The Chief Executive has overall responsibility for the strategic and operational
management of LCHS NHS Trust, including ensuring that the organisations policies and
procedures comply with all legal, statutory and good practice requirements.
4.1
General Managers and Heads of Clinical Service
Responsible for identifying and implementing polices relevant to their area of
responsibility. They are also responsible for ensuring that all staff have access to and
are made aware of policies that apply to them. All staff are responsible for the
implementation of LCHS polices and procedures as part of their core duties
4.2
Practitioners
It is the responsibility of these individuals to ensure that they are competent to
administer oxygen and record the appropriate clinical observations. They should be
competent in the use of equipment for the delivery of oxygen, in the case of any evident
or suspected malfunction or inaccuracy of equipment this should be reported to a senior
member of staff and appropriate action taken.
4.3
All Clinical Professionals
Who are involved in the administration of oxygen should be aware of this sop and its
principles. Documentation and communication are pivotal to minimising risks for
patients and all actions should be documented contemporaneously or as soon as
possible after the event.
5
Review
This sop will be reviewed annually by the Medicines Management Committee and
approved by the Quality Scrutiny Group.
6
Evidence Base
See references Section 27
7
Risk Management
7.1
The NHSLA risk management standards 2012-2013 (NHS Litigation Authority) outline
the requirements for Medical Devices Training (5.5) and Medicines Management (5.10).
7.2
The NPSA (2009) Oxygen safety in hospitals - Rapid Response Report – from reporting
to learning NPSA/2009/RRR006, aims to ensure that safe systems are in place to treat
patients needing oxygen. An audit tool based on this guidance is detailed in Appendix
3.
6
Part One
Administration of Emergency Oxygen
8
Emergency Situations
8.1
In the emergency situation an oxygen prescription is not required. Oxygen should be
given to the patient immediately, without a formal prescription or drug order, but
documented in the patient’s record. All patients who have a cardiac or respiratory arrest
should have 100% oxygen provided, along with basic / advanced life support.
8.2
All critically ill patients should be given 100% oxygen (15l/m reservoir mask),
immediately (see fig.1), the aim should to stablilise the patient and then to achieve
normal or near-normal oxygen saturations for all acutely ill patients, apart from those at
risk of hypercapnic respiratory failure or those receiving terminal palliative care.
Fig.1
Critical illnesses requiring high levels of supplemental oxygen
•
•
•
The initial oxygen therapy is a reservoir mask at 15 l/m
Once stable, reduce the oxygen dose and aim for a target saturation range of
94-98%
Patients with COPD and other risk factors for hypercapnia who develop critical illness
should have oxygen saturations of 88-92% pending the results of blood gas
measurements, after which these patients may need controlled oxygen therapy or
supported ventilation if there is severe hypoxaemia and / or hypercapnia with respiratory
acidosis.
Cardiac arrest or resuscitation
Additional comments
Use bag-valve mask during resuscitation
Aim for maximum possible oxygen saturation until the
patient is stable.
Shock, sepsis, anaphylaxsis,
major pulmonary haemorrhage
Also give specific treatment for the underlying condition
Major head injury
Early intubation and ventilation if comatose
Carbon monoxide poisoning
Give as much oxygen as possible using a bag-valve
mask or reservoir mask. Check carboxyhaemoglobin
levels.
A normal or high oximetry reading should be
disregarded because saturation monitors cannot
differentiate
between
carboxyhaemoglobin
and
oxyhaemoglobin owing to their similar absorbances.
The blood gas PaO² will also be normal in these cases
(despite the presence of tissue hypoxia).
(British Thoracic Society guideline, 2008)
**The above patients will require emergency transfer to acute care except where
advanced directives are in place**
See also:
Fig. 3 (page 9)
Fig. 4 (page 10)
Serious illnesses requiring moderate levels of supplemental
oxygen if the patient is hypoxaemic
COPD and other conditions requiring controlled or low-dose
oxygen therapy
7
8.3
Oxygen should be prescribed to achieve a target level saturation of 94-98% for most
acutely ill patients or 88-92% for those at risk of hypercapnic respiratory failure (see Fig.
2). The target saturation should be written on the drug chart. ** some normal subjects,
especially people aged > 70 years, may have oxygen saturation measurements below
94% and do not require oxygen therapy when clinically stable.**
Maintaining Oxygen Saturation
Fig 2.
Titrate oxygen up or down to maintain the target oxygen saturation. The table below shows
available options for stepping dosage up or down. The chart does not imply any equivalence of
dose between Venturi masks and nasal cannulae.
Allow at least 5 minutes at each dose before adjusting further upwards or downwards (except
with major and sudden fall in saturation).
Once your patient has adequate and stable saturation on minimal oxygen dose, consider
discontinuation of oxygen therapy.
Seek medical advice
if patient appears
to need increasing
oxygen therapy or if
there
is
a
rising
National Early Warning
Score (NEWS)
score
Venturi 24% 2-4 l/min
Nasal cannulae 1 l/min
Venturi 28% 4-6 l/min
Nasal cannulae 2 l/min
Blue
White
Venturi 35% 8-10 l/min
All patients should have
ABG
Within 1 hour of requiring
increased oxygen
Venturi 40%
10-12 l/min
or simple face mask
at 5-6 l/min
Venturi 60%
12-15 l/min
or simple face mask
7-10 l/min
Red
Green

oxygen dose
needed to keep
Spo² in target range






NEWS score
C O2 retention
Drowsiness
Headache
Flushed face
Tremor
Nasal cannulae 4 l/min
Yellow
Where ABG is required, transfer
to Acute care should be
considered, send ABG to lab as
directed by medical staff.
Ensure continued monitoring of
SPO2
Signs of respiratory
Deterioration

Respiratory rate
(especially if >30)

O2
Seek medical advice
Reservoir mask at 15l/min oxygen flow
If reservoir mask required, seek
Senior medical input immediately

For venturi masks, the higher flow rate is required if the respiratory rate is >30
Patients in a peri-arrest situation and critically ill patients should be given maximal oxygen therapy via a reservoir mask
via reservoir mask or bad-valve mask whilst immediate medical /paramedic help is arriving (except for patients with
COPD with known oxygen sensitivity recorded in patient’s notes and drug chart: keep saturation at 88-92% for this
subgroup of patients)
(British Thoracic Society guideline, 2008)
8.4
Oxygen should be given by staff who are trained in oxygen administration, using
appropriate devices and flow rates in order to achieve the target saturation. Any
qualified nurse / health professional can commence oxygen therapy in an
emergency situation.
8.5
Oxygen is a treatment for hypoxaemia, not breathlessness (oxygen has not been
shown to have any effect on the sensation of breathlessness in non-hypoxaemic
8
patients). However, a sudden reduction of more than 3% in a patient’s oxygen
saturation within the target saturation range should prompt fuller assessment of the
patient (and oximeter signal) because this may be the first evidence of an acute illness.
8.6
Oxygen saturation should be checked by pulse oximetry in all breathless and acutely ill
patients, urgent blood gas analysis should be undertaken when necessary (transfer
should be consider for all acutely ill patients). The inspired oxygen concentration
should be recorded on the observation chart with the oximetry result.
8.7
The other vital signs of pulse, blood pressure, temperature and respiratory rate, should
also be recorded. All acutely ill patients should be assessed and monitored using the
National Early Warning Score (NEWS).
Fig 3.
9
Fig 4.
Part Two
Administration of Non-Emergency Oxygen
10
9
Indications for prescribed Oxygen in LCHS Community Hospitals
9.1
Oxygen therapy is used for a variety of clinical conditions but primarily where the
patient is unable to maintain their own oxygen levels. Within the community
hospitals, patients requiring oxygen may fall into the following clinical groups







Cardiac failure
Respiratory failure/distress
Palliative care
Chronic obstructive Pulmonary Disease
Asthma
Post myocardial infarction
Pneumonia
(This list is not exhaustive and is intended as a guide only to clinicians)
10
Assessing and Monitoring Patients Requiring Oxygen Therapy
10.1 On admission to hospital patients should have baseline observations of Temperature,
Pulse, Respirations, Blood Pressure and Oxygen saturation levels recorded using a
pulse oximeter.
11
Identifying Appropriate Target Saturations
11.1 The normal range for peripheral saturation (SpO2) levels is 94 -98%. The exceptions
are patients at risk of hypercapnic respiratory failure (usually patients with moderate or
severe COPD, severe chest wall or spinal disease, neuromuscular disease or severe
obesity) for this group the target is oxygen saturations set at 88 to 92 per % ( until
arterial blood gases have been interpreted). Where patient’s oxygen saturations are
lower than this further assessment of their health and referral to any recent recordings
should be made. It is not acceptable that the first response is the application of oxygen
(except in an emergency) as in the case of a patient with Chronic Obstructive
Pulmonary Disease (COPD) this may be very harmful.
11.2 10 -15% of patients with COPD have type II respiratory failure (Bateman and Leach
1998) and for these patients a falling oxygen level is their drive to breathe. These
patients need to have their hypoxia corrected but the dose of oxygen given needs to be
carefully administered and monitored, this should be reviewed as a potential issue
when oxygen therapy is considered.
11.3 Clinical signs of inadequate oxygenation to consider when making an assessment are:






Is the patient’s SpO2 below 94%?
Does the patient have a raised pulse rate?
Does the patient have a raised respiratory rate?
Does the patient have altered skin colour? Is there cyanosis?
Are there signs of agitation, confusion or an altered level of consciousness?
Are they using their accessory muscles when breathing?
Consideration should be given to:
11






12
Optimisation of medication and inhalers
Compliance against prescription
Inhaler technique
Evidence of or diagnosis of anaemia
Is treatment for COPD ( saturations will be lower)
Pre existing respiratory conditions
Contraindications
12.1 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 the lowest possible rate of administration.
12.2 Other Precautions/ Hazards/ Complications of Oxygen Therapy





13
Drying of nasal and pharyngeal mucosa
Oxygen toxicity
Skin irritation
Fire hazard
Potentially inadequate flow resulting in lower oxygen absorption than
intended (equipment fault should be considered).
Prescribing Oxygen
13.1 Oxygen should be prescribed in the designated section of the hospital prescription
card and the appropriate target saturation should recorded on the chart and on the
National Early Warning Score Chart.
14
Types of equipment to administer oxygen therapy
14.1 All staff involved in the provision and administration of oxygen should be able to
demonstrate competency with the equipment in use within their clinical area of work.
Where cylinders are in use staff should understand the process for changing the flow
meters (usually undertaken by Facilities Team).
12
14.2 All equipment should be regularly checked and stocks of masks readily available and
accessible. Where there is both a supply of piped air and oxygen the regulators should
be clearly distinguishable and where necessary labelled.
14.3 Piped oxygen will be the main source of supply, the use of cylinders should be kept to a
minimum. Where the use of oxygen cylinders is unavoidable systems should be in
place to ensure that supplies are readily available, accessible and checked on a regular
basis( during intentional rounding) when in use. In addition there needs to be clear
segregation of full and empty cylinder supplies. There should be clear distinction
between oxygen and piped air. When piped air is not required flow meters should be
removed but readily available for use.
14.4 Following admission any patients requiring non emergency oxygen therapy should be
reviewed by a doctor/ non-medical prescriber at the earliest opportunity and a
prescription for oxygen together with the desired oxygen saturation range clearly
documented on the inpatient prescription chart, and National Early Warning Score
(NEWS). The correct oxygen administration device can then be selected.
15
Administering oxygen
15.1 Once the target saturation has been identified and prescribed, guidance regarding the
most appropriate delivery system to reach and maintain the prescribed saturation is
provided below:
15.2 Oxygen administration devices are many and variable. For emergency situations where
a high percentage oxygen is required the mask of choice for those who will tolerate a
mask is a non rebreathe mask with reservoir This can be connected directly to the flow
meter with a flow rate of 15 litres / minute (l/min) and deliver 85% oxygen. This product
is only licensed for emergency situations and once stabilised an alternative mask
should be used. Guidance from the British Thoracic Society states that in an
emergency, oxygen should always be given immediately and documented later.
15.3 Nasal Speculum deliver a low range of oxygen between 24 – 35% and are connected
directly to the oxygen with an oxygen flow rate of up to 4 l/min These are safe and easy
to use, are comfortable and allow the patient to eat drink and talk.
15.4 Venturi devices come as individual colour-coded barrels that are attached to an aerosol
mask. The system delivers a specific percentage of oxygen to the patient Different
coloured barrels are selected depending on the percentage of oxygen required. The
oxygen flow rate needed for the different barrels varies according to the manufacturer
and this flow rate will always be stated on the device. (Section 23)
15.5 This is the device of choice when it is important to deliver an accurate percentage of
oxygen (e.g. Type II respiratory failure).
15.6 Medium concentration (MC) masks deliver a medium range of oxygen, generally
considered to be 35 - 60%. The mask is connected directly to the oxygen flow meter
with a flow of 5 – 10 l/min. The oxygen flow should be adjusted according to the flow
rate or the desired SpO2 range stated clearly. This mask is ideal for people who are
suffering with Asthma, Pulmonary Embolism, Myocardial Infection, Pneumonia or other
forms of type I respiratory failure. When using this type of mask flow rates should be
maintained at 5 l/min or more as lower rates may result in re-breathing of exhaled air.
This makes it difficult to achieve a low inspired oxygen concentration and so these
masks are generally unsuitable for patients with type II respiratory failure.
16
Nebulised therapy and oxygen
13
16.1 When nebulised therapy is administered to patients at risk of hypercapnic
respiratory failure (retention of CO2), it should be driven by compressed air. If
necessary, supplementary oxygen should be given concurrently by nasal cannulae
at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other
specified target range.
16.2 All patients requiring 35% or greater oxygen therapy should have their nebulised
therapy by oxygen at a flow rate of >6 l/min and should have pulse oximetry for the
duration of delivery.
17
Humidification
17.1 Humidification may be required for some patient groups, especially patients with a
tracheostomy and those who have difficulty in clearing airway secretions or mucus.
It is not routinely required.
18
Prescribing and Monitoring
18.1 The doctor, nurse practitioner or specialist nurse, is required to prescribe oxygen and
this should be done at the earliest opportunity with guidance on the range of oxygen
saturation levels required. The delivery device and flow rate should always be recorded
on the physiological observations chart (BTS 2008) this is also in line with LCHS Trust
policies and procedures.
18.2 Oxygen therapy will be adjusted to achieve target saturations rather than giving a fixed
dose to all patients with the same disease. Nursing staff will be able to adjust the dose
delivered (following discussion with a senior clinician competent in the prescription of
oxygen / respiratory clinicians) this will be reflected on the prescription chart. The
patient’s requirement for oxygen should be monitored at each drug round and their
oxygen saturation levels recorded. If oxygen is still required the Registered Nurse must
sign the prescription chart confirming the quantity of oxygen that is being administered.
18.3 The on-going requirement should be monitored to assess the patient’s progress and
requirements for discharge. A Home Oxygen Order Form (HOOF) will need to be
completed, signed by the prescribing clinician and faxed to the home oxygen supplier.
This should be undertaken at least 24hrs prior to discharge. Part A of HOOF can only
be completed by the ward, for Part B where portable cylinders may be required there is
a need to contact the community oxygen nurse or secondary care. Oxygen is only
required if SPO2 <92% on air at rest and CBG/ABG P O2 <7.3 on air at rest, ambulatory
O2 if saturations <90% when mobilising. COPD patients should be referred to the O 2
nurse if levels are as above.
19
Transfer and Transportation of Patients Receiving Oxygen
19.1 Patients who are transferred from one area to another must have clear documentation
of their on-going oxygen requirements and documentation of their oxygen saturation.
19.2 Patients requiring oxygen therapy whilst being transferred from one area to another
should be accompanied by a trained member of the nursing staff wherever possible. If
this does not occur, clear instructions must be provided for personnel involved in the
transfer of the patient, which must include delivery device and flow rate.
20
Weaning and Discontinuation
14
20.1 Oxygen therapy should be reduced in stable patients with satisfactory oxygen
saturation levels. Once oxygen has been discontinued the prescription should be
reviewed by the patient’s doctor/senior clinician and discontinued on the prescription
chart.
21
Infection Prevention and Control
21.1 All oxygen administration devices should be used in accordance with the
manufacturer’s guidance and will generally be single patient use unless specifically
stated on the packaging.
21.2 At all times administration devices should be kept visibly clean and protected from
contamination. When in use they should be checked as part of on-going hygiene needs,
devices should be cleansed or replaced as indicated by the manufacturer. Prior to use,
devices should be stored in a clean area, off the floor and protected from
contamination. During intermittent use care should be taken to ensure they are visibly
clean and dry before putting into a designated container ready for its next use. For
hospital patients this container should be clearly labelled with the patient’s name.
21.3 In addition to oxygen administration sets, all nebuliser masks, mouthpieces and tubing
can be re-used for the same patient unless specifically stated on the packaging. All
administration equipment except the tubing should be washed after each use with
general purpose detergent and warm water. It should then be thoroughly dried using a
disposable soft paper towel. The tubing should be attached to the gas delivery device
and turned on for a few seconds, which will remove any dampness from inside the
tubing.
21.4 With regard to nebulisers, if a compressor is used, when unplugged it will need to be
wiped over with a disinfectant wipe, this should be part of routine cleaning schedules
(daily/weekly) and in addition should be undertaken between use with different patients
or more often if actually contaminated. The compressor should be stored clean and dry
without nebuliser equipment attached.
21.5 Administration devices should not be stored connected to the oxygen supply, with the
exception of those required in emergency situations, which should remain connected
and ready for use, the mask and tubing should be protected from contamination ideally
by retaining within original packaging which should be included in regular cleaning
schedules.
21.6 At all times healthcare staff should comply with LCHS standard infection prevention and
control practices within the infection prevention and control policies and procedures
policy guidance on use of personal protective equipment and local cleaning schedules .
22
Training
22.1 Staff should be able to demonstrate the knowledge of the use of equipment when
administering oxygen, together with competency in recording the patient’s oxygen
saturation and taking the appropriate action required. This should be assessed by an
appropriate senior clinician together with equipment used, which should form part of
each areas induction pack. Competencies to: Administer oxygen safely and effectively
(CHS78 https://skillsforhealth.org.uk/competence can be found at Appendix 1) and
should be completed at induction and reviewed annually.
23
Monitoring and Recording Oxygen
15
23.1 Clinical staff will be required to be competent in the use of applying an Early Warning
Score, (LCHS uses the National Early Warning Score to ensure holistic clinical
assessment and appropriate treatment interventions) The patient's oxygen saturation
and oxygen delivery system should be recorded on this chart alongside other
physiological variables. All patients on oxygen therapy should have regular pulse
oximetry measurements. The frequency of measurements will depend on the condition
being treated and the stability of the patient.
24
Summary Oxygen Administration Protocol (and weaning protocol)
Action
All patients requiring oxygen therapy will
have a prescription for oxygen therapy
recorded
on
the
patients
drug
prescription chart. N.B exceptions- see
emergency situations
The prescription will incorporate a target
saturation that will be identified by the
clinician prescribing the oxygen.
The prescription will incorporate an initial
starting dose (i.e. delivery device and
flow rate)
The drug chart should be signed at every
drug round
Once oxygen is in situ the nurse will
monitor observations in line with trust
policy. All patients should have their
oxygen saturation observed for at least
five minutes after starting oxygen
therapy. If a patient is receiving
intermittent therapy they may be
monitored at least 8 hourly.
The oxygen delivery device and oxygen
flow rate should be recorded alongside
the oxygen saturation on the bedside
observation chart.
Oxygen saturations must always be
interpreted alongside the patients clinical
status incorporating the early warning
score.
If the patient falls outside of the target
saturation range, the oxygen therapy will
be adjusted accordingly
The saturation should be monitored
continuously for at least 5 minutes after
any increase or decrease in oxygen dose
to ensure that the patient achieves the
desired saturation range.
Saturation higher than target specified
or >98% for an extended period of
time.
Step down oxygen therapy as per
guidance for delivery
Rationale
Oxygen should be regarded as a drug
and should be prescribed. BTS National
guidelines (2008). British National
Formulary (2013).
Certain groups of patients require
different target ranges for their oxygen
saturation:patients are at risk of hyperoxaemia,
particularly patients with COPD.
To provide the nurses with guidance for
the appropriate starting point for the
oxygen delivery system and flow rate
To ensure that the patient is receiving
oxygen if prescribed and to consider
weaning and discontinuation
To identify if oxygen therapy is
maintaining the target saturation or if an
increase or decrease in oxygen therapy
is required
To provide an accurate record and allow
trends in oxygen therapy and saturation
levels to be identified.
To identify early signs of clinical
deterioration, e.g. elevated respiratory
rate
To maintain the saturation in the desired
range.
The patient will require weaning down
from current oxygen delivery system.
16
Action
Consider
therapy
Rationale
discontinuation of oxygen The patients clinical condition may have
improved negating the need for
supplementary oxygen
Saturation lower than target specified
Check all elements of oxygen delivery In most instances a fall in oxygen
system for faults or errors.
saturation is due to deterioration of the
patient however equipment faults should
be checked for.
Step up oxygen therapy as per protocols To assess the patients response to
in appendix (i). Any sudden fall in oxygen oxygen increase, and ensure that PaC
saturation should lead to clinical O2 has not risen to an unacceptable
evaluation
and
in
most
cases level, or Ph dropped to an unacceptable
measurement of blood gases
level and to screen for the cause of
deteriorating
oxygen
level
(e.g.
pneumonia, heart failure etc)
Monitor Early Warning Score and
respiratory rate for further clinical signs of
deterioration
Patient safety
Monitor Early Warning Score and To detect further clinical signs of
respiratory rate
deterioration
Saturation within target specified
Continue with oxygen therapy, and
monitor patient to identify appropriate
time for stepping down therapy, once
clinical condition allows
A change in delivery device (without an (The change may be made in stable
increase in O2 therapy) does not require patients due to patient preference or
review by the medical team.
comfort).
25
Audit
25.1
To ensure compliance with the policy the following outcomes will be measured through
audit (Appendix 2)
Standard
Percentage Compliance
All patients requiring oxygen will be 100%
assessed on admission and a clear
clinical need identified
The prescription for Oxygen will have all
the following recorded:




100%
Route
Amount
Delivery System
Duration
Patients
will
receive
oxygen
in 100%
accordance to a current prescription and
17
Standard
Percentage Compliance
this will be recorded in the nursing notes.
Documentation of Oxygen levels on a
daily basis should be recorded in the
nursing notes and as appropriate on the
patients National Early Warning Score
100%
Staff will be able to demonstrate their 100%
knowledge of the use of equipment in
place to administer oxygen
26
Oxygen Devices
Device
1.
Nasal Cannulae
(When using nasal cannula).
Position the tips of the cannula in the
patient’s nose so that the tips do not
extend more than 1.5cm into the nose
Description
Nasal cannulae consist
of pair of tubes about
2cm long, each
projecting into the
nostril and stemming
from a tube which
passes over the ears
and which is thus selfretaining
Purpose
Cannulae are
preferred to masks
by most patients.
They have the
advantage of not
interfering with
feeding and are not
as inconvenient as
masks during
coughing and
sneezing.
It is not advisable to
assume what percent
oxygen (FI O2 ) the
patient is receiving
according to the
Litres delivered but
this is not important if
the patient is in the
correct target range
2. Place tubing over the ears and
Set the flow rate to
achieve the desired
range
under the chin as shown above.
Educate patient re prevention of
pressure areas on the back of
the ear.
3. Adjust flow rate, usually 2-4
l/min but may vary from 1-6
l/min in some circumstances.
Device Venturi Mask
Description
Purpose
18
A mask
incorporating a
device to enable a
fixed concentration
of oxygen to be
delivered
independent of
patient factors or fit
to the face or flow
rate. Oxygen is
forced out through
a small hole
causing a Venturi
effect which
enables air to mix
with oxygen.
This is a high
performance
oxygen mask
designed to deliver
specified oxygen
concentration
regardless of
breathing rate or
tidal volume.
Venturi devices
come in different
colours for %
Blue 24%
White 28%
Yellow 35%
Red 40%
Green 60%
Action
Rationale
1. When using the venturi mask

2. Connect the mask to the
appropriate Venturi barrel
attached firmly into the masks
inlet

3. Fasten oxygen tubing securely.
Assess the patients condition
and functioning of equipment at
regular intervals according to the
care plan


4. Adjust flow rate. The minimum
flow rate is indicated on the
mask or packet. The flow should
be doubled if the patient has a
respiratory rate above 30 per
minute.
Device
flow)
Simple face mask (variable
To ensure the patient receives the
correct concentration of oxygen
Correctly
secured
tubing
is
comfortable
and
prevents
displacement of mask/cannulae
To ensure patient’s safety and that
oxygen is being administered as
prescribed
Higher flows are required for patients
with rapid respiration and high
inspiratory flow rates. This does not
affect the concentration of oxygen but
allows gas flow rate to match the
patients breathing pattern
Description
Purpose
19
Mask has a soft
plastic face piece,
vent holes are
provided to allow air
to escape. Maximum
50%-60% at 15 l/min
flow.
This is a variable
performance
device. The
oxygen
concentration
delivered will be
influenced by:
a. the oxygen
flow rate(
litres per
minute) used,
leakage
between the
mask and
face;
This is a variable
performance
device. The
oxygen
concentration
delivered will be
influenced by:
NOT to be used
for CO2 retaining
patients.
Action
Rationale
If using simple face mask gently place
mask over the patient’s face, position the
strap behind the head or the loops over
the ears then carefully pull both ends
through the front of the mask until secure.
Ensure a comfortable fit and delivery of
prescribed oxygen is maintained. To
prevent irritation.
Check that strap is not across ears and if
necessary insert padding between the
strap and head.
Flows below 5 l/m do not give enough
oxygen and may cause increased
resistance to breathing and may also
cause CO2 re-breathing due to the small
mask size.
Adjust the oxygen flow rate. Must never
be below 5 l/min.
Reservoir mask (non re
breathe mask)
Device
Description
Mask has soft plastic
face piece with flap
valve exhalation
ports which may be
removed for
emergency air
intake. There is also
a one way valve
between the face
mask and the
Purpose
In non re breathing
systems the
oxygen may be
stored in the
reservoir bag
during exhalation
by means of a one
way valve. High
concentration of
oxygen 80-90%
can be achieved at
20
reservoir bag.
relatively low flow
rates.
Action
Rationale
Ensure the reservoir bag is inflated
before placing mask on the patient.
To ensure optimal follow of oxygen to the
patient.
Adjust oxygen flow to the prescribed
rate.
Inadequate flow rates may result in
administration of inadequate oxygen
concentration to the patient.
In disposable reservoir, oxygen flows directly into the mask during inspiration and
into the reservoir 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 rebreathing.
Tracheostomy mask for
patients with tracheostomy or
laryngectomy
Device
Tracheostomy mask
Description
Mask designed for
“neck breathing
patients”. Fits
comfortably over
tracheostomy or
tracheotomy.
Exhalation port on
front of mask.
Variable percentage
Gently place mask over the patient’s
This is a variable
performance device
for patients with
tracheostomy or
tracheotomy. The
oxygen
concentration
delivered will be
influenced by:
a. The oxygen
flow rate (litres
per minute) used.
b. the patient’s tidal
volume and
breathing rate.
(Delivers unpredictable concentrations that
vary with the flow rate)
Action
Purpose
Rationale
Ensure a comfortable fit and delivery of
21
airway, position the strap behind the
head then carefully pull both ends
through the front of the mask until
secure.
Adjust the oxygen flow rate to achieve
the desired target saturation range.
Start at 4 l/min and adjust the flow up
or down as necessary to achieve the
desired oxygen saturation range.
Device
Oxygen flow meter
prescribed oxygen is maintained.
To ensure that the correct amount of
oxygen is given to keep the patient in the
target range.
Description
Device to allow the
patient to receive an
accurate flow of
oxygen usually
between 2 and 15
litres per minute
Purpose
To ensure that the
patient receives the
correct amount of
oxygen.
May be wall mounted
or on a cylinder
Take special care
with twin oxygen
outlets which may be
mistaken for oxygen
outlets.
Oxygen flow meter
Action
Rationale
Attach the oxygen tubing to the nozzle on
the flow meter.
To ensure that the patient receives the
correct amount of oxygen.
Turn the finger-valve to obtain the desired
flow rate. The CENTRE of the ball shows
the correct flow rate. The diagrams show
the correct setting to deliver 2 l/min.
27
References
22
Bateman, N.T., and Leach, R.M (1998) ABC of Oxygen: Acute Oxygen Therapy. BMJ:
1998;317:798-801 (19 September).
British Thoracic Society (2008) Guideline for Emergency Oxygen use in Adult Patients
www.brit-thoracic.org.uk
Hunt, J (2010) Oxygen therapy administration, Policy and Guidelines: the administration
of short burst, sustained (medium term) and emergency oxygen to adults in hospital.
Royal United Hospital Bath.
National Patient Safety Agency (NPSA) (2009) Oxygen Safety in hospitals: Information
for Nurses, Midwifes and AHPs. www.nrls.npsa.nhs.uk/alerts.
National Early Warning Score – Standardising the Assessment of Acute Illness Severity
in the NHS (2012)
23
Appendix 1
CHS78 Administer oxygen safely and effectively
Overview
This standard is about the safe and effective administration of oxygen in all healthcare
settings, at home and in any environment where an individual requires oxygen therapy.
Users of this standard will need to ensure that practice reflects up to date information
and policies.
Version No 1
Knowledge and Understanding
You will need to know and understand:
1. your responsibilities and accountability under the current, national and local
legislation, policies, protocols and guidelines with respect to the administration
of oxygen
2. the importance of working within your own sphere of competence and seeking
advice when faced with situations outside your sphere of competence
3. the hazards and complications which may arise during the administration of
oxygen and how you can minimise such risks
4. the range of information which should be made available to the individual
5. the national guidelines for risk management and adverse incidents
6. the effect of oxygen on individuals
7. potential adverse effects of oxygen therapy and how they can be prevented
and/or minimised
8. when it is safe or not safe to administer oxygen
9. the importance of the manufacturers labelling oxygen equipment with safety
guidance
10. how to obtain written guidance on the effective use of oxygen
11. the risks and complications of using oxygen
12. the methods to assess and monitor the individual during the administration of
oxygen
13. the factors which may compromise the comfort and dignity of individuals during
the use of oxygen and how the effects can be minimised
14. accepted best practice in the use oxygen
15. the contraindications to administering oxygen
16. the equipment and accessories to be used
17. the correct procedure for reporting faulty equipment
18. Palliative Oxygen Therapy and Short Burst Oxygen Therapy (SBOT) and their
implications
24
19. the Home Oxygen Order Form (HOOF) and the Home Oxygen Consent Form
(HOCF)
20. legislation and legal processes relating to valid consent
21. methods of obtaining valid consent and how to confirm that sufficient information
has been provided on which to base this judgement
22. the actions to take if valid consent cannot be obtained
23. the importance of respecting individuals’ privacy, dignity, wishes and beliefs and
how this can be achieved
24. the importance of minimising any unnecessary discomfort, and ways to achieve
this
Performance Criteria
You must be able to do the following:
1. confirm the individual's details
2. check the oxygen prescription and the prescribed administration route (face
mask, mouthpiece or nasal cannulae)
3. check that the baseline assessment for oxygen therapy has been completed
4. explain and demonstrate the procedure for administering oxygen to the
individual
5. ensure that you adhere to the health and safety and COSHH measures relevant
to the administration of oxygen to prevent or minimise the potential adverse
effects of oxygen therapy
6. check the oxygen equipment has been labelled with safety guidance by the
manufacturer as per the statutory regulations
7. perform basic checks to confirm that all the equipment is working correctly in
accordance with the manufacturer’s instructions. Report any faults immediately
according to procedure
8. assist the individual to find a comfortable position for the delivery of oxygen
within the constraints of the treatment/environment
9. ensure that the individual can summon assistance should they be concerned
about their condition or equipment
10. record the administration of oxygen in the patient held records, as appropriate,
according to local guidelines
11. recognise the need to monitor and review the individual’s condition on a regular
basis and refer them to others when necessary
Additional Information
This National Occupational Standard was developed by Skills for Health.
This standard links with the following dimension within the NHS Knowledge and Skills
Framework (October 2004):
Dimension: HWB7 Interventions and treatments
25
Appendix 2
OXYGEN AUDIT IN COMMUNITY HOSPITALS – NPSA/2009/RRR006
April 2013
Background
Oxygen is one of the most commonly used medicines in hospital environments, and is
used across a range of healthcare specialities
Following a trigger incident reported to the Reporting and Learning System where a
patient was inadvertently connected to air instead of oxygen, the National Patient
Safety Agency has issued guidance on oxygen safety in hospitals.
Aims of the Audit




The validity of the prescription route
Correct documentation in the Nursing Notes
Oxygen levels monitored and recorded daily
Number of patient receiving Oxygen at the time of the audit
Audit to be undertaken by:
Skegness Hospital
Louth County Hospital
Johnson Community Hospital
John Coupland Hospital
26
Methodology
Audit of all patients on the ward who have received Oxygen therapy from …. …
to ……………………………………
Completion instructions
All sections of the attached data collection forms must be completed with either a
Yes or No, please do not leave any blank spaces.
Summarisation of Data:
Please summarise your data onto the enclosed Results Form and return this together
with your completed data collection forms by …………….to your ward manager
N.B. If you have no patients appropriate for the audit please complete a Nil Return e.g.
return the form with NIL Return written across the front sheet.
Please keep a photocopy of the completed forms
27
OXYGEN AUDIT IN COMMUNITY HOSPITALS – NPSA/2009/RRR006
RESULTS FORM
Please enter the name of your hospital:
Contact Name
of person completing form
No:
Job Title
Telephone
Question
Q1: Number of patients who received Oxygen therapy during the
time of the audit
Criteria
Number
Achieved
(Note 1)
Number
% Achieved
(Note 2)
LCHS
%Target
Standard Set
C1:The prescription for Oxygen should
have all the following recorded:
 Route
 Amount
 Delivery System
 Duration
C2: Documentation of Oxygen therapy
should be recorded in the nursing notes.
C3: Documentation of monitoring of
Oxygen levels on a daily basis should be
recorded in the nursing notes.
NOTES:
1.
Number achieved – enter here the total number of ‘Y’ responses from the data
collection form for each criterion.
2.
% Achieved – enter here the percentage of patients who met each criterion i.e.
Number of ‘Y’ responses
______________________________
Number of ‘Y’ and ‘N’ responses x 100
28
Data Collection Form
Patient
ID
e.g.
1.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Criterion 1
The prescription for Oxygen
should have all the following
recorded:
 Route
 Amount
 Delivery System
 Duration
Yes or No
Y
Criterion 2
Documentation of Oxygen
therapy should be recorded in
the nursing notes.
Yes or No
Y
Criterion 3
C3: Documentation of
monitoring of Oxygen levels
on a daily basis should be
recorded in the nursing
notes.
Yes or No
N
Please photocopy the following data collection forms as necessary if more than
40 are patients included in the audit
Equality Analysis
29
Name of Policy/Procedure/Function*
Standard Operating Procedure for Administration and use of Emergency and Non-Emergency
Oxygen in Lincolnshire Community Health Services
Equality Analysis Carried out by: Jill Anderson
Date: February 2017
Equality & Human rights Lead: Rachel Higgins
Director\General Manager: Lisa Green
A.
Briefly give an outline of the key objectives of
the policy; what it’s intended outcome is and
who the intended beneficiaries are expected to
be
The aim of this service operating procedure is to produce
a unified approach to the administration and care of
patients requiring oxygen therapy:
- All patients who require supplementary oxygen
therapy receive therapy that is appropriate to
their clinical condition and in line with national
guidance (British Thoracic Society 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 oxygen
delivery method alone.
- Those who administer oxygen therapy will
monitor the patient and keep within the target
saturation range.
B.
C.
D.
Does the policy have an impact on patients,
carers or staff, or the wider community that
we have links with? Please give details
Is there is any evidence that the policy\service
relates to an area with known inequalities?
Please give details
Will/Does the implementation of the
policy\service result in different impacts for
protected characteristics?
The policy defines how oxygen will be prescribed for
those patients that require it.
No
No
Yes
No
Disability
X
Sexual Orientation
X
Sex
X
Gender Reassignment
X
Race
X
Marriage/Civil Partnership
X
Maternity/Pregnancy
X
Age
X
Religion or Belief
Carers
X
X
If you have answered ‘Yes’ to any of the questions then you are required to carry out a full Equality
Analysis which should be approved by the Equality and Human Rights Lead – please go to section 2
The above named policy has been considered and does not require a full equality analysis
Jill Anderson
Equality Analysis Carried out by:
February 2017
Date:
30
Audit and Monitoring
Minimum requirement to be
monitored
Process
monitoring
audit
Audit of :
Audit
completed by
community
hospital
wards and
reported to
Quality
Scrutiny
Group
 The prescription
for oxygen.
 Documentation
of Oxygen
Therapy
 Monitoring of
Oxygen Levels
for
e.g.
Responsible
individuals/
group/
committee
Frequency of
monitoring/aud
it
Quality
Scrutiny
Group
Quarterly
/spot audits
Responsible
individuals/ group/
committee
(multidisciplinary)
for review of results
Responsible individuals/
group/ committee for
development of action
plan
Responsible individuals/
group/ committee for
monitoring of action plan
Quality Scrutiny
Group
Quality Scrutiny
Group
Quality Scrutiny
Group
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan