Gillian Lowrey, Respiratory Consultant
The problem
Mrs AC
• 50 year old woman, systemic sclerosis
• Pit Stop in ED Oxygen saturations 68%
• Blood gas on air 15:06
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pH 7.33 - low
pCO2 10.6 – high!!!
pO2 5.3 – Low!!!
Lactate 1.1
BE 13
Bicarb 35.1
To MAU
• Transfer Obs sheet shows time of 17:35
• RR 15 T 35.4 GCS 15 Sats 100%
• *NO RECORD OF SUPPLEMENTAL
OXYGEN*
• No Oxygen prescription
• Triage sheet indicates observations done at
18:05 on MAU
• Oxygen Saturations 100% on 8 litres of oxygen
Clerked at 21:00
• GCS 5, decreased respiratory effort.
• Clammy and bounding pulse
• ABG:
pH 7.12 – dangerously low
pCO219.6 – dangerously high
pO2 25.8 – too high!!!
Bic 36.7
TO ITU!!!
Oxygen is the most commonly
used drug in Emergency
Medicine
• 34% of emergency ambulance patients
receive Oxygen
• Oxygen used in 2 million ambulance
journeys/year
• 15% of Hospital patients receive oxygen
at any given time
Oxygen can save lives...
• Essential in severely ill patients with low
blood oxygen levels
...but too much can be
harmful
Cornet AD, 2012 ARCH INT MED Jan 9
Acute Exacerbations COPD
• Compared titrated with high concentration
oxygen in pre-hospital setting
• Mortality reduced by 58% overall (78% in
those with confirmed COPD)
• 9% to 2% in those with confirmed COPD
• Number needed to harm = 15
• Estimated 2000-4000 avoidable deaths
per year in UK
Austin MA et al BMJ 2010:341:c5462
Chaos reigned until 2008
• Most patients given too much oxygen
• Oxygen rarely prescribed
• Doctors and nurses had very little
knowledge about the safe use of oxygen
Guideline developed 2008
Oxygen – there is a problem
• 281 serious incidents
between Dec 2004-June
2009
• 95% in acute hospitals
• 9 caused death
– 4 too much Oxygen
– 4 not enough Oxygen
• 35 contributed to death
NPSA Recommendations
• Deadline March 2010
• “Oxygen is prescribed in accordance with
BTS guidelines”
Key principles
1. Oxygen is the treatment for LOW oxygen levels
2. Oxygen is prescribed by target saturation
• 94%-98% or
• 88-92% if at risk of hypercapnic respiratory failure
3. Oxygen delivery device and flow administered and
changed if necessary to keep the SaO2 in the target
range
4. Target oxygen saturation prescription integrated into
patient drug chart and monitoring chart
How do we do?
National Audits 2008-2013
How do we do?
National Audits 2008-2013
• 45% of all inpatients on oxygen
have NO prescription
• Wide variation in clinical areas
and between hospitals
•6.2% of all inpatients are
receiving oxygen without
prescription
How can we do better?
• Make it happen every time
• Make oxygen toxicity a “never event”
• Reinforce safe prescribing and titration with
doctors and nursing staff – mandatory
training @ induction
• Report errors and incidents
• Target low compliance areas
A Solution.......
Oxygen Saturation Wristband
Project
• All patients admitted to ward set target
oxygen saturation on prescription
• Nurse puts colour wristband on all
patients on first drug round as per the
prescription
• 4 month pilot on respiratory wards
Results
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95% compliance with oxygen prescription
86% within target prescription
Improved patient awareness (61% v 48%)
81% patients and 92% relatives felt
reassured about oxygen use
• 71% intended to continue to wear at
home – benefit in pre-hospital setting
Conclusion
• Wristbands can improve the prescription
of target saturations and titration of
oxygen
• Benefits include
• reducing incidents of oxygen toxicity
• promoting the safe and timely titration of
oxygen
• potential cost savings
• Save lives!
Acknowledgements
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Sue Smith
Gill Ogden
Liz Mullaney
Liz Burgess
Andy Adams
Cath Rowe
Peter Cull
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Kate Geofferson
Shirley Pagett
Mark Cannell
David Jones
Justine Williams
Sandra Mir
Respiratory Unit staff