Oxygen therapy administration Policy and Guidelines: the administration of short burst, sustained (medium term) and emergency

oxygen to adults in hospital

Reference Number:

7017

Author & Title:

Julian Hunt, Consultant Nurse Critical Care Corporate

Responsible Directorate:

Review Date:

December 2013

Ratified by (committee):

Clinical Governance Committee

Date Ratified:

December 2010

Version:

1.0

• • Related Procedural Documents • • • •

Policy and Guidelines for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults The Nursing Care And Management Of Adults With Tracheostomies Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults Resuscitation policy Medical Gas Pipeline System Operational Policy Medical equipment policy

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Index:
1.  2.  3.  4.  5.  Introduction __________________________________________________________ 4  Purpose of this policy ___________________________________________________ 4  Definitions ___________________________________________________________ 4  Aims and Objectives of this policy _________________________________________ 5  Responsibilities _______________________________________________________ 5  5.1  5.2  5.3  5.4  5.5  6.  7.  Medical staff and non-medical prescribers_______________________________ 5  Nursing staff ______________________________________________________ 6  Critical Care Outreach / Medical Nurse Practitioners / Night Nurse Practitioners _ 6  Ward managers / Clinical support staff _________________________________ 6  Critical Care Outreach / Clinical educators / Clinical Skills Trainers ___________ 6 

Monitoring Compliance _________________________________________________ 7  Summary Oxygen Administration protocol___________________________________ 8  Saturation higher than target specified or >98% for an extended period of time. _______ 9  Saturation lower than target specified ________________________________________ 9 

8. Prescribing, administering and monitoring oxygen _____________________________ 10  8.1  8.2  8.3  8.4  8.5  Identifying appropriate target saturations _______________________________ 10  Indicating oxygen target saturation range on the Vital Signs Chart ___________ 10  Personnel who may administer oxygen ________________________________ 11  Monitoring and recording oxygen _____________________________________ 11  Emergency situations ______________________________________________ 12 

8.6  Exclusions to targeted oxygen saturation range prescription, monitoring and delivery of oxygen ______________________________________________________ 12  8.7  8.8  8.9  9.  9.1  11.  12.  13.  14.  15.  16.  Specialist areas __________________________________________________ 13  Indications ______________________________________________________ 13  Contra-indications ________________________________________________ 13  Oxygen administration and carbon dioxide retention ______________________ 13  Peri-operative and immediately post-operatively ___________________________ 15  Nebulised therapy and oxygen_________________________________________ 15  Normal Oxygen saturations ___________________________________________ 15  Humidification______________________________________________________ 16  Training __________________________________________________________ 16  Health and Safety Issues _____________________________________________ 17 
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Cautions ____________________________________________________________ 13 

10.Transfer and transportation of patients receiving oxygen ________________________ 14 

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17.  18. 

References and Further Reading_______________________________________ 17  Acknowledgements _________________________________________________ 18 

Appendix 1: Consultation Schedule __________________________________________ 19  Appendix 2: Ward equipment list for oxygen masks and delivery systems _____________ 20  Appendix 3: Oxygen escalator ______________________________________________ 21  Appendix 4: Patients who may have hypoxic drive _______________________________ 22  Appendix 5: Adult vital signs chart – target saturation range________________________ 23  Appendix 6: Oxygen administration devices (expanded oxygen escalator)_____________ 24  Appendix 7: Humidification _________________________________________________ 29  Appendix 8: BOC Oxygen cylinder sizes and capacities ___________________________ 30  Appendix 9: Sample oxygen prescriptions______________________________________ 30  Equality Impact Assessment Tool ____________________________________________ 31  Consultation Checklist _____________________________________________________ 32  Ratification Check List _____________________________________________________ 33 

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Domiciliary oxygen is oxygen provided in the home by cylinder or concentrator for continuous or intermittent use. 2010) and therefore requires prescribing in all but emergency situations. (O’Driscoll et al. Definitions Administration of short. medium term (and emergency) oxygen to adults on general wards For the purpose of this policy and guideline medium term oxygen is to be distinguished from domiciliary oxygen and “short burst” oxygen therapy.1. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 4 of 33 Ref. Introduction This policy and guidelines applies to all clinical staff of the Royal United Hospital Bath NHS Trust who use oxygen therapy in the care of patients. although many of the principles applied here can be generalised to those other instances. Broad consistency with British Thoracic Society guidelines Meeting the recommendations of the National Patient Safety Agency in the clinical management of patients receiving oxygen therapy • This is a clinical policy and does not relate to the infrastructure of providing oxygen which is managed in accordance with Health Technical Memoranda HTM02 as described in the Trust Medical Gas Pipeline Systems operational policy 3. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the Healthcare Professional’s role. This policy and guidelines document relates to oxygen given within hospital and not domiciliary oxygen. 2. Failure to administer oxygen appropriately can result in serious harm to the patient. 2008).. However oxygen should be regarded as a drug (British National Formulary. The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. Purpose of this policy Maintaining best practice and high quality patient care The purpose of this policy is to ensure that high quality care is delivered to patients with regard to the administration of oxygen to and the appropriate monitoring of patients receiving oxygen.: Status: V2 . The purpose of the policy and guideline is: • To maintain a standard of care that is consistent with current best practice.burst.

The system of prescribing target saturation aims to achieve a specified outcome.1 Medical staff and non-medical prescribers To ensure that oxygen therapy is safely and appropriately used without unnecessary risk to patients. • Oxygen will be prescribed according to a target saturation range. Responsibilities All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. • In a medical emergency high concentration oxygen is administered by staff who are trained in its use. This policy and guideline does include the control of oxygen cylinders ensuring that adequate availability of medical gas cylinders is maintained. 4. Thorax. unless local guidelines dictate otherwise. This policy applies to all members of staff who are involved in any aspect of the development and use of procedure development. Key organisational duties are identified as follows: 5. 5. and that the patient receives expert review immediately. • Those who administer oxygen therapy will monitor the patient and keep within the target saturation range. Aims and Objectives of this policy The aim of this guideline is to ensure that: • All patients who require supplementary oxygen therapy receive therapy that is appropriate to their clinical condition and in line with national guidance (BTS Guideline.: Status: V2 . particularly children over eight years of age. 2008). rather than specifying the oxygen delivery method alone. This is achieved by: • Ensuring that oxygen therapy is prescribed (on the Medicines Administration Record (See Appendix 9). Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 5 of 33 Ref.Short burst oxygen therapy is that provided at home or in hospital for administration for a few minutes to support patients who have hypoxia related breathlessness related to chronic lung pathology or to support patients having severe cluster headaches. The policy and guideline is applicable to adults only. • Ensuring that oxygen therapy is routinely reviewed and incorporated into clinical management plans. • Ensuring that oxygen target saturation ranges are identified for each patient on admission to hospital (on the vital signs assessment chart). but many of the principles here apply to children’s care.

• Contribution to the training and education of staff who use oxygen therapy in their clinical practice. • Ensuring that high concentration oxygen is appropriately administered to patients in the event of a medical emergency and whilst medical help is being sought. (This may be necessary in the absence of a prescription or medical instruction for the administration of oxygen).3 Critical Care Outreach / Medical Nurse Practitioners / Night Nurse Practitioners To ensure that oxygen therapy is safely and appropriately used without unnecessary risk to patients. • Ensuring that patients on oxygen therapy receive observations of vital signs that are appropriate to their clinical needs. This is achieved by: • Providing support to ward staff in the selection.5 Critical Care Outreach / Clinical educators / Clinical Skills Trainers To facilitate the training of all staff . Some specialist areas will provide logistical support for particular items required for oxygen therapy that may not be available locally and are not routinely used. • Ensuring that patients receiving oxygen have the dose adjusted to meet the prescribed oxygen target saturation range. setting up and delivery of appropriate oxygen therapy.5. This is achieved by: • Checking the oxygen prescription and delivery system on every drug administration round and ensuring that the Medicines Administration Record (“drug chart”) for each patient receiving oxygen is completed. • Ensuring that oxygen delivery is managed in a way that is appropriate to the clinical needs of the patient. Maintain logistics function in storage and supply of materials for a range of oxygen delivery systems (Appendix 2 provides a list of required oxygen and humidification equipment for ward use).2 Nursing staff To ensure that oxygen therapy is safely and appropriately used without unnecessary risk to patients.: Status: V2 .4 • • • • Ward managers / Clinical support staff To ensure that appropriate equipment for the administration of oxygen is available for use in all general wards and clinical areas. 5.in the selection and use of an appropriate range of equipment for the administration of oxygen for use in all general wards and clinical areas. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 6 of 33 Ref. To ensure that availability of pulse oximeters is consistent with the demand for their use. 5. • Review of patients who are profoundly hypoxic when asked to do so by ward staff. Ward managers should ensure that all staff who are directly involved with the handling and administration of oxygen equipment in use have attended medical gas training 5.

All incident reports relating to oxygen therapy will be reviewed by the Medicines Advisory Group (MAG). in order to identify themes and trends and propose appropriate risk reduction measures to prevent reoccurrence and improve patient safety.: Status: V2 .• • • Teaching the use of high concentration oxygen in clinical emergencies. Teaching staff who use oxygen therapy equipment how to select and use it safely and appropriately Contributing to the maintenance of training records. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 7 of 33 Ref. at least quarterly. Monitoring Compliance The use of medical equipment relating to oxygen therapy will be monitored as identified within the medical Equipment policy. 6.

B exceptions-emergency situations The prescription will refer to a target saturation range that will be identified by the clinician prescribing the oxygen in accordance with the Trust's oxygen guideline Certain groups of patients require different target ranges for their oxygen saturation. of the target range change of position.g.7. Certain groups of patients are at risk of hyperoxaemia. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 8 of 33 Ref. deep breathing and coughing or other clinical instruction should be considered before adjusting oxygen therapy. Summary Oxygen Administration protocol RATIONALE Oxygen should be regarded as a drug and should be prescribed. be recorded on the vital signs chart and care plan Oxygen saturations must always be To identify early signs of clinical deterioration. British National Formulary (2010). ACTION All patients requiring oxygen therapy will have a prescription for oxygen therapy recorded on the patients drug prescription chart. All patients should have their oxygen saturation observed for at least five minutes after starting oxygen therapy. elevated respiratory rate. BTS National guidelines (2008). particularly patients with COPD. To provide an accurate record and allow trends The oxygen delivery device and oxygen flow rate (or oxygen percentage delivered) should in oxygen therapy and saturation levels to be identified. status incorporating the Early Warning Score. Oxygen saturations are not a component of the EWS. interpreted alongside the patient’s clinical e. If a patient is receiving intermittent therapy they may be monitored at least 8 hourly. 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. This includes patients who have had recent Myocardial Infarction (MI) or stroke The drug chart should be signed at every drug To ensure that the patient is receiving oxygen if round prescribed and to consider weaning and discontinuation in consultation with parent medical team To identify if oxygen therapy is maintaining the Once oxygen is in situ the nurse will monitor target saturation or if an increase or decrease observations in line with the Policy and Guidelines for Vital Signs Assessment (VSA) in oxygen therapy is required and the use of Early Warning Scoring (EWS) in Adults. N. If the patient’s oxygen saturation falls outside To maintain the saturation in the desired range.: Status: V2 .

once clinical condition allows • A change in delivery device (without an increase in O2 therapy) does not require review by the medical team.Saturation higher than target specified or >98% for an extended period of time. To assess the patients response to oxygen increase.: Status: V2 .g. The patients clinical condition may have improved negating the need for supplementary oxygen In most instances a fall in oxygen saturation is due to deterioration of the patient however equipment faults should be checked for (including water traps) Note that with some very sick patients pulse oximetry may not be possible. Saturation within target specified Continue with oxygen therapy. (The change may be made in stable patients due to patient preference or comfort). pneumonia. Some patients may experience transient mucus plugging leading to hypoxia which can be improved by manoeuvres other than simply increasing oxygen concentration. and monitor patient to identify appropriate time for stepping down therapy.g. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 9 of 33 Ref. • Ensure that pulse oximetry signal is reliable and accurate. Many of these patients are likely to be managed as a medical emergency. and ensure that PaCO2 has not risen to an unacceptable level. physiotherapy or encouraged cough may be required before oxygen delivery is increased The patient will require weaning down from current oxygen delivery system. heart failure etc). Oxygen delivery methods The oxygen escalator should be used to identify a suitable method for oxygen delivery Humidification needs must be assessed regularly in keeping with individual needs and at least every 24 hours. or pH dropped to an unacceptable level and to screen for the cause of deteriorating oxygen level (e. • Step down oxygen therapy as per guidance for delivery • Consider discontinuation of oxygen therapy Saturation lower than target specified • Check all elements of oxygen delivery system for faults or errors. • Step up oxygen therapy as per oxygen escalator (Appendix 3) Any sudden fall in oxygen saturation should lead to clinical evaluation and in most cases measurement of blood gases • Monitor EWS and respiratory rate for further clinical signs of deterioration • Other instructions relating to position change. The oxygen delivery device needs to be matched to an individuals clinical needs e. humidification.

• The groups of conditions which patients who may have hypoxic drive are: Chronic hypoxic lung disease • Chronic Obstructive Pulmonary Disease (COPD) • Severe Chronic Asthma • Bronchiectasis / Cystic fibrosis Chest wall disease • Kyphoscoliosis • Thoracoplasty Neuromuscular disease Obesity hypoventilation For patients with these conditions a target oxygen saturation range of 88-92% is recommended. 8. National Collaborating Centre for Chronic Conditions (2008). Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 10 of 33 Ref. For most other conditions a target saturation range of 94-98% is recommended. a different target saturation range may be appropriate. It is not routine to aim for target saturations of 100% (The implication of doing so is that most patients will receive too much oxygen). There are rare clinical indications where a higher saturation target saturation is required e. Prescribing. The need for supplemental oxygen therapy should form part of the management plan for a patient and be documented in the plan along with the appropriate target saturation range. and are not in the process of immediate resuscitation.1 Identifying appropriate target saturations Oxygen should be prescribed to achieve a target saturation of 94-98% for most acutely unwell patients or 88-92% for those at risk of hypercapnic respiratory failure (Appendices 4 and 9) Hypoxic drive refers to the stimulus to breathe for some patients being the lack of oxygen.: Status: V2 . For patients who do rely on hypoxic drive as their stimulus to breathe. overoxygenation can have severe and potentially fatal outcomes. In the absence of conditions that may cause hypoxic drive normal BTS target saturations are currently recommended with the lower end of the target saturation range desirable. administering and monitoring oxygen 8. Weston (2010). Wijesinghe (2009). For patients who have had a myocardial infarction or a stroke.2 Indicating oxygen target saturation range on the Vital Signs Chart An oxygen section on the vital signs chart has been designed to assist administration of oxygen (Appendix 5). Supplemental oxygen is not recommended unless the patient is hypoxic (saturations less than 95%).8.g. carbon monoxide poisoning.

Patients with noisy or laboured breathing or respiratory rate of less than 8 or more than 25 should be reported immediately to the duty doctor. All staff who are directly involved with the handling and administration of oxygen equipment in use must attend medical gas training. 8. Do not stop oxygen therapy in order to carry out blood gas sampling. usually in consultation with parent medical team). Oxygen administration must not be delayed and needs to be instituted as soon as it is clinically indicated. Oxygen therapy should be increased if the saturation is below the desired range and decreased if the saturation is above the desired range (and eventually discontinued as the patient recovers.3 Personnel who may administer oxygen Once the target saturation has been identified and prescribed. or other professional or nonprofessional staff who have received training in the use of oxygen and been deemed competent within their normal area of working can administer oxygen therapy according to these guidelines. unless it is part of a documented plan for patients under the direct care of respiratory physicians. doctor. Patients should be monitored accurately for signs of improvement or deterioration. Nurses should also monitor skin colour for peripheral or central cyanosis and respiratory rate. Any registered nurse. guidance regarding the most appropriate delivery system to reach and maintain the prescribed saturation is provided for those administering oxygen in Appendix 6.4 Monitoring and recording oxygen The patient's oxygen saturation and oxygen delivery system should be recorded on the vital signs chart alongside other physiological variables. measurement of blood gases. Critically ill patients should have their oxygen saturations monitored continuously and recorded with a frequency appropriate to their physiological condition. All recordings of oxygen saturation should be associated with respiratory rate recording at the same time (NCEPOD. Patients with mild breathlessness due to a stable condition will need less frequent monitoring. or physiotherapist. All patients receiving oxygen therapy should have regular pulse oximetry measurements. Any sudden fall in oxygen saturation should lead to clinical evaluation of the patient and in most cases.The frequency of oximetry measurements will depend on the condition being treated and the stability of the patient. 2005).: Status: V2 . regardless of oxygen saturations. A baseline blood gas should be taken for all patients with oxygen saturation on air of below 94%.8. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 11 of 33 Ref.

Oxygen should be given to the patient immediately without a formal prescription or drug order but documented later in the patient’s clinical record. Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients pending the results of urgent blood gas results after which these patients may need oxygen therapy set to appropriate target oxygen saturation range as part of their continuing medical management plan. Medical.8. nocturnal or short-burst) where specific individual instructions for oxygenation and target saturation range may be required. Some non-professional staff who have received specific training may also commence oxygen in a medical emergency. Patients admitted to critical care unit (intensive and high dependency care). If the patient has severe hypoxaemia and / or hypercapnia with respiratory acidosis then non-invasive ventilation with closely regulated and monitored oxygen therapy may be required.5 Emergency situations In an emergency situation an oxygen prescription is not required. 8. All peri-arrest patients and patients who acutely become critically ill. nursing and allied health professional students can commence oxygen therapy in an emergency under supervision. allied health professional or doctor can commence oxygen therapy in an emergency. A subsequent written record must be made of what oxygen therapy has been given to every patient along with the recording of all other emergency treatment.6 Exclusions to targeted oxygen saturation range prescription. the prescriber should write ‘target saturations not indicated’ in the text section of the vital signs chart and cross through the oxygen prescription area of the chart (Note vital signs are no longer recorded for a patient on an end of life pathway). monitoring and delivery of oxygen Patients receiving oxygen as part of the management of a medical emergency (until a definitive management plan which includes oxygenation is produced). Patients admitted who are normally on long term oxygen therapy (continuous. Patients receiving oxygen as part of palliative care or patients on the end of life care pathway (in which case. All patients who have had a cardiac or respiratory arrest should have high concentration oxygen provided along with basic or advanced life support. Operating theatres or PACU where specific oxygen instructions are provided by intensivists / anaesthetists. Any registered nurse. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 12 of 33 Ref.: Status: V2 . should be given high concentration oxygen (15 litres per minute via a reservoir bag mask) whilst awaiting immediate medical review.

and thus prevention of potentially irreversible damage to vital organs. There are several factors which lead to the rise in CO2 with oxygen therapy in patients with hypercapnic respiratory failure (Appendix 4). 8. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 13 of 33 Ref. or type of haemoglobin (for example acute gastro-intestinal blood loss or carbon monoxide poisoning.1 Oxygen administration and carbon dioxide retention In patients with chronic carbon dioxide retention. caused by hypoxaemia (low PaO2). but only if associated with hypoxaemia (abnormally high levels may be harmful to patients with ischaemic heart disease and stroke). heart failure. sickle cell crisis). oxygen administration may cause further increases in carbon dioxide and respiratory acidosis.7 Specialist areas This policy is for general use within general wards and departments and for transfer between departments. if there is a clinical indication for ongoing oxygen therapy. asthma. neuromuscular disorders. Therefore the most common reasons for oxygen therapy to be initiated are: Acute hypoxaemia (for example pneumonia. Pneumocephalus – high flow oxygen may increase the resolution of pneumocephalus in patients with a basal skull fracture (Note: Mask Continuous Positive Airway Pressure [ CPAP] is contra-indicated) Post operative state – general anaesthesia can lead to decrease in functional residual capacity with in the lungs (especially following thoracic orabdominal surgery) resulting in hypoxaemia (Ferguson 1999).8. This may occur in patients with COPD.: Status: V2 . Abnormalities in quantity. morbid obesity or musculoskeletal disorders.9 Contra-indications There are no absolute contraindications to oxygen therapy in hospital if indications are judged to be present. pulmonary embolus) Ischaemia (for example myocardial infarction. Supplemental O2 should be administered with caution in patients suffering from paraquat poisoning (BNF 2010) and with acid inhalation or previous bleomycin lung injury. There is some evidence to suggest a decreased incidence of post-operative wound infections with short-term oxygen therapy following bowel surgery.8 Indications The rationale for oxygen therapy is prevention of cellular hypoxia. The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest possible FiO2. 9. Patients transferring from specialist areas must be transferred with a prescription for their oxygen therapy based on target saturation range. Other indications include: Pneumothorax – oxygen may increase the rate of resolution of pneumothorax in patients for whom a chest drain is not indicated. Cautions 9. 8. shock.

which should occur as soon as possible. If a patient transfers from an area not utilising the target saturation system their oxygen should be administered as per the transferring areas prescription until the patient is reviewed and transferred over to the target saturation scheme. supply should be provided from a wall outlet rather than a cylinder if a patient is required to wait in a particular area for treatment investigation.: Status: V2 . then oxygen saturation should be checked for five minutes before transfer is made. If this does not occur. 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. Cylinders should only be used if there is no piped oxygen available. As a general principle for patients being transferred on oxygen therapy. clear instructions must be provided for personnel involved in the transfer of the patient. Patients being transferred on oxygen therapy must have their oxygen requirement calculated and a check made to ensure that sufficient oxygen is available for the transfer. its suitability and effectiveness must be checked with pulse oximetry before transfer. Patients with unstable respiratory condition may require a longer period of monitoring before transfer Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 14 of 33 Ref.9.Transfer and transportation of patients receiving oxygen Patients who are transferred from one area to another must have clear documentation of their ongoing oxygen requirements and documentation of their oxygen saturation. 10.2 • • • • • • Other precautions/Hazards/Complications of oxygen therapy Drying of nasal and pharyngeal mucosa Oxygen toxicity Absorption atelectasis Skin irritation Fire hazard Potentially inadequate flow resulting in lower FiO2 than intended due to high inspiratory demand or inappropriate oxygen delivery device or equipment faults. If a patient is transferred on a different oxygen delivery system from that which was being used in the ward or department. Recommended target saturation range should be prescribed before transfer. If the oxygen delivery device is changed for transfer. which must include delivery device and flow rate and recommended target oxygen saturation range.

All patients requiring 35% . If necessary. Peri-operative and immediately post-operatively The usual procedure for prescribing oxygen therapy in these areas should be adhered to. it should be prescribed using the target saturation scheme. If a patient is transferred to the ward. Where for example a patient is receiving oxygen via a reservoir bag mask at 15 litres a minute and remains hypoxic. Patients receiving oxygen via Aquapak. Ref.98% when awake.6 litres/minute and should receive continuous pulse oximetry for at least the duration of the nebuliser treatment.50% oxygen therapy should have their nebulised therapy driven by oxygen at a flow rate of 4 . The nebuliser should be driven by air or oxygen as appropriate. 13. it should be driven by compressed air. using a suitable target saturation range. Delivery of nebuliser using a mouthpiece along with a reservoir bag mask may be possible. if oxygen therapy is to be continued. critical care outreach or Night Nurse Practitioner. supplementary oxygen should be given concurrently by nasal prongs at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other specified target range. Pulse oximetry should be used for the first five minutes of any addition of a nebuliser. The driving gas should be oxygen or air (compressor or wall supply) according to the level of hypoxia of the patient and the patient’s oxygen requirement. or high flow venturi at greater than 40% or high-flow should have a nebulised drug administered using a T piece added to the circuit. 12. Such help may be sought from the medical team. If a patient is requiring oxygen via a reservoir bag mask and needs a nebuliser the nebulised drug may be given using a nebuliser and mouthpiece in addition to the high concentration oxygen. help my be required to administer prescribed nebulised drug treatment.: Status: V2 Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 15 of 33 . Expert help may be required for profoundly hypoxic patients. Nebulised therapy and oxygen When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure.For specific guidelines for transferring a patient who requires high flow oxygen see the Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults 11. as this constitutes a change in oxygen delivery. Normal Oxygen saturations • In adults less than 70 years of age at rest at sea level 96% .

especially “neck-breathing patients” and those who have difficulty in clearing airway secretions or mucus (See Appendix 7). All staff administering oxygen need to understand the use of oxygen administration systems and be trained in the use of the oxygen equipment being used.nhs. 14. via tracheal tube) Humidification is not routinely required for non-invasively ventilated patient. Staff prescribing oxygen therapy should have received training in the possible causes of hypoxic drive and identification of safe and appropriate target saturation range.uk/development/mandatory/documents/matrix_roles.ruhDocument name: Oxygen therapy administration Policy and Guidelines Issue date: Page 16 of 33 Ref. available on the intranet at http://webserver.• • Adults aged 70 and above at rest at sea level greater than 94% when awake. the method of delivery and frequency of the training. Humidification Humidification may be required for some patient groups. Humidification is not routinely required in the Emergency Department unless there is a delayed transfer beyond four hours. Patients of all ages may have transient dips of saturation to 84% during sleep. Training All health care professionals administering oxygen therapy should must attend medical gas training. The Mandatory Training policy identifies how training non-attendance will be followed up and managed and is available on the intranet at http://webserver. The Mandatory Training Matrix identifies when training needs to be undertaken. to identify what training in relation to administering oxygen is relevant for their role. Staff must refer to the Mandatory Training Matrix.: Status: V2 . • If the flow rate exceeds 4 litres per minute for several days where nasal cannulae or Hudson mask are used • Tracheostomy or laryngectomy patients (“neck-breathing patients)” (heated humidification required for minimum 36 hours for fresh tracheostomies or laryngectomies (See Tracheostomy policy) • Cystic Fibrosis patients • Bronchiectasis patients • Patients with a chest infection retaining secretions • Patients ventilated invasively (i.ruhbath. Expert help should be sought as use of humidification can influence ventilator efficiency or safety.xlsi. 15.swest.e.

greases and creams should not be used on oxygen cylinders or equipment connections as there is a risk of explosion and fire if they come into contact with oxygen. 17. unless the breathing circuit is a completely sealed one. Potential for injury exists if care is not taken. “Medical Cylinder Data”.swest. Therefore there is potential for injury. Connexion and disconnexion of Schräder valves must be done with firm grip of equipment to avoid accidental pressure forcing tubing to propel away from the valve port.uk/staff_resources/governance/policies/documents/non_clinical_polic ies/black_hr/HR_148_Mandatory_training_policy. (http://bnf. Appropriate manual handling techniques should be employed Oxygen cylinders should be well secured when used.bath. (2005). All staff should have appropriate training that is appropriate for their role in oxygen use. Last accessed 4th November 2010) British Oxygen Corporation (2005).pdf 16. BMA and RPS Publishing Group. Oils. Oxygen cylinder regulators should not be changed in patient clinical areas. This includes electric hair dryers. “An Acute Problem”.: Status: V2 . References and Further Reading British National Formulary (2010). No sources of ignition should be used near oxygen ports (in use or not) unless there has been a risk assessment. All gas supply wall outlets or terminal units (including oxygen) must be appropriately labelled. particularly for the transport of patients. Health and Safety Issues Oxygen supports combustion and may be stored under high pressures.org.nhs. Oxygen delivery systems should be disconnected from patients and held away during emergency defibrillation. Oxygen cylinders are heavy. BOC National Committee of Enquiry into Patient Outcome and Death. NCEPOD Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 17 of 33 Ref.

The Cochrane Library 2010 (16 June). (2008) “BTS guideline for emergency oxygen use in adult patients. Rapid Response report – from reporting to learning NPSA/2009/RRR006 O’Driscoll B. 18.org.uk/clinicalinformation/emergency-oxygen/emergency-oxygen-use-in-adult-patients. 63: Supplement VI. prospective. blinded-endpoint study to assess whether routine oxygen treatment in the first 72 hours after a stroke improves long-term outcome” Weston C. Weatherall M. (2010).thecochranelibrary.” Heart 95(3):198–202.” Thorax.com/details/editorial/742329/Oxygen-therapy-inacute-myocardial-infarction--too-much-of-a-good-thing--by-Dr-C. “Oxygen therapy in acute myocardial infarction – too much of a good thing?” [editorial]. http://www.: Status: V2 . open. Acknowledgements The appendix on humidification was produced by Kerry Joyce. Perrin K. and Gail Jones (Physiotherapists at the Royal United Hospital as well as the author) Consent for use of photographs from Louise Barton and Lauren Hunt Some photographs borrowed from BTS guideline online materials The example of local oxygen policy from http://www. (2009). Davison A. Ranchord A. Beasley R.brit-thoracic.National Patient Safety Agency (2009). Simmonds M. Howard L. “Routine use of oxygen in the treatment of myocardial infarction: systematic review.aspx was used as a basis for this guideline. “Oxygen Safety in Hospitals”. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 18 of 33 Ref. randomised.html (accessed 4 November 2010). Stroke Oxygen Study (unpublished) Protocol summary: “A multi-centre. Wijesinghe M.

Ward Manager Respiratory Ward Mark Mallett. Medical Director Robin Fackrell. Consultant intensivist Kim Gupta. Acute Care Consultant Geoff Allen Julie Blackman. Consultant. Respiratory Nurse Specialist Antoni Salamon. Acute Care Consultant Alison Harries. Ward Manager MAU Alexandra Lucas. Principal Pharmacist Andy House. Respiratory Ward Issy Wyber. Older Persons Unit Helen Jeffcoat. Consultant Intensivist Kevin Roles. Clinical Skills training manager Medical Nurse Practitioners Tim Craft. Head of Estates Date Consulted 27th July 2010 27thJuly 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 27th July 2010 August 2010 27th July 2010 27th July 2010 November 2010 Name of Committee Critical Care Delivery Group Medicines Advisory Group Medical Gas Committee Operational Governance Committee Clinical Governance Committee Date of Committee 27th July 2010 27th July 2010 December 2010 Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 19 of 33 Ref. Ward Manager SAU Judith Rollason. Respiratory Nurse Specialist Mark Grover. Director of Nursing Resuscitation / Clinical skills team Jerry Nolan. Nurse Consultant Stroke Regina Brophy.: Status: V2 . Philip Kaye. Consultant ED Dominic Williamson. Claire Fullbrook-Scanlon. Pharmacist Susie Slade. Consultant Intensivist Critical Care Outreach nurses Band seven nurses (Critical Care) Consultant Physicians. Consultant ED Night Nurse Practitioners Andrew Padkin. Consultant ED Gerrit Van Rensberg. Surgical Nurse Practitioner Clare Taylor.Appendix 1: Consultation Schedule Name and Title of Individual Francesca Thompson.

: Status: V2 . Where there are long term requirements for some equipment temporary stock for individual wards may be required. Disposable equipment Hudson masks (simple masks) Nasal cannulas Reservoir Bag Masks Aerosol masks Aerosol tubing 7mm Green bubble tubing Venturi valves 24% Venturi valves 28% Venturi valves 35% Venturi valves 40% Nebulisers Nebuliser T pieces Nebuliser mouthpieces Aquapak water (500 and 1000 mls) Aquapak venturi connectors High Flow and Continuous Positive Airway Pressure (CPAP) equipment High flow and CPAP equipment is not for routine use on general wards. Outside specialist areas it should only be used as a bridge to transfer based on clinical need. with expert support.Appendix 2: Ward equipment list for oxygen masks and delivery systems All general wards where acutely unwell patients are admitted should have access to the following range of equipment (Stock levels need to be determined locally and where appropriate there should be sharing arrangements between wards to ensure that access to the following is possible). It may be obtained (with expertise) from the following areas or teams: • Critical Care Nursing Outreach (Bleep 7719) • Night Nurse Practitioners (Bleep 7428 or 7429) • Critical Care Unit (ITU & HDU) (Extension 5010) • Respiratory Ward (Extension 4405) • Medical Assessment Unit (Extension 1214) • Coronary Care Unit (Extension 5012) Tracheostomy masks and Aquapak heaters These may be obtained from the following areas or teams: • Critical Care Nursing Outreach (Bleep 7719) • Night Nurse Practitioners (Bleep 7428 or 7429) • Head and Neck Nurses (Bleep 7169) • Critical Care Unit (ITU & HDU) (Extension 5010) • Waterhouse Ward (Extension 4425) Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 20 of 33 Ref.

Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 21 of 33 Ref.: Status: V2 . NASAL CAN = nasal cannulae) Oxygen delivery systems deliver either a measure of oxygen in litres per minute or an oxygen concentration expressed as a percentage See Appendix 6 for more information about different types of oxygen delivery device.Appendix 3: Oxygen escalator (RBM = Reservoir bag mask.

patients with a significant smoking history. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 22 of 33 Ref.: Status: V2 .Appendix 4: Patients who may have hypoxic drive Patients who may have hypoxic drive and normally require oxygen titrated to an oxygen saturation target range of 88 – 92% are people with the following conditions: • • • • • • • • • Chronic hypoxic lung disease COPD Severe Chronic Asthma Bronchiectasis / Cystic Fibrosis Chest wall disease Kyphoscoliosis Thoracoplasty Neuromuscular disease Obesity hypoventilation Consider also.

Appendix 5: Adult vital signs chart – target saturation range Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 23 of 33 Ref.: Status: V2 .

No humidification is required or should be added. e. eat. the percentage of oxygen delivered may be much reduced. and is inappropriate for continued use in a patient with a lung disease. These deliver a low to moderate concentration of oxygen. wear glasses and read without too much difficulty. If a patient has a blocked nose. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 24 of 33 Ref.g. Mouth breathers will get less oxygen support than patients who are breathing at least in part through their nose. It is not recommended for sustained use.: Status: V2 . Hudson mask (also known as simple oxygen mask) This is a plastic mask with several small vent holes on each side.40%%. It is used for short burst oxygen therapy. so the oxygen given is recorded in litres per minute. They are widely used for people who cannot (or will not) tolerate a mask. It is suitable for use overnight for a post-operative patient with no complicating lung disease. and can be used to deliver oxygen up to 5 litres per minute. It is a variable performance mask which is generally used with 3 to 5 litres of oxygen per minute where it will deliver up to 35 . It is attached to the oxygen supply using 7 mm oxygen tubing. a patient who s prescribed oxygen for a few minutes after exertion to ease hypoxic breathlessness in chronic lung disease. They should be used with caution if the patient is confused and should not be used for patients emerging from anaesthesia due to the risk of strangulation.Appendix 6: Oxygen administration devices (expanded oxygen escalator) Nasal cannulae These are the most commonly used means of giving oxygen therapy as they are comfortable and well tolerated and allow patients to communicate. drink. If the flow is set too low (less than three litres per minute of oxygen) the mask may contribute to re-breathing which will allow a patient to retain carbon dioxide. They are described as a variable performance system which means that it is not possible to be precise about the exact concentration of oxygen given. This type of mask is generally used for patients emerging from anaesthesia and for a few hours post-operatively. or as an adjunct if the patient is too hypoxic on a mask alone.

This generates a rate of flow which may in some situations approach the patient’s peak inspiratory flow. the need for humidification is increased as the oxygen concentration increases and an Aquapak (which is an adjustable venturi system) is recommended. A venturi is a simple design of valve that uses oxygen supplied through a port which allows room air to be drawn in. Although there are venturi valves that can deliver 60% oxygen. and who are unable to manage with nasal cannulae. The mask is suitable for patients who require low to moderate oxygen concentration.: Status: V2 .Venturi mask In this Trust venturi masks are provided as a range of different venturi valves that are designed to fit onto a standard aerosol mask. Venturi valve rating and colour coding Valve rating Colour 24% Blue 28% White 35% Yellow 40% Red The green 60% venturi valve is not recommended for use as humidification is inadequate for a venturi valve of this rating. If a patient is tachypnoeic it is advisable to increase the flow rate above that indicated on the valve but note that this will not increase the oxygen concentration). Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 25 of 33 Ref. The advantage of this type of mask is that it delivers a precise percentage of oxygen at high rates (at least for low oxygen concentrations). On the side of each rating of venturi valve is printed or embossed the flow rate that is required to maintain the stated oxygen concentration (see below).

Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 26 of 33 Ref. this should not be used (it only exists because the company have not changed their manufacturing process in line with current good practice). This system is useful for controlled oxygen in a patient with the specific need for added moisture at low oxygen percentages (40% and less). Although Aquapak bottles do have a connector for 7mm oxygen (green bubble) tubing. The system is recommended for all patients requiring greater than 40% oxygen for more than three hours provided that good oxygen saturations can be maintained. but where a patient has low saturations these may be improved by increasing the flow of the oxygen above 10 litres.5 metres.: Status: V2 . It has a bottle of water that connects to the bottom of the device and it attaches to an oxygen flow meter to regulate the oxygen flow. The system is set by adjusting the oxygen flow rate and by rotating the adjustable collar on the device. (This does not mean that the inspired concentration is actually 98% because with Aquapak flow may not match demand). The system can deliver oxygen concentrations of up to 98%. It is possible to add an optional heater which turns this “cold-nebulised” system into a heated humidifier. This system uses an aerosol mask with 22mm aerosol (“Elephant”) tubing. This allows delivery of oxygen between 24% and 98% of oxygen into the aerosol tubing to the patient. Humidification is only achieved by using aerosol tubing and ensuring that its length is around 1.Aquapak This device is a disposable adjustable venturi valve which is used with aerosol tubing and an aerosol mask.

sputum retention. mucus plugging and desiccation of lung tissue).Above 80% oxygen concentration. If an aquapak is used for humidification and water traps are used to capture condensed water from the aerosol tubing between humidifier and patient. reduced ciliary action.e. In the immediate and acute situation the flow of gas can be titrated over whatever range (up to 15 litres) that is required to achieve a target saturation. A reservoir bag mask may improve oxygenation while this is being arranged. An alternative for longer-term use would be an Aquapak system or if that proves inadequate an adjustable venturi and high flow system. care must be taken to ensure that the trap is well positioned and emptied frequently. Reservoir bag mask This is a mask that is designed to provide high concentrations of oxygen for short periods.: Status: V2 . then oxygen via high flow circuit should be considered. If a patient remains so hypoxic that they still require this system after three hours. If it is allowed to overfill then intermittent or complete interruption of delivered oxygen is possible. if oxygen saturations cannot be maintained within the targeted range. At 15 litres per minute the system will deliver about 90% oxygen. then they need a medical review and a suitable treatment plan. This type of mask is a variable performance mask and should be used for no longer than three hours. at 10 litres per minute the system will deliver about 70% oxygen. Long term use leads to complications associated with dry lung tissue (i. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 27 of 33 Ref.

HIGH FLOW (ADJUSTABLE VENTURI) WITH HEATED WIRE HUMIDIFIER AND AEROSOL MASK Continuous Positive Airway Pressure by face mask Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 28 of 33 Ref.: Status: V2 . Coronary Care. Respiratory ward and the Medical Assessment Unit.High Flow Oxygen and Continuous Positive Airway Pressure (CPAP) This circuitry is not routinely available on general wards. as well as Critical Care (ITU & HDU). It is used in the Emergency Department. Critical Care Outreach will establish patients on high flow and provide support in its use on general wards or establish CPAP as a bridge to transfer to a more suitable clinical area.

Added humidification for non-invasive ventilators requires expert advice and care and is unlikely to be used in the ward setting. Humidification is not routinely used in the emergency department setting. even for mask CPAP. Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 29 of 33 Ref. Humidification is not routinely required for short burst CPAP which is usually managed by physiotherapists.Appendix 7: Humidification Humidification assessment Assessment No sputum No chest signs Comments Low or no oxygen requirement Target saturation range achieved with <40% oxygen or 4l (via nasal cannulae or Hudson mask) Comfortable respiratory pattern Respiratory rate less than 20 (or normal for that individual) Chest clear on auscultation Suggested humidification None required Loose sputum No increased oxygen requirement Loose sputum Increased oxygen requirement Chest signs Thick sputum No increased oxygen requirement Thick sputum Increased oxygen requirement Retained secretions With chest signs Increased work of breathing Probable increased oxygen requirement or at least a tendency to desaturate Increased respiratory rate None required Aquapak humidification Saline nebulisers Consider Aquapak humidification Aquapak Consider saline nebulisers Aquapak Saline nebulisers Consider humidifier heater for Aquapak Consider heated wire humidification Consider expert help JH July 2010 Note on humidification for Non-Invasive Ventilation and Continuous Positive Airway Pressure (CPAP) systems: For non-invasive ventilation. Bi-level Posiitve Airway Pressure (BiPAP) humidification is not routinely required as usually oxygen concentrations are not high and NIV machines use room air (which contains some moisture) and the upper respiratory tract is intact.: Status: V2 . but it will need to be instituted if therapy continues on the ward – usually the Medical Assessment Unit (MAU). Respiratory ward or the Coronary care Unit (CCU).

Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 30 of 33 Ref. Note: Oxygen prescription pre-printed on chart will be implemented in the future.: Status: V2 .Appendix 8: BOC Oxygen cylinder sizes and capacities Cylinder size AZ C AD CD DD PD RD D E AF DF F HX ZX G J Capacity in litres 170 170 400 460 460 300 460 340 680 1360 1360 1360 2300 3040 3400 6800 Appendix 9: Sample oxygen prescriptions If preferred the starting oxygen device and flow rate may be specified as an additional instruction.

the assessment is now complete 1. medium or low. Does the policy. what are these measures? No Policy and guidelines Julian Hunt Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 31 of 33 Ref. service. service strategy. procedure or function include measures which promote equality? 2. procedure or function aimed at? • Patients • Staff: involved in the administration of oxygen therapy to patients Are any of the following groups adversely affected by the policy? If yes is this high.g. If the answer is no to all categories. ethnicity & nationality No Low Male/Female/transgender: No Low Age. young or older people: No Low Sexual orientation: No Low Religion. Clinician): Person responsible for the assessment: Name: Julian Hunt Job Title: Consultant Nurse Is this a new or existing policy. procedure or function? New Who is the policy/service strategy. medium or low impact (see attached notes): Group Affected? Impact Disabled people: No Low Race. Manager. procedure or function: Lead (e. service strategy. strategy.: Status: V2 . This applies whether the impact assessment is high.Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval Initial Screening Policy. If yes. Director. belief and faith: No Low If the answer is yes to any of these proceed to full assessment.

Does the document include a training plan? Does the document include relevant references? Are up to date National Guidelines included? If you are the appropriate forum. have the necessary resources been agreed to implement this document? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed in the document? Other comments from meeting. What are the cost implications of implementing this document? Equipment Staffing (additional) Training Other £ £ £ £ Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No Yes / No Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Yes / No / N/A Are there any other department affected? Document endorsed without further comment? Further amendments to document suggested? Name of Chair: Carol Peden Signature: ____________________________________ Date: __________________ Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 32 of 33 Ref. Dear Chairman Please would you disseminate this document for comment at your next meeting and return any amendments/comments to: Julian Hunt. attach this to each copy of the policy being sent to a meeting for comment. please provide a contact name for the author. sustained (medium term) and emergency oxygen to adults in hospital Name of author: Julian Hunt Are there any elements of this policy which present operational issues that require further discussion? If yes.: Status: V2 .Consultation Checklist Author. Consultant Nurse Critical Care Title of meeting: Operational Governance Committee Date of meeting: Policy Title and Reference: Oxygen Policy and Guidelines: the administration of short burst.

Title of meeting: Date of meeting: Title and Reference of document: Oxygen Policy and Guidelines: the administration of short burst. sustained (medium term) and emergency oxygen to adults in hospital Name of author: Julian Hunt. please provide a contact name for the author. have the necessary resources been agreed to implement this document? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? What are the cost implications of implementing this policy? Equipment Staffing (additional) Training Other £ £ £ £ Yes No N/A Yes Yes Yes Yes Yes Yes No No No No No No N/A N/A N/A N/A N/A N/A Yes Yes Yes Yes Yes Yes No No No No No No N/A N/A N/A N/A Document endorsed without further comment? Further amendments to document suggested? Name of Chair: Michael Earp Signature: ________________________________ Date: ________________________ Document name: Oxygen therapy administration Policy and Guidelines Issue date: Page 33 of 33 Ref. Consultant Nurse Critical Care Clinical Governance Committee Are there any elements of this policy which present operational issues that require further discussion? If yes. attach this to each copy of the policy being sent to a Committee for final ratification.: Status: V2 . Does the document include a training plan? Is the policy referenced? Are up to date National Guidelines included? If you are the appropriate forum. Dear Chairman Please would you review this document at your next meeting and agree final approval and organisational ratification.Ratification Check List Author.

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