Audit of oxygen prescribing before and after the introduction of a prescription chart

Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'

Oxygen is a life-saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non-invasive ventilation and humidified high-flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.

The Oxygen project: a prospective study to assess the effectiveness of a targeted intervention to improve oxygen management in hospitalised patients

BACKGROUND

Oxygen is commonly used in the acute care setting. However, used inappropriately, oxygen therapy can result in adverse consequences, including progressive respiratory failure and death.

AIM

To investigate the effectiveness of a targeted intervention to improve prescribing practice and therapeutic application of supplemental oxygen.

METHODS

Respiratory, Oncology and Surgery wards were targeted for the intervention. Nursing and junior medical staff from these wards undertook an education programme about safe use of oxygen. Cross-sectional data about oxygen prescribing, administration and monitoring were collected on inpatients in these wards at baseline, and at 3 and 6 months post-intervention, using a modified version of the British Thoracic Society Oxygen Audit Tool.

RESULTS

At baseline, there was a written prescription for oxygen in 56% of patients (n = 43) using oxygen and this increased to 75% (n = 44) at 3 months, and remained at 65% (n = 48) at 6 months. However, the increased prescription rates were not statistically significant when compared to baseline (χ² = 3.54, df = 1, P = 0.06 and χ² = 0.73, df = 1, P = 0.40, respectively). The observed increase in oxygen prescriptions was driven by the medical wards: Oncology ward at 3 months (χ² = 8.24, df = 1, P = 0.004); and Respiratory ward at 3 months (χ² = 3.31, df = 1, P = 0.069) and 6 months (χ² = 4.98, df = 1, P = 0.026).

CONCLUSION

The education programme intervention to improve oxygen prescription showed promise in the medical wards but did not impact outcomes in the surgical ward setting, where different strategies may be needed.

Improvements and Shortcomings in Emergency Oxygen Prescribing: A Quality Improvement Initiative at an Acute Tertiary Care Hospital

Oxygen is one of the most commonly used yet poorly prescribed drugs. The 2015 British Thoracic Society (BTS) emergency oxygen audit highlighted the national shortcomings in oxygen prescribing and administration. A 2017 local audit at the Royal Sussex County Hospital, Brighton, UK, continued to demonstrate poor compliance with the BTS Oxygen Prescribing Guidelines in all areas audited. This study carried out yearly reaudits in November 2018 and 2019 to objectively measure the impact of implementing trust-wide and local interventions (July 2018 and August 2019).Intervention 1 included introduction of the National Early Warning Score (NEWS2) scale and redesigning drug charts with tick-boxes for target oxygen saturations. Intervention 2 included mandatory junior doctor teaching on safe oxygen prescribing, ‘oxygen safety’ posters on audited wards, and reminders at handover for staff to measure and document oxygen saturations.Following Intervention 1, all patients with valid oxygen prescriptions had a specified target saturations range. Intervention 2 ensured all patients had actual saturations within their prescribed target range, and 99% had oxygen saturations documented with sufficient frequency for their NEWS2 score. These were huge improvements from previous audits, during which a significant proportion of patients were at risk of hypercapnia, and those over- or underoxygenated were left unrecognised for hours. Despite improvements, 14% of patients continued to use oxygen without valid prescriptions in 2019, and drug charts were inconsistently signed for during drug rounds.Although the implemented changes enabled drastic improvements for patient safety and quality in oxygen use, future work should ensure oxygen is always treated as a drug with suitable prescription and documentation.

Impact of oxygen therapy algorithm on oxygen usage in the emergency department

BACKGROUND

Although oxygen is one of the oldest drugs available, it is still one of the most inappropriately administered drugs leading to over utilization of this very expensive resource.

MATERIALS AND METHODS

This prospective observational study was done in a large emergency department (ED) in India. The pattern of oxygen usage was studied before and after the strict implementation of an oxygen treatment algorithm. The algorithm was taught to all doctors and nurses and its implementation was monitored regularly. The main outcome measures were proportion of patients receiving oxygen therapy, inappropriate usage, and avoidable direct medical cost to the patient.

RESULTS

The 3-week pre-protocol observation phase in April 2016 included 3769 patients and the 3-week post-protocol observation phase in April 2017 included 4608 patients. The baseline demographic pattern was similar in both the pre-protocol and post-protocol groups. After the strict implementation of the algorithm, the number of patients receiving oxygen therapy decreased from 9.63% to 4.82%, a relative decrease of 51.4%. The average amount of total oxygen used decreased from 55.4 liters per person in pre-protocol group to 42.1 liters per person in the post-protocol group with a mean difference of 13.28 (95% CI 5.30-21.26; P = 0.001). Inappropriate oxygen usage decreased from 37.2% to 8.6%. There was a significant decrease in inappropriate oxygen use for indications like low sensorium (60.8% vs 21.7%) and trauma (88.5% vs 15.8%). The mortality rate in the pre-protocol phase was 2.7% as compared with 3.2% in the post-protocol phase. The total duration of inappropriate oxygen usage significantly decreased from 987 h to 89 h over the 21-day study period.

CONCLUSION

The implementation of an oxygen therapy algorithm significantly reduces inappropriate oxygen use and decreases treatment cost to the patient with no additional mortality risk.

Current practice of prescription and administration of oxygen therapy: An observational study at a single teaching hospital

Objectives

Oxygen therapy, commonly used clinically, should be administered according to the physician's prescription; however, accumulating evidence signals some degree of inaccuracy in this perspective. This study aimed to evaluate the current practice of prescription and administration of oxygen therapy.

Methods

This observational study was conducted at a teaching hospital in the Eastern province of KSA. All inpatients in general wards who were on supplemental oxygen (O₂) were included. Patient's demographic data and physician's prescription items were collected from patient medical charts and the respiratory care (RC) department charts. Oxygen administration to inpatients was monitored and matched with oxygen prescriptions recorded on the medical and RC charts.

Results

Among 152 inpatients, 21 were on supplemental O₂. Of these, 20 had written prescriptions in their medical charts, but only 18 had information recorded in the RC charts. Of the 5 items required by hospital guidelines for oxygen prescription, 30% of patients had 3 items; whereas 70% of patients had only 2 items. Mode of oxygen delivery was recommended in all physicians' prescriptions, but flow rate and FiO₂ were ordered in only 30% of prescriptions. Among the 6 patients with a written record of target SpO₂ range, 2 had a value outside of the target range and 2 of 6 patients had a flow rate that differed from the prescribed rate.

Conclusion

Current practice for oxygen therapy prescription and administration was suboptimal. Nation-wide investigations and remediations of oxygen therapy practice is needed to improve patient care.

Development and validation of a questionnaire to assess the doctors and nurses knowledge of acute oxygen therapy

Background

Prescription and administration of oxygen in emergencies by healthcare providers are reported to be inappropriate in most settings. There is a huge gap in the knowledge of health care providers on various aspects of oxygen therapy, and this may be a barrier to optimal oxygen administration. Hence, it is essential to ascertain providers’ knowledge of acute oxygen therapy so that appropriate educational interventions are instituted for better delivery. There is no available validated instrument to assess knowledge of acute oxygen therapy. The study aimed to develop, validate and evaluate the test-retest reliability of a questionnaire to determine the doctors and nurses understanding of acute oxygen therapy.

Methods

This study involved the development of the questionnaire contents by a literature review, assessment of face validity (n = 5), content validity, using a panel of experts (n = 10), item analysis and test-retest reliability among a sample (n = 121) of doctors and nurses.

Results

Face validity indicated that the questionnaire was quick to complete (10–15 min), most items were easy to follow and comprehensible. The global content validity index (S-CVI) was 0.85. The test-retest reliability statistics showed a kappa coefficient of 0.546–0.897 (all P<0.001) and percentage agreement of 80–98.3% indicating high temporal stability in the target population. In total, 90% of the items fulfilled the reliability acceptance criteria. Item discrimination analysis showed that most questions were at an acceptable level. The final questionnaire included 37 item questions and eight sections.

Conclusion

The designed questionnaire is a reliable and valid tool for assessing knowledge of acute oxygen therapy among doctors and nurses.

Can we improve the prescribing and delivery of oxygen on a respiratory ward in accordance with new British Thoracic Society oxygen guidelines?

The British Thoracic Society recommends oxygen delivery to achieve target oxygen saturation range between 94% and 98% for medically unwell adult patients, and 88% to 92% in patients at risk of hypercapnic respiratory failure. Interviews with our medical and nursing staff suggested that oxygen was sometimes being given to patients without a valid order and there was a failure to titrate oxygen to the stated oxygen saturation range. Our aim was to improve appropriate oxygen delivery to 90% of our patients on a 30-bedded respiratory ward within 3 months. We identified several key steps to safe oxygen delivery on our ward. These include the recording of target oxygen saturation range, the prescribing of an oxygen order on drug chart and the correct bedside delivery of oxygen to the patient. To help improve compliance of these key steps, the following plan-do-study-act (PDSA) interventions were undertaken: (1) Educational announcements at board rounds. (2) A communication oxygen poster. (3) Highlighting improvement progress to teams via email. (4) Pharmacist review of inpatient drug chart. (5) Display of target oxygen saturation range at patient bedside. At baseline, only 50% of drug charts had a recorded oxygen order and 60% of drug charts had a set target oxygen saturation range. Following PDSA interventions, both measures improved to 93%. Our main outcome measure of appropriate oxygen delivery to the patient improved from a baseline of 20% to 80% on completion. Our quality improvement programme has shown simple interventions can improve oxygen prescribing and appropriate delivery of oxygen to the patient. The most effective PDSA interventions were sharing our measurements via email and displaying target oxygen saturation ranges by the patient bedside. We aim to provide future oxygen educational sessions at induction to our staff and scale our quality improvement programme to other wards including our acute medical unit.

Familiarity of Physicians and Nurses with Different Aspects of Oxygen Therapy; a Brief Report

INTRODUCTION

Oxygen is a drug and physician and nurses should be familiar with the effects and potential risks of oxygen therapy. The current study aimed to assess familiarity of physicians and nurses with various aspects of oxygen therapy.

METHOD

In this cross sectional study, the familiarity of physicians and nurses with various aspects of oxygen therapy in a teaching hospital was evaluated using a validated questionnaire. The collected data were analyzed using SPSS 21 software.

RESULTS

57 physicians and 79 nurses returned the completed questionnaire (response rate 97.1%). Mean clinical work experience of participants was 6.9±5.7 (1-15) years. 98.2% of physicians believed that oxygen therapy can be associated with risk and should be recorded in the patient's medical file. These measures were 92.4% and 98.2% for nurses. 38 (27.9%) participants correctly pointed out the reasons for oxygen therapy. Regarding necessary measurements and monitoring for oxygen therapy, 49 (86%) physicians and 65 (82.3%) nurses chose the correct answer. In addition, regarding necessity of blood gas analysis during oxygen therapy, 44 (77.2%) physicians and 55 (69.6%) nurses chose the correct answer.

CONCLUSION

The findings showed that the familiarity level of participants with some aspects of O₂ therapy such as its indications, necessary measurements and monitoring during therapy, and identifying delivery devices was fair to weak (<80%).

[Assessment of physicians' and nurses' knowledge and practices of aerosol therapy]

INTRODUCTION

Aerosol therapy is an efficient, but complex procedure. National and international practice guidelines are regularly updated. However, only a few studies have assessed the application of guidelines by users. The aim of this study is to assess the knowledge and practices of physicians and nurses regarding these guidelines.

METHODS

Two self-administered questionnaires were designed by a working team and presented to physicians and nurses of four university hospitals in Paris. A pharmacy resident collected and analyzed the data with the aid of an online survey website.

RESULTS

A total of 481 physicians and nurses completed the questionnaires (33 % of physicians and 67 % of nurses). Only 241/480 physicians and nurses (50 %) knew that several intravenous drugs cannot be nebulized. Ninety-four of 422 (22 %) of them always choose oxygen as the driving gas and 239/311 nurses (77 %) think that single use nebulizers can be re-used for the same patient.

CONCLUSIONS

This survey shows that many physicians and nurses lack knowledge and use inappropriate practices. Based on these results, a booklet has been designed by the working team. This booklet should help health professionals to harmonize practices across hospitals and to follow the guidelines correctly.

Acute oxygen therapy: a review of prescribing and delivery practices

Oxygen is a commonly used drug in the clinical setting and like other drugs its use must be considered carefully. This is particularly true for those patients who are at risk of type II respiratory failure in whom the risk of hypercapnia is well established. In recent times, several international bodies have advocated for the prescription of oxygen therapy in an attempt to reduce this risk in vulnerable patient groups. Despite this guidance, published data have demonstrated that there has been poor uptake of these recommendations. Multiple interventions have been tested to improve concordance, and while some of these interventions show promise, the sustainability of these interventions are less convincing. In this review, we summarize data that have been published on the prevalence of oxygen prescription and the accurate and appropriate administration of this drug therapy. We also identify strategies that have shown promise in facilitating changes to oxygen prescription and delivery practice. There is a clear need to investigate the barriers, facilitators, and attitudes of clinicians in relation to the prescription of oxygen therapy in acute care. Interventions based on these findings then need to be designed and tested to facilitate the application of evidence-based guidelines to support sustained changes in practice, and ultimately improve patient care.

Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'

The purpose of the Thoracic Society of Australia and New Zealand guidelines is to provide simple, practical evidence-based recommendations for the acute use of oxygen in adults in clinical practice. The intended users are all health professionals responsible for the administration and/or monitoring of oxygen therapy in the management of acute medical patients in the community and hospital settings (excluding perioperative and intensive care patients), those responsible for the training of such health professionals, and both public and private health care organizations that deliver oxygen therapy.

A new oxygen prescription produces real improvements in therapeutic oxygen use

In the UK, safe use and administration of oxygen therapy was unsatisfactory prior to the implementation of national guidelines in 2008. Each year since then the British Thoracic Society (BTS) has conducted a national audit that has demonstrated a slow but steady improvement in oxygen use across four key standards. Sandwell and West Birmingham NHS Hospitals Trust has participated in this audit process but has failed to show consistent improvements. The aim of this quality improvement project was to produce meaningful and sustained improvements in oxygen use across each of the four standards.

Four interventions were developed over three PDSA cycles and included: 1. a new oxygen prescription chart, 2. oxygen ‘alert’ stickers for use on drug and MEWS charts, 3. point of care resources, and 4. senior led educational sessions for healthcare staff. Each intervention was tested on the Acute Medical Unit over seven days and data collected using the BTS data collection form.

The QIP improved oxygen use across each of the standards: baseline measurement for standard one demonstrated that 55% of patients using oxygen had a valid oxygen prescription, improving to 94% after PDSA cycle three. For standard two, baseline measurement demonstrated that 50% of patients had a documented oxygen target saturation range, improving to 94% after PDSA cycle three. For standard three, baseline measurement demonstrated that 84% patients using oxygen had saturations documented on the MEWS chart, improving to 100% after PDSA cycle three. Finally, baseline measurement of standard four demonstrated that 0% patients with a valid oxygen prescription had it signed for at drugs rounds, improving to 18% after PDSA cycle three.

Oxygen use was substantially improved during the QIP. Following engagement with stakeholders a new oxygen prescription will be rolled out within the Trust with projected annual savings of £30,400.

The acute prescription of oxygen in orthopaedic trauma patients

BACKGROUND

In trauma and orthopaedic surgery high flow oxygen can save lives by preventing severe hypoxaemia. Conversely, excessive oxygen can cause harm, and inadequate monitoring of its use has been reported in both pre-hospital and hospital audits. In 2008 the British Thoracic Society published guidelines on the use of emergency oxygen in adults.

METHOD

Data were collected before, 3 months after and 12 months after the introduction of an oxygen prescription chart and education of junior doctors and ward staff.

RESULTS

A total of 84 patients were recorded in the first study, 76 in the second and 72 in the third. After education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments correctly prescribed increased from 10/84 (12%) to 56/76 patients (74%, P<0.001) at 3 months. Twelve months after education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments prescribed decreased to 37/72 (51%, P<0.001).

CONCLUSIONS

Education and the use of oxygen prescribing charts significantly improved the prescription of oxygen. The effect of the intervention fell at 12 months, suggesting poor sustainability. Continued education and feedback to ward staff is vital to maintain change and improve sustainability.

Multicentre audit of inpatient management of acute exacerbations of chronic obstructive pulmonary disease: comparison with clinical guidelines

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) exacerbations are a major cause of hospital admission and clinical guidelines for optimised management are available. However, few data assessing concordance with these guidelines are available. We aimed to identify gaps and document variability in clinical practices for COPD admissions.

METHODS

Medical records of all admissions over a 3-month period as COPD with non-catastrophic or severe comorbidities or complications at eight acute-care hospitals within the Hunter New England region were retrospectively audited.

RESULTS

Mean (SD) length of stay was 6.3 (6.1) days for 221 admissions with mean age of 71 (10), 53% female and 34% current smokers. Spirometry was performed in 34% of admissions with a wide inter-hospital range (4-58%, P < 0.0001): mean FEV1 was 36% (18) predicted. Arterial blood gases were performed on admission in 54% of cases (range 0-85%, P < 0.0001). Parenteral steroids were used in 82% of admissions, antibiotics in 87% and oxygen therapy during admission in 79% (with oxygen prescription in only 3% of these). Bronchodilator therapy was converted from nebuliser to an inhaler device in 51% of cases early in admission at 1.6 (1.7) days. Only 22% of patients were referred to pulmonary rehabilitation (inter-hospital range of 0-50%, P = 0.002). Re-admission within 28 days was higher in rural hospitals compared with metropolitan (27% vs 7%, P < 0.0001).

CONCLUSIONS

We identified gaps in best practice service provision associated with wide inter-hospital variations, indicating disparity in access to services throughout the region.

Learning safe practice by improving care: student-led intervention on oxygen prescribing in a respiratory ward

BACKGROUND AND OBJECTIVE

The primary aim of this intervention was to improve oxygen prescribing in accordance with the 2008 British Thoracic Society guidelines for the prescription of emergency oxygen in adults.

METHODS

Eight final year medical students reviewed the drug charts of all patients admitted to the respiratory ward on a daily basis in order to collect data on five audit questions: (1) Has oxygen (O2) been prescribed? (2) Has an O2 target saturation level been indicated? (3) Has O2 been prescribed as an 'as required' (PRN) or 'continuous therapy'? (4) Has the prescription been signed? (5) Has O2 been signed for in every drug round since the original prescription? Following an initial audit cycle an educational poster was distributed to all clinical staff via email and hard copies of the poster were placed strategically throughout the ward before its effectiveness was measured.

RESULTS

During the pre-intervention phase, compliance with all five measures varied from 0 to 25%. There was an increase in the variation in compliance after the poster intervention to 14-44%; however, this masked better overall compliance with all five investigative questions with figures of 44%, 39% and 42% being recorded in three of the four post-intervention days. Overall there was increased compliance with four of the five audit questions. Indeed compliance with question 3 rose from 14% to 83%.

CONCLUSIONS

The poster intervention was marginally effective while also showing that students can improve prescribing in a clinical setting.

Oxygen therapy multicentric study--a nationwide audit to oxygen therapy procedures in internal medicine wards

Oxygen therapy is a common and important treatment in Internal Medicine wards, however, several studies report that it isn't provided accordingly with the best of care. The goal of this work is to evaluate oxygen therapy procedures in Portuguese Internal Medicine wards, comparing them to the standards established by the British Thoracic Society (BTS) in its consensus statement "BTS guideline for emergency oxygen use in adult patients". Between September 3rd and 23rd 2010, each one of the 24 enrolled hospitals audited the oxygen therapy procedures for one randomly chosen day. All Internal Medicine inpatients under oxygen therapy or with oxygen prescription were included. Data was collected regarding oxygen prescription, administration and monitoring. Of the 1549 inpatients, 773 met inclusion criteria. There was an oxygen prescription in 93,4%. Most prescriptions were by a fixed dose (82,4%), but only 11,6% of those stated all the required parameters. Absence of oxygen therapy duration and monitoring were the most frequent errors. Oxygen was administered to only 77,0% of the patients with fixed dose prescriptions. FiO(2) or flow rate and the delivery device were the same as prescribed in 70,9 and 89,2% of the patients, respectively. Out of the 127 patients with oxygen therapy prescriptions by target SatO(2) range, 82,7% were on the prescribed SatO(2) objective range. Several errors were found in oxygen therapy procedures, particularly regarding fixed dose prescriptions, jeopardizing the patients. Although recommended by BTS, oxygen therapy prescriptions by target SatO(2) range are still a minority.

Oxygen therapy for acute myocardial infarction-then and now. A century of uncertainty

For about 100 years, inhaled oxygen has been administered to all patients suspected of having an acute myocardial infarction. The basis for this practice was the belief that oxygen supplementation raised often-deficient arterial oxygen content to improve myocardial oxygenation, thereby reducing infarct size. This assumption is conditional and not evidence-based. While such physiological changes may pertain in some patients who are hypoxemic, considerable data suggest that oxygen therapy may be detrimental in others. Acute oxygen therapy may raise blood pressure and lower cardiac index, heart rate, cardiac oxygen consumption, and blood flow in the cerebral and renal beds. Oxygen also may lower capillary density and redistribute blood in the microcirculation. Several reports now confirm that these changes occur in humans. In patients with both acute coronary syndromes and stable coronary disease, oxygen administration may constrict the coronary vessels, lower myocardial oxygen delivery, and may actually worsen ischemia. There are no large, contemporary, randomized studies that examine clinical outcomes after this intervention. Hence, this long-accepted but potentially harmful tradition urgently needs reevaluation. Clinical guidelines appear to be changing, favoring use of oxygen only in hypoxemic patients, and then cautiously titrating to individual oxygen tensions.

Improving the safety of oxygen therapy in the treatment of acute myocardial infarctions

AIM

The article examines the evidence for giving oxygen routinely to patients with suspected myocardial infarction, and addresses the challenges in changing practice.

BACKGROUND

It has been thought that administering oxygen to patients suffering from acute myocardial infarctions may be beneficial, but there is a lack of supporting evidence. Furthermore there is evidence that the use of oxygen in some circumstances may not improve clinical outcome. Despite conflicting evidence, guidelines in the past have recommended supplementary oxygen as part of treatment. Therefore it was necessary to understand and identify best practice.

METHODS

Evidence was collated using electronic databases. Search terms included 'acute myocardial infarction' 'acute coronary syndrome' 'oxygen' and 'hypoxia', 'hyperoxaemia'.

CONCLUSION

A systematic review of studies did not confirm that the use of routine oxygen in the acute stages of a myocardial infarction reduces myocardial ischemia. In reality, some evidence suggests that oxygen may even increase myocardial ischemia. Therefore it is crucial that emergency care nurses/practitioners across the world use observation skills and monitoring such as pulse oximetry to recognise the clinical need for supplementary oxygen to be given to a patient.

Physiotherapy practice and delegation policies in oxygen administration: a survey of ontario hospitals

PURPOSE

As of 2008, the Regulated Health Professions Act in Ontario stipulates that administration of oxygen is a controlled act, which physiotherapists are not authorized to perform but which may be delegated to physiotherapists by another health professional authorized to perform this act. The aims of this study were (1) to survey physiotherapy practice of oxygen administration in Ontario hospitals and (2) to determine the proportion and characteristics of hospitals with delegation policies for physiotherapists to administer oxygen.

METHOD

Postal surveys were sent to 208 hospitals. Data were collected on hospital characteristics; the presence of delegation policies; and the practice and training of physiotherapists, physiotherapy assistants, and students in oxygen administration. Data were described by summative statistics. Fisher's exact test and Cramer's V statistic were used to examine associations. Potential prognostic factors were analyzed using logistic regression.

RESULTS

Response rate was 82.7%. Physiotherapists administered oxygen in 39% of hospitals, and 28% of hospitals had delegation policies. Larger, urban, or teaching hospitals and those with a matrix structure were most likely to have delegation policies and physiotherapists who administered oxygen. Rehabilitation hospitals were also likely to have such policies.

CONCLUSION

Physiotherapists administer oxygen in less than half of Ontario hospitals, very few of which have delegation policies.

The use of medical orders in acute care oxygen therapy

The life of every living organism is sustained by the presence of oxygen and the acute deprivation of oxygen will, therefore, result in hypoxia and ultimately death. Although oxygen is normally present in the air, higher concentrations are required to treat many disease processes. Oxygen is therefore considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription. Administration is typically authorized by a physician following legal written instructions to a qualified nurse. This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patients hypoxia and ultimate outcome. Delaying the administration of oxygen until a written medical prescription is obtained could also have the same effect. Clearly, defined protocols should exist to allow for the legal administration of oxygen by nurses without a physicians order because any delay in administering oxygen to patients can very well lead to their death.

Improved oxygen prescribing using a nurse-facilitated reminder

Poor oxygen prescribing and administration is well documented despite junior doctor education and oxygen prescription charts. This prescribing behaviour can be harmful to patients. This study examines whether oxygen prescribing and the appropriateness of oxygen therapy would be increased by medical admissions unit (MAU) nurse education and a nurse-mediated reminder strategy to junior medical staff. A quality improvement study was carried out involving a prospective single centre audit, educational intervention to MAU nurses, and implementation of a nurse-facilitated oxygen prescribing reminder strategy with prospective re-audit. The study took place in a 26-bed MAU in a 678-bed teaching hospital with a lung centre serving a population of 540,000. Fifty-one patients were involved in the initial and re-audits and two nurses were involved in the audit team. A team of 10 acute medical nurses were involved in facilitating the appropriate administration and prescription of oxygen by liaison with junior medical staff. Oxygen prescription and appropriateness of oxygen therapy were measured. Results showed an improvement in oxygen prescribing from 0% to 49% (p < 0.0001). Non-significant improvements in appropriate oxygen prescription (pre- versus post-intervention) overall (70.6% versus 76.5%, p = 0.65); more marked reduction in type 1 respiratory failure errors (18.4% versus 3.8%, p = 0.13) and less marked reduction in type 2 respiratory failure errors (61.3% versus 44.0%, p = 0.49). In conclusion, significant and quick improvements in oxygen prescribing behaviour are achievable through a nurse-facilitated reminder strategy with reduction in inappropriate oxygen prescribing. These strategies are relevant to other ward settings and aspects of patient care.

An audit of oxygen therapy on a respiratory ward

Oxygen therapy can be a life-saving intervention, which is widely available and commonly prescribed by medical staff. Patients often receive oxygen therapy in hospital but, like any other drug, oxygen can be dangerous when given in the wrong concentration.

AIMS

To review the current literature. To examine current prescribing practice plus methods of oxygen delivery on a respiratory ward.

METHOD

A prospective audit was conducted on patients receiving oxygen therapy over a 4-week period. The ward was audited pre- and post-education sessions. Education was on oxygen prescribing and oxygen therapy.

RESULTS

The literature revealed that oxygen was often poorly prescribed by doctors and at times poorly administered by nurses. Of the 55 patients audited pre-education, only 5% of patients had a prescription. This increased to 20% post-education (P=0.042). The initial audit uncovered 14 issues surrounding oxygen delivery. This fell to one post-education (P<0.001). Reassuringly, all patients had arterial oxygen saturation recorded.

CONCLUSION

Current rates of oxygen prescribing remain unsatisfactory despite doctors being made aware of the audit findings. Education on oxygen therapy improved the delivery of oxygen therapy to patients on a respiratory ward.

How much do new junior doctors in emergency medicine understand about oxygen therapy?

Oxygen is routinely prescribed in hospital practice. It should be prescribed like any other drug, specifying delivery device, flow rate and desired inspired concentration. There appears to be continued deficiency in the provision of guidance for, and understanding of, the principles of oxygen therapy.

Oxygen: Can we prescribe it correctly?

INTRODUCTION

Oxygen is one of the most common drugs used in secondary care. It is often used incorrectly on hospital wards, and it has been suggested that prescribing oxygen would facilitate correct administration. However, the knowledge of hospital doctors who would prescribe oxygen, and that of nurses who administer it, has not been tested.

METHODS

A questionnaire was prepared to test a person's knowledge of oxygen delivery devices and their use in different clinical scenarios. This questionnaire was given to 30 junior doctors and 53 nurses working on an acute medical ward in a district general hospital.

RESULTS

The majority of doctors and nurses could not identify less commonly used oxygen delivery devices, such as a non-rebreathing mask with reservoir bag. A quarter of the doctors and nearly half the nurses were unable to select the correct dose and method of administration of oxygen in the event of cardiorespiratory arrest. The majority prescribed oxygen wrongly in the various clinical scenarios that dealt with respiratory failure.

CONCLUSION

Junior doctors and nurses do not have sufficient knowledge and understanding of oxygen therapy to be able to prescribe the drug appropriately and safely.

Omissions and errors during oxygen therapy of hospitalized patients in a large city of Greece

Omissions and errors are commonly found concerning hospital oxygen use and the use of nebulizers. The aim of the study was to record oxygen use in seven hospitals located in a large district city of Greece. Another aim was to record the use of nebulizers in the same hospitals. We included 105 head nurses (HNs) working in seven hospitals of a large city district of Greece. Data were collected after interviewing each HN using a questionnaire and completing an anonymous data form. Data are expressed as percentages and analyzed using the chi-square test. We found that 41% of HN believed O(2) is a gas that improves patient's dyspnea. The majority of the nurses (88.6%) stated that there was no protocol for O(2) therapy in the departments in which they worked. We found that O(2) therapy was commonly started, modified, discontinued by nurses in the absence of a medical order. Oxygen therapy was commonly not guided by arterial blood gas (ABG) analysis. We also found that there are no guidelines to prevent O(2) therapy interruption during intra-hospital transportation, and that few measures were taken to prevent O(2) explosion. In 95.2% of the departments the nebulizers were filled with tap water and were not changed on a daily basis (81.2%). Our results indicate that educational programmes, nursing protocols and guidelines are becoming mandatory in our country in order to ensure the proper use of O(2) therapy and nebulizers.

Cardiovascular effects of acute oxygen administration in healthy adults

Supplementary oxygen is commonly administered in current medical practice. However, attention has recently been drawn to the potentially disadvantageous hemodynamic consequences in certain patients. Possible mechanisms underlying the cardiovascular responses to acute hyperoxia are unclear. The effects of acute oxygen administration on heart rate, blood pressure, cardiac output, systemic vascular resistance, and baroreflex sensitivity were studied in a series of randomised, placebo-controlled studies in healthy individuals, using validated, non-invasive techniques. The effects of oxygen administration on forearm blood flow responses to locally administered acetylcholine, an endothelium-dependent vasodilator, sodium nitroprusside, an endothelium-independent vasodilator, and l-NG-monomethylarginine, a nitric oxide synthase inhibitor, were studied using venous occlusion plethysmography. Oxygen administration for 1 hour caused a reduction in heart rate (P < 0.01) and cardiac index (P < 0.05), and an increase in mean arterial pressure (P < 0.01), systemic vascular resistance (P < 0.05), large artery stiffness (P < 0.05), and baroreflex sensitivity (P < 0.05). There were no effects on vascular responses in the isolated forearm bed. These findings indicate that oxygen administration causes acute effects on cardiovascular function, which might be important in the context of acute illness.

Chronic obstructive pulmonary disease * 9: management of ventilatory failure in COPD

The management of respiratory failure during acute exacerbations of COPD and during chronic stable COPD is reviewed and the role of non-invasive and invasive mechanical ventilation is discussed.

Interrupting drug therapy in the perioperative period

Millions of patients undergo surgery each year and an increasing proportion of these patients are consuming therapeutic drugs. Drug therapy is often withheld in the immediate perioperative period and after major surgery, in particular, there is often a prolonged period of fasting. This may lead to withdrawal effects including recurrence or worsening of patients' disease symptomatology. These effects will occur during a period of physiological and pathophysiological stresses and render patients more vulnerable to drug withdrawal phenomena. Thus, patients may be exposed to greater and sometimes unnecessary risks in the perioperative period. There are relatively few studies that have investigated this problem. The ones that have, however, confirm that drug abstinence in the perioperative period is a relatively common phenomenon and one study has demonstrated an association between duration of drug abstinence and adverse outcomes. The pathophysiological effects of major surgery on gastrointestinal function, neuro-humoral and cytokine adaptive responses to surgical stress are under-appreciated. These responses can reduce the effectiveness of oral administration and exacerbate co-existing disease processes. These problems are compounded by a fragmented approach to perioperative drug therapy with no one group of healthcare professionals assuming responsibility for this aspect of care. This may in part be a consequence of the complexities of rationalising drug therapy in the perioperative period together with the lack of readily available and evidence based information strategies for individual drugs or drug classes. An additional problem relates to the formulations, inherent pharmacokinetics and limited routes of administration of many prescribed drugs. These can prevent a 'seamless' transition from preoperative to postoperative management. Consumers, health professionals, pharmaceutical companies and drug regulatory agencies must all play a part in rectifying this problem. There remains a need for further research to clarify the effects of abstinence on patient outcomes and also to identify optimum strategies to avoid unwanted drug abstinence.