Emergency Oxygen Professor Thida Win 10/03/2015SCN Emergency Oxygen Event

Why Important Oxygen is the main ‘‘fuel’’ of the cells and it is essential for humans to maintain a safe level of oxygen in the bloodstream Oxygen is the most commonly use drug in emergency situation 10/38/2015SCN emergency Oxygen Event 34% of emergency ambulance patients receive oxygen 1 ~14% of UK hospital patients were on oxygen during BTS audits Approx 2-4 million people per year in UK

too much of a good thing! 10/38/2015SCN emergency Oxygen Event Human experiments found evidence of “leaky airways” in healthy subjects after inhaling 30% oxygen for 45 hours Griffith DE et al Am Rev Respir Disease 1986 ; 134: Risks of hyperoxaemia

10/38/2015SCN emergency Oxygen Event JL Smith J Physiology 1899 Vol 24 p19-35

BTS Oxygen guideline Strategy 2005 Guideline 2008 Due to update this year 10/38/2015SCN emergency Oxygen Event

Audit 1 July-Sept 2008 Before Guideline launch in October 2008 Audit 2 November 2009 Audit 3 Oct-November 2010 Audit 4 Aug-November 2011 Audit 1 July-Sept 2008 Before Guideline launch in October 2008 Audit 2 November 2009 Audit 3 Oct-November 2010 Audit 4 Aug-November 2011 Oxygen champions conducted audits Methodology- BTS online Audit tool BTS Emergency Oxygen Audits Audit 5 Aug-November /38/2015SCN emergency Oxygen Event

*Definition of “on oxygen” in included patients with a prescription who were not on oxygen at the time of audit Year Hospitals Wards , Patients14,830 7,11322,01741,009 38,094 Percent on Oxygen 17.5% 18.4% 15.5% 13.7% 14.0% Overview of results /38/2015SCN emergency Oxygen Event

Prescription of oxygen 32% of patients who were using oxygen had some sort of written order for oxygen use in % in 2009 (47 Trusts) 56% in 2010 (90 Trusts) 48% in 2011 (156 Trusts) 52% in 2012 (145 Trusts) Possible selection bias in earlier audits (more medical wards) 10/38/2015SCN emergency Oxygen Event

Year Percent On oxygen 17.5%18.4%15.5%13.7%14.0% Target Range 10%40%41%43%46% No Written Order 68%31%44%52%48% Percent of all hospital patients on oxygen with no written order 11.9%5.7%6.8%7.1%6.7% Oxygen prescribing /38/2015SCN emergency Oxygen Event

Year Percent of drug rounds on which oxygen was signed for on the drug chart 5%27 %16 %20 % Percent of expected observation rounds with oximetry 94 %93 %99 %100 % Drug rounds & Observation Rounds 10/38/2015SCN emergency Oxygen Event

Observations Rounds for 2483 patients on Oxygen with a Target Range % of patients within the target range 31% of patients outside the target range 10% not possible to judge due to use of NEWS chart Below Target Range Above Target Range By 1%3%6% By 2%3%7% By >2%3%9%* Total9% Below target range 22% Above target range *It is not possible to be more than 2% above target range if the patient’s target range is 94-98%. Therefore, all patients who are more than 2% above target must be at risk of hypercapnic respiratory failure. 10/38/2015SCN emergency Oxygen Event

Implementation Audits Year 2009 Feb n= Nov n= n= N= N=95 Oxygen Policy Implemented 6%21%37%89%83% Printed Oxygen Prescription 9%28%51%72%80% O2 on Monitoring Chart 7%34%33%58%69% Nurse Training Implemented 7%13%18%31%42% Doctor training implemented 4%10%11%31%42% 10/38/2015SCN emergency Oxygen Event

Summary Things are getting better—but slowly There are institutional barriers to modernisation of clinical practice Training of health care professionals is the greatest challenge BTS Oxygen Audits are supported by NAGCAE (National Advisory Group on Clinical Audit and Enquiries) and included in Trust Quality Accounts 10/38/2015SCN emergency Oxygen Event

EOE BTS Oxygen Audit Audit Period: 15 August - 15 November 2012 Oxygen delivery and management of acutely ill patients, was published in October Trusts in EOE 2 did not participate 3 did not answer 13 included in survey, but 1 have incomplete data 10/38/2015SCN emergency Oxygen Event

The Guideline’s key recommendations Oxygen therapy should be adjusted to achieve target saturations rather than giving a fixed dose to all patients with the same disease Oxygen will require a prescription in all situations except for the immediate management of critical illness 10/38/2015SCN emergency Oxygen Event

10/38/2015SCN emergency Oxygen Event

94-98% 10/38/2015SCN emergency Oxygen Event BTS 55%

10/38/2015SCN emergency Oxygen Event BTS – 45%

Above the target 10/38/2015SCN emergency Oxygen Event

Below target range 10/38/2015SCN emergency Oxygen Event

Above and below range 10/38/2015SCN emergency Oxygen Event BTS, Above 23%, below 9%

Observation and range 10/38/2015SCN emergency Oxygen Event

Observation rounds 10/38/2015SCN emergency Oxygen Event

Summary 7-34% of patients were on Oxygen Majority with higher target range, however, surprisingly big number with lower target range (except southend) Significant number without prescription Significant number without signature More Above the range than below 10/38/2015SCN emergency Oxygen Event

Limitations.. No data for education No data for Observation Chart No data for organisational factor No data on Ambulance No data on harm Data Long time ago- a lot moved on Cross section data of given time 10/38/2015SCN emergency Oxygen Event

Since.... Unify drug chart New Observation Chart Different pathway progress Acute Chest team/ Chest specialist in MAU Electronic prescription Care Bundle – Pneumonia – COPD 10/38/2015SCN emergency Oxygen Event

More Evidence Risk to COPD patients 50 years or anectotes, now good evidence 10/38/2015SCN emergency Oxygen Event Mortality in acute COPD was 9% V 4% when high concentration oxygen was compared with controlled oxygen (target 88-92%) 1 Mortality in acute COPD was 11% V 7% comparing >35% oxygen with lower doses 2 Need for ventilatory support; 22% V 9% 2 1. Austin MA, et al. BMJ Oct 18;341:c5462. doi: /bmj.c Roberts CM et al. Thorax 2011: 66: 43

Other at Risk Other hypercapnia risk, such as Morbid Obesity, Muscle disease, Scoliosis etc Myocardial Infarction Stroke Post Resuscitation Ventilated ICU Patients Traumatic Brain Injury 10/38/2015SCN emergency Oxygen Event

Oxygen is medicine If it is used properly it is beneficial and safe Giving too much or too little oxygen may cause harm Giving oxygen to those who do not need it may cause harm 10/38/2015SCN emergency Oxygen Event

AIMS of today... Re enthuse oxygen Champions Re publish what’s out there Re member oxygen guideline Re mind oxygen Audit Re emphasize importance of education Re organise oxygen group Re energise all enthusiastic colleagues 10/38/2015SCN emergency Oxygen Event