Policy for the Prescription, Administration and Monitoring Of Oxygen ...

Table of Contents1. Introduction ...........................................................................................................32. Purpose of this Policy ...........................................................................................33. Scope ................................................................................................................. 34. Definitions/Glossary ......................................................................................... ....35. Ownership and Responsibilities ............................................................................46. Standards of Practice ............................................................................................46.1. Identifying appropriate target saturations ..................................................46.2. Prescribing oxygen on the drug chart ........................................................46.3. Administering oxygen ................................................................................ 46.4. Monitoring and recording oxygen ...............................................................56.5. Emergency situations .................................................................................56.6. Exclusions ..................................................................................................56.7. Specialist areas ..........................................................................................66.8. Indications ..................................................................................................66.9. Contra-indications ......................................................................................66.10 Cautions .....................................................................................................66.11. Transfer and transportation of patients receiving oxygen ..........................76.12. Peri-operative and immediately post operatively .......................................76.13. Nebulised therapy and oxygen ..................................................................76.14. Normal oxygen saturations ........................................................................76.15. Summary oxygen administration protocol (& weaning protocol) .............. 76.16. Humidification ............................................................................................77. Dissemination and implementation ......................................................................98. Monitoring compliance and effectiveness ............................................................99. Updating and review ..........................................................................................1010. Equality and diversity .........................................................................................10Appendix a Indications for oxygen therapyAppendix b Oxygen prescription boxAppendix c Administering oxygen therapyAppendix d Oxygen delivery devices and equipmentAppendix e Flowchart for administration of oxygenAppendix f Personnel who may administer oxygenAppendix g HumidificationAppendix h Health and safetyPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 2 of 34

1. Introduction1.1. The administration of supplemental oxygen is an essential element of appropriatemanagement for a wide range of clinical conditions. Following a NPSA Rapid ResponseReport in 2009 (Ref 1), it is now mandatory for oxygen to be prescribed in all butemergency situations. Failure to administer oxygen appropriately can potentially result inserious harm tot he patient. The safe implementation of oxygen therapy with appropriatemonitoring is an integral component of the healthcare professional's role.1.2. This version supersedes any previous versions of this document.2. Purpose of this Policy/ProcedureThe aim of this policy is to ensure that:‣ All patients who require supplementary oxygen therapy receive therapy that isappropriate to their clinical condition and in line with the British Thoracic SocietyEmergency Oxygen Therapy National Guidelines (Ref 2).‣ Oxygen is prescribed according to a target saturation range. The system ofprescribing target saturation aims to achieve specific outcome rather than specifyingthe oxygen delivery method alone.‣ The multidisciplinary team will administer and monitor the patient in keeping with thetarget saturation rate.3. Scope1.1. This policy is intended for all healthcare professionals initiating, delivering andmonitoring oxygen4. Definitions / GlossaryABG Arterial blood gasNIV Non-invasive ventilationIPPV Invasive positive pressure ventilationBiPAP Bilevel positive pressure ventilationCPAP Continuous positive pressure ventilationCOPD Chronic obstructive pulmonary diseaseICU Intensive care unitHDU High dependency unitpH pHPaO 2 Arterial oxygen tensionPaCO 2 Arterial carbon dioxide tensionPtCO 2 Transcutaneous carbon dioxideHR Heart rateRR Respiratory rateFi02 Fraction of inspired oxygenSpO2 Oxygen saturations measured by pulse oximetryPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 3 of 34

provided for those administering oxygen in Appendices c and d. Personnel who mayadminister oxygen is shown in Appendix f.6.4. Monitoring and recording oxygenThe patient's oxygen saturation and oxygen delivery system should be recorded on thebedside observation chart alongside other physiological variables. The codes for oxygendelivery devices should be recorded on the observation charts (MEWS).All patients on oxygen therapy should have regular pulse oximetry measurements. Thefrequency of oximetry measurement will depend on the condition being treated and thestability of the patient. Critically ill patients should have their oxygen saturations monitoredcontinuously. Patients on oxygen should have their saturations recorded at intervals inline with the RCHT minimum observation policy (MEWS).At every drug round nursing staff must ensure that every patient receiving oxygen arewithin the documented target saturation range. If not, oxygen therapy should be increasedif the saturation is below the desired range and decreased if the saturation is above thedesired range (and eventually discontinued as the patient recovers). Nursing staff need toremain with the patient until the target saturation range is achieved. See Appendix e formore details. Medical staff should be informed if there is a significant increase in oxygenrequirement (Appendix e). Patients should be monitored accurately for signs ofimprovement or deterioration. Nurses should also monitor skin colour for peripheralcyanosis and respiratory rate.6.5. Emergency situationsIn an emergency situation an oxygen prescription is not required. Oxygen should begiven to the patient immediately without a formal prescription or drug order butdocumented later in the patient's record.All peri-arrest and critically ill patients should be given high flow oxygen (15L/m reservoirmask) whilst awaiting immediate medical review. Patients with COPD and other riskfactors for hypercapnia, who develop critical illness, should have the same initial targetsaturations as other critically ill patients pending urgent blood gas results, after whichthese patients may need controlled oxygen therapy or supported ventilation if there issevere hypoxaemia and/or hypercapnia with respiratory acidosis.All patients who have cardiac or respiratory arrest should have high flow oxygen providedalong with basic/advanced life support.A subsequent written record must be made of what oxygen therapy has been given toevery patient alongside the recording of all other emergency treatment.Any qualified nurse/health professional can commence oxygen therapy in an emergencysituation. This will be in line with local policies within relevant clinical areas.6.6. Exclusions‣ Patients admitted to specialist areas with a specialised oxygen prescribing policy (seeSection 6.7).Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 5 of 34

‣ Patients receiving oxygen as part of palliative care, or patients on the end of life carepathway (in which case the prescriber should choose 'target saturations not indicated'on the drug chart/JAC EPMA system).6.7. Specialist areasThis policy is for general use within general wards and department. Where specific clinicalguidelines are required oxygen administration within specialist areas, they must beapproved via the appropriate clinical governance forum. They should reflect whereverpossible the principles within this policy. Patients transferring from specialist areas mustbe transferred with a prescription for their oxygen therapy utilising target saturation if theclinical indication is ongoing. If a patient transfers from an area not utilising the targetsaturation system, their oxygen should be administered as per the transferring area'sprescription until the patient is reviewed and transferred over to the target saturationscheme and this should occur as soon as possible.6.8. IndicationsThe rationale for oxygen therapy is prevention of cellular hypoxia, caused by hypoxaemia(low PaO 2 ) and thus prevention of potentially irreversible damage to vital organs.Oxygen is not a treatment for breathlessness and other caused of tissue hypoxia e.g.anaemia, ischaemia must be addressed. Indications for oxygen therapy are listed inAppendix a.6.9 Contra-indicationsThere are no absolute contra-indications to oxygen therapy if indications are judged to bepresent. the goal of oxygen therapy is to achieve adequate tissue oxygenation using thelowest possible Fi0 2 . Supplemental oxygen should be administered with caution inpatients suffering from paraquat poisoning and with acid inhalation or previous belomycinlung injury.6.10 Cautions6.10.1 Oxygen induced hypercapniaA subgroup of patients with chronic obstructive pulmonary disease will develop oxygeninduced hypercapnia. Other at risk groups include neuromuscular disorders, morbidobesity and chest wall deformities. These high risk patients must be administered withcontrolled oxygen only and regular blood gases should be performed to monitor PaCO 2and pH if oxygen therapy is increased.6.10.2 Other complications of oxygen therapy‣ Coronary and cerebral artery vascoconstriction‣ Pulmonary toxicity‣ Drying of nasal and pharyngeal mucosa‣ Skin irritation‣ Fire hazard‣ Pressure sores resulting from the delivery device.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 6 of 34

6.11 Transfer and transportation of patients receiving oxygenPatients who are transferred from one area to another must have clear documentation oftheir ongoing oxygen requirements and documentation of their oxygen saturation. If apatient transfers from one area not utilising the target saturation system (see specialistareas above) their oxygen should be administered as per the transferring areasprescription until the patient is reviewed and transferred to the target saturation schemeand this should occur as soon as possible.Patients requiring oxygen therapy while being transferred from one area to another shouldhave oxygen therapy reviewed prior to leaving the clinical area and on return by trainednursing staff. Clear instructions must be provided for personnel involved in the transfer ofthe patient, which must include delivery device and flow rate. Please also refer to thePortering Services policy on Changing Medical Gas Cylinders.6.12 Peri-operative and immediately post operativelyTheatres and recovery follow the AAGBI guidelines [ref 3,4] with respect to oxygenadministration.However, when patients are transferred back to the ward from recovery, oxygen shouldbe prescribed on the RCHT drug chart as discussed in Section 6.6.13 Nebulised therapy and oxygenWhen nebulised therapy is administered to patients at risk of hypercapnic respiratoryfailure, (see Section 6.10.1) , it should be driven by compressed air. if necessarysupplementary oxygen should be given concurrently by nasal prongs at 1 - 4 litres perminute to maintain an oxygen saturation of 88 - 92% or their specified target range.All patients requiring 35% or greater oxygen therapy should have their nebulised therapyby oxygen at a flow rate of >6 litres/minute.6.14 Normal oxygen saturations‣ In adults less than 70 years of age at rest at sea level 96 - 98% when awake.‣ Aged 70 and above at rest at sea level greater than 94% when awake.‣ Patients of all ages may have transient dips of saturation to mid-80's% during sleep.6.15 Summary oxygen administration protocol (and weaning protocol)ACTIONAll patients requiring oxygen therapy willhave a prescription for oxygen therapyrecorded on the patients drug prescriptionchart or JAC EPMA system. N.B.Exceptions - see emergency situations.The prescription will incorporate as targetsaturation that will be identified by theclinician prescribing the oxygen inRATIONALEOxygen should be regarded as a drug andshould be prescribed. BTS NationalGuidelines (2008). British Formulary(2012).Certain groups of patients require differenttarget ranges for their oxygen saturation,see Appendix a: Tables 1 - 4.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 7 of 34

accordance with the Trust's oxygenguidelineThe prescription will incorporate an initialstarting dose (i.e. delivery device and flowrate)The administration of oxygen should berecorded at every drug round ether on thedrug chart or the JAC EPMA systemOnce oxygen is in situ the nurse will monitorobservations in line with Trust policy. Allpatients should have their oxygen saturationobserved for at least 5 minutes after startingoxygen therapy.Oxygen flow rate should be recordedalongside the oxygen saturation on thebedside observation chartOxygen saturations must always beinterpreted alongside the patient's clinicalstatus incorporating the early warning score.if the patient falls outside of the targetsaturation range the oxygen therapy will beadjusted accordingly. the saturationsshould be monitored for at least 5 minutesafter any increase or decrease in oxygendose to ensure that the patient achieves thedesired saturation range.Saturations higher than target specified‣ Step down oxygen therapy as perguidance for delivery‣ Consider discontinuation pf oxygentherapyCertain groups of patients are at risk ofhyperoxaemia, particularly patients withCOPD.To provide the nurses with guidance for theappropriate starting point for oxygendelivery system and flow rateTo ensure that the patient is receivingoxygen and that oxygen saturation is withinthe target rangeto identify if oxygen is maintaining the targetsaturation or if an increase or decrease inoxygen therapy is requiredTo provide an accurate record and allowtrends in oxygen therapy and saturationlevels to be identifiedTo maintain the saturation in the desiredrangeThe patient will require weaning down forcurrent oxygen delivery system. SeeAppendix e.The patient's clinical condition may haveimproved negating the need forsupplementary oxygenSaturations lower than target specified‣ Check all elements of oxygen deliverysystem for faults or errors.‣ Step up oxygen therapy as perprotocols in Appendix e. Any suddenfall in oxygen saturation should lead toclinical evaluation and inmost casesmeasurement of blood gases.‣ Monitor Early Warning Score andrespiratory rate for further clinical signsof deterioration‣ Check and ensure that the patient isPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 8 of 34In most instances a fall in oxygen saturationis due to deterioration of the patient,however, equipment faults should bechecked for.To assess the patient's response to oxygenincrease, and ensure that PaCO 2 has notrisen to an unacceptable level, or pHdropped to an unacceptable level and toscreen for cause of deteriorating oxygenlevelPatient safetyMeasurements of oxygen saturations are

well perfusedSaturation within target specifiedContinue with oxygen therapy, and monitorpatient to identify appropriate time forstepping down therapy once clinicalcondition allowsA change in delivery device (without anincrease in O 2 therapy) does not requirereview by the medial teamOxygen delivery methodsThe trust's recommended delivery deviceswill be utilised to ensure a standardisedapproach to oxygen delivery see Appendixdreliant upon adequate arterial perfusion ofthe patient(The change may be made in stablepatients due to patient preference orcomfort)Previous audits have demonstrated widevariations in delivery devices across clinicalareas, potentially increasing the risk ofadverse incidents6.16. HumidificationHumidification may be required for some patient groups but is not essential, even forpatients on prolonged therapy. See Appendix g.7. Dissemination and ImplementationIt is mandatory that all nurses administering oxygen complete the Emergency Oxygenmodule on NLMS or attend a training session.All medical students and doctors should be taught about the oxygen policy. this will befacilitated through regular junior doctor teaching, departmental meetings and GrandRounds.Regular audits are being performed in clinical area as. Additionally the Trust will take partin the National BTS audit to benchmark out practice against the rest of the country.The British Thoracic Society has appointed oxygen champions in all Trusts to helpintroduce the Guideline. Dr M Wijesinghe and Nurse Julie Jephson are the oxygenchampions for RCHT.8. Monitoring compliance and effectivenessElement to bemonitoredLeadToolFrequencyReportingarrangementsActing onrecommendationsOxygen prescription and monitoringDr Meme WijesingheBritish Thoracic Society annual Emergency Oxygen AuditAnnualMedical Gases Group, Medication Practice CommitteeDr Meme WijesinghePolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 9 of 34

and Lead(s)Change inpractice andlessons to besharedResults will be fed back to Ward Managers/Sisters and Matrons.9. Updating and ReviewThis policy will be reviewed and updated every three years10. Equality and DiversityThis document complies with the Royal Cornwall Hospitals NHS Trust serviceEquality and Diversity statement".10.1 Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 2.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 10 of 34

Appendix 1. Governance InformationDocument TitlePolicy for the prescription, administration andmonitoring of oxygen in adultsDate Issued/Approved: 14 th December 2012 2012Date Valid From: 14 th December 2012 2012Date Valid To: 1 st December 2015Directorate / Department responsible(author/owner):Pharmacy DepartmentContact details: 01872 252593Brief summary of contentsPolicy for the prescription, administration andmonitoring of emergency oxygen in adultsSuggested Keywords:Target AudienceExecutive Director responsible forPolicy:Oxygen, reservoir mask, hypercapnic,respiratory, oxygen therapy, oximetry.saturationRCHT PCT CFTMedical DirectorDate revised: November 2012This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation:Emergency Oxygen PolicyMedical Gases GroupMedication Practice CommitteeDivisional Manager confirmingapproval processesName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderLinks to key external standardsDivisional Manager for Diagnostics andTherapeuticsNot required{Original Copy Signed}Internet & Intranet Intranet OnlyClinical/ PharmacyCQC Outcome 9 Medicines ManagementNHSLAPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 11 of 34

Related Documents:Training Need Identified?NPSA Oxygen safety in hospital RapidResponse Report (NPSA/2009/RRR06)BTS guideline for emergency oxygen use inadult patients(2008)YesVersion Control TableDateVersionNoSummary of ChangesChanges Made by(Name and Job Title)05/09/09 V1.0 First Issue Johanna Kendall05/11/12 V2.0Complete review - changes made toformatting and content.Dr M WijesingheAll or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 12 of 34

Appendix 2.Initial Equality Impact Assessment Screening ForName of service, strategy, policy or project (hereafter referred to as policy) to beassessed:Policy for the prescription, administration and monitoring of emergency oxygen inadultsDirectorate and service area:Is this a new or existing Procedure?Name of individual completingTelephone:assessment: Linda Matthews01872 2525931. Policy Aim* To ensure that all activities relating to the precription,administration and monitoring of emergency oxygen use inadults comply with accepted standards of good practice.2. Policy Objectives* To provide evidence based guidelines on the prescription,administration and monitoring of emergency oxygen inadults3. Policy – intendedOutcomes*4. How will you measurethe outcome?All activities connected to the prescription, administrationand monitoring of emergency oxygen to adults comply withaccepted standards of good practice.Periodic clinical audit5. Who is intended tobenefit from the Policy?6a. Is consultationrequired with theworkforce, equalitygroups, local interestgroups etc. around thispolicy?b. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this procedure.Patients receiving oxygen therapyYesYes via a multidisciplinary working group which formulatedthis policy.the Medication Practice Committee, Senior Medical, Nursingand Pharmacy staff*Please see Glossary7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notes forareas of possible impact and also the Glossary if needed.• Where you think that the policy could have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relations withinequality groups, tick the ‘Positive impact’ box.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 13 of 34

• Where you think that the policy could have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.• Where you think that the policy has no impact on any of the equality group(s) listed belowi.e. it has no effect currently on equality groups, tick the ‘No impact’ box.Equality Positive Negative No Reasons for decisionGroupImpact Impact ImpactAgeXThis policy is applied irrespectiveof adult patient ageDisability X this policy is applied to patientsirrespective of any disability.Religion orbeliefX This policy describes activities notrelated to faith and beliefGender X This policy describes therapies notaffected by gender.Transgender X This policy describes therapies notaffected by transgender.Pregnancy/MaternityX This policy describes therapies notaffected by pregnancy/maternityRace X This policy describes therapies notaffected by pregnancy/maternitySexualOrientationX This policy describes therapies notaffected by sexual orientationMarriage / CivilPartnershipX This policy describes therapies notaffected by marriage or civilpartnershipYou will need to continue to a full Equality Impact Assessment if the following have beenhighlighted:• A negative impact and• No consultation (this excludes any policies which have been identified as notrequiring consultation).8. If there is no evidence that the policypromotes equality, equal opportunitiesor improved relations - could it beadapted so that it does? How?Full statement of commitment to policy ofequal opportunities is included in the policyPlease sign and date this form.Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/oRoyal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House,Penventinnie Lane, Truro, Cornwall, TR1 3LJA summary of the results will be published on the Trust’s web site.Signed ________________________________________Date _________________________________________Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 14 of 34

APPENDIX a. Indications for oxygen therapyThe British Thoracic Society divide patients into four different groups depending on theirdiagnosis and oxygen requirements:1. Critical illness requiring high levels of supplementary oxygen.2. Serious illness requiring moderate levels of supplemental oxygen is the patient ishypoxaemic.3. COPD and or other condition requiring controlled low-dose oxygen therapy.4. Conditions for which patients should be monitored closely but oxygen therapy is notrequired unless the patient is hypoxaemic.The following tables set out how oxygen should be administered and the grades of evidencesupporting oxygen use in these conditions.Table 1: Critical illnesses requiring high levels of supplemental oxygen‣ The initial oxygen therapy is a reservoir mask 15L/min‣ Once stable, reduce the oxygen dose and aim for target saturation range 94 - 98%‣ If oximetry is unavailable, continue to use reservoir mask until definitive treatment isavailable‣ Patients with COPD and other patients at risk of hypercapnia who develop critical illnessshould have the same initial target saturations as other critically ill patients pending theresults of blood gas measurements, after which these patients may need controlled oxygentherapy or supported ventilation if there is sever hypoxaemia and /or hypercapnia withrespiratory acidosis.Condition Additional comments Grade of recommendationCardiac arrest or resuscitation Use bag-valve mask during active Grade DresuscitationAim for maximum possible oxygensaturation until patient is stableShock, sepsis, major trauma, neardrowning,Also give specific treatment for the Grade Danaphylaxis, major underlying conditionpulmonary haemorrhageMajor head injury Early intubation and ventilation if Grade DcomatoseCarbon monoxide poisoning Give as much oxygen as possible using abag-valve mask or reservoir mask. Checkcarboxyhaemoglobin levels.A normal or high oximetry reading shouldbe disregarded because saturationmonitors cannot differentiate betweencarboxyhaemoglobin and oxyhaemoglobinowing to their similar absorbencies. theblood gas PaO2 will also be normal inthese cases (despite the presence oftissue hypoxia)Grade CPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 15 of 34

Table 2: Serious illnesses requiring moderate levels of supplemental oxygenif the patient is hypoxaemicThe initial oxygen therapy is a nasal cannulae at 2 - 6 1/min (preferably) or simple face mask at 5- 10 l/min unless stated otherwise.for patients not at risk of hypercapnic respiratory failure who have saturations

Deterioration of lung fibrosisor other intersistitial lungdiseaseSevere anaemiasickle cell crisishypoxaemic. Most patientswith pneumothorax are nothypoxaemic and do notrequire oxygen therapy.Use a reservoir mask at 10 -15 l/min if admitted forobservation. aim at 100%saturation) oxygenaccelerates clearance ofpneumothorax is drainage isnot requiredReservoir mask at 10 - 15l/min if initial SpO2

Table 3: COPD and other conditions requiring controlled or low-dose oxygen therapy‣ Prior to availability of blood gases, use 28% Venturi mask at 4 l/min and aim for an oxygensaturation of 88 - 92% for patients with risk factors for hypercapnia but no prior history ofrespiratory acidosis.‣ Adjust target range to 94 - 98% if the PaCO 2 is normal (unless there is a history ofprevious NIV or IPPV) and recheck blood gases after 30 - 60 minutes.‣ Aim at a pre-specified saturation range (from alert card) in patients with a history ofprevious respiratory acidosis. These patients may have their own venture mask. In theabsence of an oxygen alert card but with a history of previous respiratory failure (use NIVor IPPV), treatment should be commenced using a 28% oxygen mask at 4 l/min in prehospitalcare of a 24% venturi mask at 2 - 4 l/min in hospital settings with an initial targetsaturation of 88 - 92% pending urgent blood gas results.‣ If the saturation remains below 88% in pre-hospital care despite a 28% venture mask,change to nasal cannulae at 2 - 6 l/min or a sample mask at 5 l/min with a targetsaturation of 88 - 92%. All at risk patients with alert cards, previous NIV or IPPV or withsaturation 50 years who are long-term smokers with ahistory of chronic breathlessness on minor exertion, such as walking on level ground, andno other known cause of breathlessness should be treated as if having COPD for thepurposes of this guideline. Patients with COPD may also use terms such as chronicbronchitis and emphysema to describe their condition but may sometimes mistakenly use'asthma'. FEV 1 should be measured on arrival in hospital if possible and should bemeasured at least once before discharge from hospital in all cases of suspected COPD.‣ Patients with a significant likelihood of severe COPD or other illness that may causehypercapnic respiratory failure should be triaged as very urgent and blood gases shouldbe measured on arrival at hospital.‣ Blood gases should be re-checked after 30 - 60 min (or if there is clinical deterioration)even if the initial PaCO 2 measurement was normal.‣ If the PaCO 2 is raised by pH is ≤ 7.35 ([ H - ] ≤ 45 nmol/l), the patient has probably gotlong-standing hypercapnia; maintain target range of 88 - 92 % for these patients. Bloodgases should be repeated at 30 - 60 min to check for rising PaCO 2 or falling pH.‣ If the patient is hypercapnic ( PaCO 2 >6 kPa or 45 mm Hg) and acidotic (pH

CF (cystic fibrosis); COPD (chronic obstructive pulmonary disease); CPAP (continuouspositive airway pressure) IPPV (intermittent positive pressure ventilation); PaCO 2 (arterialcarbon dioxide tension): SpO 2 (arterial oxygen saturation measure by pulse oximetry.Condition Additional Comments Grade of RecommendationCOPDExacerbation of CFChronic NeuromuscularDisordersChest Wall DisordersMorbid ObesityMay need lower range ifacidotic or if known to bevery sensitive to oxygentherapy. Ideally use alertcards to guide treatmentbased on previous blood gasresults. Increase flow by50% if respiratory rate is >30(see recommendation 32)Admit to regional CF centreif possible, if not, discusswith regional centre ormanage according toprotocol agreed withregional CF centre. Ideallyuse alert cards to guidetherapy. Increase flow by50% is respiratory rate is>30 (see recommendation32)May require ventilatorsupport. Risk hypercapnicrespiratory failureFor acute neuromusculardisorders and subacuteconditions such as GuillainVarre syndrome (see table4)Grade CGrade DGrade DGrade DGrade DPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 19 of 34

Table 4. Conditions for which patients should be monitored closely butoxygen therapy is not required unless the patient is hypoxaemic‣ If hypoxaemic, the initial oxygen therapy is nasal cannulae at 2–6 l/min or simple facemask at 5–10 l/min unless saturation is ,85% (use reservoir mask) or if at risk fromhypercapnia (see below).‣ The recommended initial target saturation range, unless stated otherwise, is 94–98%.‣ If oximetry is not available, give oxygen as above until oximetry or blood gas results areavailable.‣ If patients have COPD or other risk factors for hypercapnic respiratory failure, aim at asaturation of 88–92% pending blood gas results but adjust to 94–98% if the PaCO2 isnormal (unless there is a history of respiratory failure requiring NIV or IPPV) and recheckblood gases after 30–60 min.Condition Additional comments Grade ofrecommendationMyocardial infarction andacutecoronary syndromesMost patients with acute coronaryartery syndromes are nothypoxaemic and the benefits/harmsof oxygen therapy are unknown insuch casesGrade DStroke Most stroke patients are nothypoxaemic. Oxygen therapy maybe harmful for non-hypoxaemicpatients with mild to moderatestrokesPregnancy and obstetricemergenciesOxygen therapy may be harmful tothe foetus if the mother is nothypoxaemicGrade BGrades A–DHyperventilation ordysfunctionalbreathingExclude organic illness. Patientswith pure hyperventilation due toanxiety or panic attacks are unlikelyto require oxygen therapy.Rebreathing from a paper bag maycause hypoxaemia and is notrecommendedGrade CMost poisonings and drugoverdoses (see table 1 forcarbon monoxidepoisoning)Hypoxaemia is more likely withrespiratory depressant drugs, giveantidote if available (e.g. naloxonefor opiate poisoning).Check blood gases to excludehypercapnia if a respiratorydepressantdrug has been taken. Avoid highblood oxygen levels in cases ofPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 20 of 34Grade D

Poisoning with paraquat orbleomycinMetabolic and renaldisordersAcute and subacuteneurologicaland muscular conditionsproducing muscleweaknessacidaspiration as there is theoreticalevidence that oxygen may beharmfulin this conditionMonitor all potentially serious casesof poisoning in a level 2 orlevel 3 environment (highdependency unit or ICU)Patients with paraquat poisoning orbleomycin lung injury may beharmed by supplemental oxygen.Avoid oxygen unless the patient ishypoxaemicTarget saturation is 88–92%Most do not need oxygen(tachypnoea may be due toacidosis in thesepatients)These patients may requireventilatory support and they needcarefulmonitoring which includesspirometry. If the patient’s oxygenlevel fallsbelow the target saturation, theyneed urgent blood gasmeasurementsand are likely to need ventilatorysupportGrade CGrade DGrade CPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 21 of 34

Appendix b. Oxygen prescription boxPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 22 of 34

Appendix c. Administering oxygen therapyACTIONRATIONALE1 Ensure airway is patent To promote effective oxygenation2 The type of delivery device used willdepend on the needs and comfort ofthe patient. Most stable patientsprefer nasal cannulae to masks.3 Ensure oxygen is prescribed on theprescription chart.The exception to this action wouldbe in an emergency situation wherethe resuscitation guideline should befollowed.4 Ensure that the flow rate or dose ofoxygen is clearly stated5 Inform patient or relative/carer of thecombustibility of oxygen6 Show and explain the oxygendelivery system to the patient7 Assemble the oxygen deliverysystem carefully8 Attach oxygen delivery system tooxygen source9 Attach oxygen delivery system topatient in accordance withmanufacturers instructions10 Turn on flow rate in accordance withmanufacturers instructions andprescription11 Ensure patient has either a drink ora mouthwash within reach12 Clean oxygen mask regular withgeneral purpose detergent and drythoroughly. For single patientdevices discard after use.To provide accurate oxygendeliveryTo ensure a complete record ismaintained.In accordance with theadministration of medicinespolicyOxygen supports combustion,therefore there is always adanger of fire when oxygen isbeing usedTo obtain consent andcooperationTo ensure oxygen is being givenas prescribedTo ensure oxygen supply isreadyTo facilitate oxygen delivery topatientTo administer correct % ofoxygenTo prevent drying of the oralmucosaTo minimise infection riskPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 23 of 34

Appendix d. Oxygen delivery devices and equipmentNasal CannualeDESCRIPTIONNasal cannulae consist of a pair of tubes about 2cm long each projecting into the nostriland stemming from a tube which passes over the ears and which is thus self-retainingPURPOSECannulae are preferred to masks by most patients. They have the advantage of notinterfering with feeding and are more convenient as masks during coughing and feeding.They are a variable performance device and deliver a flow rate rather than a percentage ofoxygen.1.2.3.4.ACTION(When using nasal cannula).Position the tips of thecannula in the patient's noseso that the tips do not extendmore than 1.5cm into thenose.Place tubing over the ears andunder the chin as describedabove. Educate patient reprevention of pressure areason the back of the ear.Adjust flow rate, usually 2-4L/min but may vary from 1-6L/min in some circumstances.If the patient is requiring anemollient for the treatment ofdry skin secondary to oxygentherapy, a water basedproduct should be used.suitable products include aquagel and aqueous cream.RATIONALEOverlong tubing is uncomfortable, whichmay make the patient reject theprocedure. Sore nasal mucosa can resultfrom pressure of friction tubing that is toolong.To allow optimum comfort for the patient.To prevent pressure soresSet the flow rate to achieve the desiredtarget oxygen saturation.Paraffin based products should not beused in any circumstances as they areflammable with oxygen.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 24 of 34

Venturi MasksDESCRIPTIONA mask incorporating a device to enable a fixed concentration of oxygen to be deliveredindependent ofpatient factors or fit to the face or flow rate. Oxygen is forced out through a small hole causing aVenturi effect which enables air to mix with oxygen.PURPOSEThis is a fixed performance oxygen mask designed to deliver a specified oxygen concentrationregardless of breathing rate or tidal volume.ACTIONRATIONALE1 (When using Venturi mask)Connect the mask to the appropriateVenturi barrel attached firmly into themask inlet.To ensure that patient receives thecorrect concentration of oxygen2 Fasten oxygen tubing securely. Correctly secured tubing is comfortableand prevents displacement ofmask/cannulae3 Assess the patient’s condition andfunctioning of equipment at regularintervals according to care plan.To ensure patient’s safety and thatoxygen is being administered asprescribed.4 Adjust flow rate. The minimum flowrate is indicated on the mask orpacket. The flow should be doubled ifthe patient has a respiratory rateabove 30 per minute.Higher flows are required for patients withrapid respiration and high inspiratory flowrates. This does not affect theconcentration of oxygen but allows thegas flow rate to match the patient’sbreathing pattern.5If the patient is requiring an emollientfor the treatment of dry skinsecondary to oxygen therapy a waterbased product should be used.Suitable products include aqua geland aqueous cream.Paraffin based products should not beused in any circumstance as they areflammable with oxygenPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 25 of 34

Simple face maskDESCRIPTIONMask has a soft plastic face piece, vent holes are provided to allow air to escape. Maximum50%-60% at15l/min flow.PURPOSEThis is a variable performance device. The oxygen delivered will be influenced by the oxygenflow rate and the patient’s tidal volume and breathing rate. They should not be used in patientswho are at risk of hypercapnic respiratory failure.ACTIONRATIONALE1 (If using simple face mask) Gentlyplace mask over the patient’s face,position the strap behind the head orthe loops over the ears then carefullypull both ends through the front of themask until secure.Ensure a comfortable fit and delivery ofprescribed oxygen is maintained.2 Check that strap is not across earsand if necessary insert paddingbetween the strap and head.To prevent irritation.3 Adjust the oxygen flow rate. Mustnever be below 5L/minTo ensure patient’s safety and that oxygen isbeing administered as prescribed.4 To ensure patient’s safety and thatoxygen is being administered asprescribed.Set the flow rate to achieve the desired targetoxygen saturation.5If the patient is requiring anemollient for the treatment of dryskin secondaryto oxygen therapy a water basedproduct should be used. Suitableproductsinclude aqua gel and aqueous creamParaffin based productsshould not be used in anycircumstance as they areflammable with oxygenPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 26 of 34

Reservoir (non-rebreathe) maskDESCRIPTIONMask has a soft plastic face piece with flap-valve exhalation ports which may be removed foremergency air-intake. There is also a one-way valve between the face mask and reservoir bag.PURPOSEIn non re-breathing systems the oxygen may be stored in the reservoir bag during exhalation bymeans of a one-way valve. High concentrations of oxygen 80-90% can be achieved at relativelylow flow rates.They should not be used for C02 retaining patients except in life- threatening emergenciessuch as cardiac arrest or major trauma.ACTION1 (Non Rebreathe Reservoir Mask)Ensure the reservoir bag is inflatedbefore placing mask on patient, thiscan be maintained by using 10-15litres of oxygen per min.2 Adjust the oxygen flow to theprescribed rate.RATIONALETo ensure the optimal flow of oxygen to thepatient.Inadequate flow rates may result inadministration of inadequate oxygenconcentration to the patient or asphyxiation3 If the patient is requiring an emollientfor the treatment of dry skinsecondary to oxygen therapy a waterbased product should be used.Suitable products include aqua geland aqueous creamParaffin based products should not be used inany circumstance as they are flammable withoxygenPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 27 of 34

Tracheostomy maskDESCRIPTIONMask designed for “neck breathing patients”. Fits comfortable over tracheostomy or tracheotomy.Exhalation port on front of mask. This is a variable performance device.PURPOSEThis is a variable performance device for patients with a tracheostomy or tracheotomy. Theoxygen delivered will be influenced by the oxygen flow rate and the patient’s tidal volume andbreathing rate.ACTION1 Gently place mask over the patient’sairway, position the strap behind thehead then carefully pull both endsthrough the front of the mask untilsecure.2 Adjust the oxygen flow rate toachieve the desired target saturationrange. Start at 4 l/min and adjust theflow up or down as necessary toachieve the desired oxygensaturation range.RATIONALEEnsure a comfortable fit and delivery ofprescribed oxygen is maintained.To ensure that the correct amount ofoxygen is given to keep the patient in thetarget range.3 For any prolonged period ofoxygen treatment via atracheostomy mask humidificationshould be considered either via acold or heated system.4 If the patient is requiring anemollient for the treatment of dryskin secondary to oxygen therapy awater based product should beused. Suitable products includeaqua gel and aqueous creamParaffin based products should not be usedin any circumstance as they are flammablewith oxygenPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 28 of 34

Oxygen flow meterDESCRIPTIONDevice to allow the patient to receive an accurate flow of oxygenPURPOSETo ensure the patient receives the correct amount of oxygenAction1 Attach the oxygen tubing to thenozzle on the flow meter.RationaleTo ensure that the patient receivesthe correct amount of oxygen.2 Turn the finger-valve to obtain thedesired flow rate. The CENTRE of theball shows the correct flow rate.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 29 of 34

Appendix e: Flowchart for Oxygen AdministrationVenturi 24% 2 - 4 L/minNasal Cannulae 1 L/mBLUEVenturi 28% 4-6 L/MinNasal Cannulae 2 L/mWHITEIMPORTANTA TWO STEP INCREASEABOVE THE RED LINE =MEDICAL REVIEWVenturi 35% 8-10 L/MinNasal Cannulae 4 l/mYELLOWVenturi 40% at 10 - 12 L/MinREDOr simple face mask at 5 - 6 L/MinIMPORTANTA ONE STEP INCREASEABOVE THE RED LINE =MEDICAL REVIEWVenturi 60% at 12 - 15 L/MinGREENOr simple face mask at 7 - 10 L/MinIMPORTANTthe following patients are atrisk of Type 2 RespiratoryFailure:COPDCystic FibrosisNeuromuscular DiseaseChest Wall deformitiesMorbid ObesityReservoir mask at 15 L/MinIf reservoir mask required, seek senior medical input immediatelyPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 30 of 34

Appendix f Personnel who mayadminister oxygenAny qualified nurse, doctor, RSCN, RNor physiotherapist. In accordance withpolicy for administration of medicines.Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 31 of 34

Appendix gHumidificationThis should only be used if specifically requested by the doctor orphysiotherapist in the following circumstances.1. If the flow rate exceeds 4 litres per minute for several days2. Tracheotomy or tracheostomy patients (“neck-breathing patients)”3. Cystic Fibrosis patients4. Bronchiectasis patients5. Patients at risk of retained secretionsCan be given by warm or cold humidifier systems(warm humidifier systems are mainly used in critical care areas)Policy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 32 of 34

Appendix (h)HEALTH AND SAFETYAction1 Inform patients and carers about thecombustibility of oxygen2 Oxygen should be stored in an areadesignated as no smoking.3 Electrical appliances should be keptat least five feet away from thesource of oxygen.4 Avoid grease or oil coming intocontact with apparatus5 Store unused cylinders in a dry wellventilated placeRationaleOxygen supports combustion, there is always adanger of fire when oxygen is being used.Oxygen can be potentially dangerous when incontact with sources of ignition andflammable material.Oxygen can be potentially dangerous when incontact with sources of ignition andflammable materialPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 33 of 34

References1. National patient safety agency Rapid Response Report. Oxygen Safety in hospitalsNPSA/2009/RRR0062. O'Driscoll BR, Howard LS, Davison AG; British Thoracic Society. Thorax. 2008 Oct;63Suppl 6:vi1-68. BTS guideline for emergency oxygen use in adult patients.3. http://www.aagbi.org/sites/default/files/postanaes02.pdfImmediate Post Anaesthetic Recovery AAGBI 20024. http://www.aagbi.org/sites/default/files/standardsofmonitoring07.pdfRecommendations for Standards of Monitoring During Anaesthesia and RecoveryPolicy for the prescription, administrationand monitoring of emergency oxygen in adultsPage 34 of 34