Your healthcare closer to home

Services provided by Central London Community Healthcare NHS Trust

www.clch.nhs.uk

Barnet Home Oxygen

Assessment Review Service

Bunmi Adebajo

Clinical & Operational Service Lead

Clinical Specialist Respiratory Physiotherapist

Central London Healthcare NHS Trust

1

NHS England Oxygen provision context

In 2012, the DoH & NHS re-ordered the prescription

of oxygen to only be undertaken by suitably qualified

and trained healthcare professionals.

Currently within the NHS in England & Wales,

specifically designated HOSAR services are

commissioned by local CCGs to provide clinical care

and support to their local oxygen user population.

NHS England Oxygen provision context

• The terms of the 2012 home oxygen supply

(HOS) contract requires that prescribers

select suitable equipment for prescription.

• Restriction of GP and all non designated

HOSAR service personnel to ordering only

temporary or emergency supply (HOOF A)

which does not include ambulatory (HOOF

B) devices applies.

3

HOS-AR Services

Why are Home Oxygen Assessment and Reviews services required?

Long-term oxygen therapy in appropriate individuals can

improve survival rates by around 40%.

At the same time 30% of people on home oxygen therapy

currently derive no clinical benefit from it.

In a recent study, at least 15,000 people were found to have no

recorded oxygen usage in a six-month period, at a cost nationally of

£13m per annum.

The total annual cost of the service in England is approximately

£120m. The introduction of HOSAR services has been shown to reduce

annual spend by up to 20%. If the scale of savings were replicated

across England, it is estimated that they could amount to between £10-

20m of savings a year. 4

Barnet HOS-ARHome oxygen assessment review service

The overarching aim of the Barnet HOS-AR is to ensure that home

oxygen is appropriately prescribed to those people who clinically

need it.

The high-level objectives of the HOS-AR are:

• To provide a systematic and integrated Service

• To provide easy access to assessment and follow up procedures delivered by

appropriately qualified and trained healthcare professionals.

• To reduce/eliminate waste and poor quality care, and strengthen affordability and value,

by targeting the service on those who will benefit from home oxygen

• To ensure a higher standard of clinical treatment and improved outcomes, through more

effective and speedier diagnosis

• To ensure that users of the Service have a positive experience of care

Barnet HOS-AR Service

6

Barnet HOS-AR

Four principal stages underpin the service operational delivery

namely:

• Stage 0 Identification and referral of persons for home

oxygen assessment

• Stage 1 Home Oxygen Assessment undertaken

– (a) Assessment for long-term oxygen therapy

– (b) Assessment for ambulatory oxygen

• Stage 2 Follow up home visits for further assessment &

review

• Stage 3 Withdrawal of oxygen therapy (were indicated)

7

National guidance for home oxygen

The Outcomes Strategy for COPD and Asthma and the subsequent NHS

Companion Document to the Strategy recommend :

Routine pulse oximetry in people with COPD whose FEV1 is lower than

50% predicted to identify those who may need long-term home oxygen

therapy and, for those identified, ensure referral for structured assessment

of need by a home oxygen assessment and review service

The NICE Clinical Guideline for COPD recommends home oxygen

assessment and review assessment for the need for oxygen therapy in :

Patients with very severe airflow obstruction (FEV1 < 30% predicted)

Patients with cyanosis

Patients with polycythaemia

Patients with peripheral oedema

Patients with a raised jugular venous pressure

Patients with oxygen saturations ≤ 92% breathing air.

8

National guidance for home oxygen

The NICE Quality Standard for COPD also highlights the

importance home oxygen assessment and review for:

People with COPD potentially requiring long-term oxygen

therapy are assessed in accordance with NICE guidance by a

specialist oxygen service.

People with COPD receiving long-term oxygen therapy are

reviewed in accordance with NICE guidance, at least annually,

by a specialist oxygen service as part of the integrated clinical

management of their COPD

9

Screening

In considering the need for oxygen therapy, the

first step is pulse oximetry, to determine whether

the individual is hypoxaemic. Pulse oximetry should

be routinely available in general practice

Such a modest investment would enable general

practice to screen patients. People who are shown to

be hypoxaemic i.e. where SpO2 is less than or equal

to 92%, whose condition is stable, should be

referred to the HOS-AR Service to have a full

assessment carried out.

. 10

Screening

Where the person’s diagnosis is unclear or when significant

co-morbidity might contribute to breathlessness or

hypoxaemia, e.g. heart failure, they should be referred to an

appropriate specialist physician

Any person with COPD who is hypoxaemia needs a confirmed

and quality-assured diagnosis

People with potential hypercapnia respiratory failure should be

also reviewed by a physician.

People whose oxygen saturation levels are satisfactory

(above 95%) do not need to be seen by a HOS-AR service 11

• Known clinical diagnosis

• Optimisation of other therapeutic measures

• Known Chronic Hypoxaemia > 92%

• SpO2 at rest or exercise de-saturation of

> 4%, tested through pulse oximetry

Referral Criteria considerations

Referral sources

• The Barnet HOSAR service can receive referrals from a

broad range of sources that have made an initial

assessment. Such referrers include :

• Primary Care

• Community services

• Secondary Care

• Tertiary Care

• Others (for example: Occupational health, private health,

self referral by patients)

13

Clinical indications for referral & disease types

• Known Chronic

Hypoxaemia < 92%

SaO2 at rest

• COPD – approx. 70% of

patients

• Severe chronic asthma

• Cystic fibrosis

• Interstitial lung disease

• Bronchiectasis

• Pulmonary vascular

disease

• Primary pulmonary

hypertension

• Pulmonary malignancy

• Chronic heart failure

• Nocturnal hypoventilation as

adjunct to ventilatory support

techniques (NIV or CPAP)

•Neuromuscular/spinal/chest

wall disease.

14

15

Hypoxic/Complex

Include complex cases with co-morbidities; or

Other diagnoses e.g. sleep apnoea

May require further specialist input prior to

oxygen therapy

Confirmed hypoxaemia < 92%

SpO2 + requires oxygen

Borderline cases SpO2

92-93%

Borderline

No hypoxaemia transfer back to

referrer

No O2 needed

Pulse Oximetry Result

Adult Home Oxygen Service assessment & review Standard Referral

pathway

16

Exclusion

• Non Barnet GP registered Adult

• Patient residence no more than 0.5miles across Barnet

Borough boundary

• Persons who cannot clinically benefit from home oxygen.

• Children (as they are under paediatric services and usually

have their own community services).

• People who have not had a clinical assessment and quality

assured diagnosis (except specific instances of palliative

patients who are not assessed or reviewed through the

normal service.

• Palliative patients should have evidence of hypoxaemia. Some

assessment of equipment may be needed and thus prescribers for

palliative patients may need discussion with the HOS-AR service. 17

LTOT ( Long term Oxygen therapy)

• Completion of a Home Oxygen

Consent form (HOCF) for all patients

when first assessed.

• Completion of a Home Oxygen

Risk assessment form (IHORM) for all

patients when first assessed

• Measured arterial blood gas tensions

– PaO2 at or below 7.3 kPa breathing

air, when clinically stable

• Assessment of impact on PaO2

following supplemental oxygen being

administered for at least 30 min – aim

for at least 8kPa

• Assessment for hypercapnia

• Assessment and training using

equipment that patient will use within the

home, ensuring safe use.

• Completion of HOOF A form

• Safety check

• Feedback to referrer/GP on outcome

of assessment and oxygen orders

• Home visit within 4 weeks of

commencement of treatment, carer to

be present if appropriate

• Review equipment risks and issues

• Assessment of further education needs

of both patient and carer

• Review of clinical status and indication

for continuing oxygen requirements

18

AMBOT ( Ambulatory Oxygen therapy)

• Assessment for use of oxygen

therapy during exercise and

activities of daily living

• Exercise oxygen desaturation of fall

in SpO2 of 4% to a value of <90%

• Short term response to use of

oxygen when undertaking exercise

tests such as 6 minute walk test or

shuttle walk test

• Determine oxygen flow rate required

to correct exercise desaturation

(SpO2 above 90%)

• Gap of 30 min rest between walk

tests is recommended

• Assessment of walking distance and

measurement of resting/end exercise

dyspnoea using a visual analogue

score/ Borg score

• Assessment of likely compliance

• Patient and carer training

• Safety check

• Completion of a HOOF B

SBOT

• Cluster headache is the only indication for oxygen therapy in the absence

of hypoxia.

• High flow oxygen is very effective in some patients in relieving

symptoms of an acute cluster headache (CH) quickly and safely.

• The evidence base is clear, and the use widely accepted in the medical

and CH patient communities (www.ouchuk.org).

• In the majority of these patients, the headaches occur in clusters

(bouts).

• Cluster headache bouts alternate with remission periods, when patients

are pain free. During the remission phase oxygen may be unused but

carried just in case patients have sudden recurrence of symptoms.

• Patients are often started on a supply by a neurologist via a GP and

thereafter self-manage their supplies; this can lead to problems with

under supply, misuse and frustration. The range of oxygen equipment

which can be prescribed by a non-specialist is limited and

specialist assessment is needed to get this right. 20

Palliative care

• A full assessment not always appropriate, however there must be

clinical evidence of hypoxaemia

•The RCP guidelines oxygen therapy in palliative care recommends use for

were hypoxaemia is present.

Oxygen is not a treatment for breathlessness• A recent systematic review concluded that oxygen is not beneficial to

non-hypoxaemic patients with cancer (Uronis, 2008) and in 2010 a

randomised controlled trial (Jenkins et al) found that patients with

nonhypoxaemic breathlessness gained no benefit from oxygen

therapy.

• Home Oxygen Therapy (Long Term Oxygen Therapy LTOT and

ambulatory oxygen if appropriate) is provided to patients with cancer

and coexistent chronic hypoxaemia.

Palliative care

• Home Oxygen should not be routinely provided for lung cancer

patients at diagnosis and should not be provided solely for the relief

of breathlessness in cancer. Other pharmacological and non-

pharmacological therapies are more appropriate

• Severe intractable breathlessness in advanced non-malignant respiratory

disease such as COPD may require palliation in the absence of terminal or end-

of-life disease . In such patients oxygen is not effective in relieving

breathlessness unless there is proven hypoxaemia

• In patients with advanced non-malignant respiratory disease in whom death is

imminent oxygen may be used where hypoxaemia cannot be proven without

undue discomfort to the patient

• There may be some patients that may develop intermittent hypoxaemia and for

those an intermittent source of home oxygen probably in the form of oxygen

cylinders may be appropriate

22

Intermittent oxygen therapy (SBOT)

It is now recognised that short burst therapy is not beneficial for relief of

breathlessness in the absence of hypoxaemia and thus should not be

used.

Intermittent oxygen therapy may be considered where patients develop

transient hypoxaemia e.g. in exacerbations of COPD, heart failure and also

in cancer patients. Such patients may develop intermittent hypoxaemia

when they develop a chest infection or heart failure in the presence of

underlying pulmonary malignancy.

Intermittent oxygen therapy will need specialist

assessment.

23

Cigarettes and E-cigarettes - The Risks

The dangers of using an electronic cigarette or

similar device whilst using oxygen therapy are

exactly the same as in smoking ordinary

cigarettes.

Electronic devices also carry a risk of

explosion or ignition and can cause a

fire whilst recharging.

24

Travel

• Oxygen prescription does not automatically exclude air

travel

• Established oxygen therapy users should speak to their

doctor in advance about air travel as a fitness to fly

assessment should be considered in all patients receiving

LTOT

• Travel includes all modes and not restricted to aircraft,

trains, cruise, ships, ferries

– Patient responsibility to check with airlines in advance to establish

what their policies and capabilities before making arrangements

– Arrangements for oxygen therapy is not only for in-flight provision

but also for transit and transfers within the airport. This must be

done at least one month before the trip

25

Review considerations

• 6 monthly review assessment for established

stable users. (CH may be annually.

• ABG or CBG may be required .

• Annual ABG to assess oxygenation and

hypercapnia; more frequent if clinical indications

• Safety checks, IHORM updates

• Renewal or adjustment of HOOF B Order if

requirements have changed

• Consideration of removal if no longer required

26

Risk considerations

• Appropriate clinical presentation

• Does the patient smoke?

• Does any one else smoke at the patient’s property?

• Does the patient use e-cigarettes

• Is there a history of drug or alcohol dependency?

• Does the home have a working smoke detector?

• Has there been a previous fire in the house?

• Has the patient had a fall in the previous three months?

• Does the patient have any identified cognition, understanding,

behaviour issues?

• Do they live in a property joined to another?

• Is property a multiple occupancy property?

• Can they independently vacant the premises?

• Are there vulnerable dependents at the residence?27

IHORM Form

28

HOCF form

29

Air liquide Portal

30

Interdependencies with other services

• The Barnet HOS-AR is interdependent with all other respiratory services

(including lung function), cardiac services, neurology, care for the elderly, social

care, smoking cessation services, pharmacists and palliative care. The service

will liaise as appropriate with these services.

• Local fire service . When required the Barnet HOS-AR will notify the local fire

service when oxygen equipment is provided and, in the case of persistent

smokers, a risk assessment of the premises requested of the fire service.

• Ambulance service . Whilst ambulance services now employ universal

precautions (28% oxygen) with respect to the risk of high concentration oxygen

in acutely unwell people with COPD, and others at risk from oxygen induced

hypercapnia, people known to be at risk should be advised and oxygen alert

cards provided. In some cases, a specific protocol (PSP) may be appropriate

depending on local ambulance service arrangements

31

Barnet Home Oxygen Referral Form

Patient Population by modality

Referral sources

34

Top five Barnet Oxygen users clinical code

35

COPD45%

Primary Pulmonary Hyper tension

26%

Cluster headache13%

ILD11%

Other conditions5%

Top five Barnet Clinical Codes for Oxygen

Summary

• Oxygen is a treatment for hypoxia not breathlessness.

• Oxygen therapy should always be planned, prescribed and reviewed by

staff trained in oxygen prescription and use.

• Long term oxygen treatment (15-24 hours per day) should only be

prescribed after specialist review and risk assessment.

• Patients who may benefit from ambulatory oxygen require specialist

assessment.

• Patients who smoke need very careful consideration for long term

oxygen therapy. Hypoxic patients who smoke should be offered clear

communication of the reasons oxygen therapy cannot safely be offered

to them whilst they smoke, individualised information about the benefits

of smoking cessation for them, treatment for tobacco dependence and

planned follow up.

36

Summary

• Patients on long term oxygen therapy at risk of harm from excessive oxygen

should be identified and their care plan shared with their GP and local hospitals

as well as ambulance and out of hours services.

• Home Oxygen Service Assessment and Review (HOSAR) services integrated

with local respiratory services are effective and vital to ensure evidence based

patient centred care and optimal value for money.

37

Questions

38