How the rational use of oxygen can improve patient safety, health outcomes and reduce waste

Craig Davidson

Oxygen lead for London Respiratory Team, NHS London

Two faces of oxygen therapy

Oxygen use in England

>85,000 people receive oxygen at homeIt costs C £120, 000,000 (2011)– (30% up on 2006, 10% total cost COPD)

Historically service/cost placed in community

Patients often do not understand why provided or how to use– 23-43% don’t use or don’t need

(Commissioning toolkit, DH)– Up to 51% continue to smoke (v < 15% Canada)

Rationale of home oxygen

• Long term oxygen therapy (LTOT)– primarily to extend life– improve QOL (cognition & sleep)– c 15 hrs/day, downside :dependency & reduced

mobility

• Other forms of Home oxygen service (HOS)– for alleviation symptoms– primarily hypoxia and breathlessness on

exertion– better ambulatory devices new contract– potentially expensive

LTOT use to prolong life

Long time ago• before recognition overlap

syndromes (OSA/OHS & COPD) and treatment (CPAP/NIV)

• not stratified for smoking• benefit small, delayed &

limited number of patients (<300)

• no benefit in less severe hypoxia

Goreka 1997

MRC

Responsible prescribing : smoking and LTOT

Smoking cessation as treatment • 2 in 3 domestic fires in homes

with O2 result of smoking

• 1 in 4 die • Risk can be predicted• Better to not start than to

remove

• 35% patients receive O2 in ambulance/ED

• 18% ward patients treated with O2

• prescribing rare • adjusting and removing

even rarer• Development raised

PCO2 increases mortality

BTS Guideline for emergency oxygen use in adult patients

Prescribing Oxygen

Oxygen is a drug and must be Oxygen is a drug and must be prescribedprescribed

• It should be prescribed to a It should be prescribed to a specific saturation rangespecific saturation range

• Device and flow rate should be Device and flow rate should be adjusted to achieve targetadjusted to achieve target

• > 1 increase in oxygen dose > 1 increase in oxygen dose requires medical review requires medical review

• Oxygen is not indicated unless Oxygen is not indicated unless patient hypoxaemic or in an patient hypoxaemic or in an emergencyemergency

• For most acutely ill patients the For most acutely ill patients the target range is target range is 94-98%94-98%

• For patients at risk of COFor patients at risk of CO22 retention the target is retention the target is 88-92%88-92%

• Disorders which increase risk of Disorders which increase risk of COCO22 retention: retention:– COPD COPD – Cystic fibrosis Cystic fibrosis – Bronchiectasis Bronchiectasis – Chest wall deformityChest wall deformity– Neuromuscular disease Neuromuscular disease – Obesity hypoventilationObesity hypoventilation

Designed by the Oxygen Steering Group July 2009

Reference: www.brit-thoracic.org.uk

In an emergency all patients should receive high flow oxygen In an emergency all patients should receive high flow oxygen

Oxygen & hypercapnic RF2011 BTS audit : 2500 cases

hypercapnic respiratory failure receiving NIV

Respondents asked was hypercapnia O2 induced

• Overall 21% oxygen toxicity– Ambulance 29% v in hospital 62%

• Only 10% took action to prevent in future• eg O2 alert card, person specific protocol (PSP)

LAS already implemented change

Delivery devicesDelivery devices

• Mortality 9% in usual care v 2% controlled therapy NNH 14 (RR 0.42)

• High flow increases– Mortality (2-4,000 avoidable deaths per year)– LOS– Need for NIV– HDU admission

Campbell 1967, Denniston 2002, Joosten 2007, Robinson 2001, Plant 2000, Wijesinghe 2009

National Patient Safety Awards 2011 Patient Safety in Clinical Practice Award (Health Service Journal and Nursing Times)

Targeted O2 in AECOPD

London Clinical Oxygen Network 2012

Barnet

Enfield

Haringey

CamdenIsling-

ton

Waltham Forest

Redbridge

HaveringBarking & Dagenham

Greenwich

Bexley

Lambeth

South-wark

Lewisham

Bromley

Richmond & Twickenham

Wandsworth

Kingston

Sutton & Merton

Croydon

Hounslow

•Tuck-Kay Loke (Croydon University Hospital)•Nikki Davies (Croydon)•Neil Roberts (Primary care Contracting SWL)

•Sonia Colwill (Director of Quality and Prescribing Bromley BSU)•Lynn McDonnell (Ambulatory lead)•Sally Hickman (Greenwich & Bromley)

•Debbie Roots (St Georges Hospital)•Anne Crawford (ONEL)•Belinda Krishek (Chief Pharmacist ONEL)

•Matthew Hodson (Homerton Hospital) •loren.Ateli (PCT)•Barbara Brese (Chief Pharmacist EL&C)Hillingdon

Harrow

Brent

EalingHammersmith & Fulham

Kensington &

Chelsea

West-minster

•Christine Mikelsons (Royal Free Hospital)•Glenda Esmond (Central London Community Healthcare)•Karen Spooner (Community Pharmacy NCL)

•Irem Patel (Imperial College Hospitals)•Beryl Bevan (Chief Pharmacist ONWL)•Will Man (Brompton & Harefield)

NHS London •Jim Pursell (HOS Lead)• Craig Davidson (COG Chair, London Respiratory Team)

BTS medical leads for O2

LRT has (so far) enrolled 23 consultants across London

Work with them • Universal prescription of O2

• Leadership in protecting patients• Push to develop quality O2 assessments • Support RNS & therapists who, most often,

involved in initiation of LTOT– (70% following admission)

• Link with GPs, CCGs & community services

One of aims LCON : promote coordination between hospitals

and community

Graham Delves

Summary

Hospitals need to take a lead in– protecting patients–supervising new starters–reaching out to community–controlling waste

(Lack of) Effect of palliative oxygen in relief of breathlessness in patients with refractory dyspnoea Lancet. 2010 376 :784-93