WGH Respiratory Quality Improvement Team

In-Patient Oxygen Safety

Objective: Ensure all patients needing supplemental oxygen

have an appropriate prescription and oxygen administration

National Guidelines. 2008 & 2017

“this is an area of medicine where there are many strongly held beliefs.......

but very few randomised controlled trials”

BTS Guidelines 2008/2017

OXYGEN PRESCRIPTION

• Oxygen should be prescribed to achieve target saturations of 94-98% for most acutely ill patients, or 88-92% for those at risk of hypercapnic respiratory failure

• Target saturation should be written or ringed on the drug chart

• Aim is to maintain normal or near normal saturations

Baseline WGH Oxygen Audits 2017

Patients on Oxygen Correctly Managed

AMU & Ward 54 (Multiple Days Spring 2017)

97 10

Whole WGH July 2017 53 1

Rolling Weekly Audit Ward 54 (August 2017)

40 3

190 14

Background

Baseline Ward 54 Audit Results

• 5 out of 53 patients on oxygen had a prescription (9%)

• 1 prescription was valid as per BTS Guidelines (1.9%)

• This patient was only within target oxygen saturation 50% of the time

NEWS Chart

Current O2 prescribing in Lothian

Aim statement

80% of respiratory patients receiving oxygen therapy on ward 54, WGH have a valid prescription and are within their target saturation range, as per BTS Guidelines for Oxygen Use in Adult in Healthcare and Emergency Setting, by March 2018

Who is involved with Oxygen?

• Nurses

• Physiotherapists

• Pharmacists

• Nurse Specialists

• Doctors

• Occupational therapists

• Clinical support workers

• Patients and their relatives

Patient admitted to ward 54

Review and decide if needs adjusted or continued on

usual oxygen

Nurse commences oxygen therapy

Nursing teamO2 saturation is monitored at

least 4 x/ day and delivery adjusted to maintain patient

within target

Decision to discontinue

O2

Wean oxygen as per guidelines

when suitable or return to baseline

LTOT dose

LUHD PRESCRIBING of OXYGEN on WARD 54, WGH as per BTS GUIDELINES, 2017Process Map

Observations and O2 delivery documented

on chart

At risk of CO2retention?

Pharmacist and physiotherapist reviews drug chart and oxygen administration.

Refer any issues back to medical or nursing team as needed

Patient on LTOT?

Decision made to adjust

oxygen delivery

No O2 required. Continue to monitor

as per policy.

SpO2 ok

Oxygen saturation prescribed on drug chart as per guidelines*

SpO2 below range

Daily medical review of oxygen prescription and saturations. ABG’s

as needed. Document on ward round.

*BTS guidelines state oxygen should be prescribed as target saturation 92-98%

or 88-92% for patients at risk of hypercapnia

Oxygen saturation measured

NHS Lothian Oxygen Quality Improvement Project

80% of respiratory

patients receiving oxygen

therapy and with a valid

prescription on ward 54, WGH are within their target oxygen

saturation range, as per

BTS Guidelines for Oxygen Use

in Adult in Healthcare and

Emergency Settings, by March 2018

Lack of suitable paperwork in line with national guidelines in

NHS Lothian

No paperwork to support correct prescribing, monitoring and

adjustment

Development of specific oxygen prescribing and monitoring chart

Explore the possibility of developing SEWS chart

Medical staff support, education Presentation of project at medical staff MDT meetings to highlight

importance of prescribing oxygen

Train medical staff to prescribe on current medicine chart until new paperwork available

Incorporate into FY1 training programme

Staff education and training

Lack of training resources and local guideline

Develop guidelines for administration of oxygen

Staff awareness sessions + reminders to check oxygen at drug rounds and ward rounds

Develop e-Learning module and make mandatory for all ward staff

Belief that Oxygen is not a medicine/ lack of awareness of guidelines

Staff engagement Medical staff engagement Agree with senior medical staff and action plan for Drs to prescribe and review

Nursing staff engagement Reminders at safety brief

Engagement of all staff involved in oxygen e.g. physio and pharmacy

Poster campaign, intranet, corridor campaign

Culture of acceptance of poor practice

throughout organisation on oxygen

prescribing and administration

Lack of awareness and reporting of harm

Improve error reporting and present this to team and management

Lack of checks/ balance from staff in support roles

Encourage pharmacists and physios to review oxygen and feedback to prescribers and nursing staff

Lack of strategy for NHS Lothian Engage with various groups/ committees to gain agreement of plan

for roll-out within NHS Lothian

Outcomes Primary Drivers Secondary Drivers Change ideas

Stickers

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Pe

rce

nta

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atie

nts

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id p

resc

rip

tio

n

Patients with a valid prescription

Process Measure 1 Run Chart

Sticker V1

Sticker V2 + ward round reminder

Process Measure 2 Run Chart

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Patients within target range

Rule 1 - Shift (6+ above CL)

Rule 1 - Shift (6+ below CL)

Rule 2 - Trend (5+ decreasing) Rule 2 - Trend (5+ increasing) Rule 3 - Too Many/Too Few Runs Centre Line (running median)

Wrong stickers being used

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Pe

rce

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d o

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ith

a v

alid

pre

scri

pti

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d

wit

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Patients with a valid prescription AND within target range

Outcome Measure Run Chart

MDT presentation

Sticker V1 Sticker V2

Baseline data

Ward round reminder

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100

01/09/2017 01/10/2017 01/11/2017 01/12/2017 01/01/2018 01/02/2018 01/03/2018 01/04/2018

Oxygen Process Measures, Monthly, Ward 54 WGH

% with valid prescription P1

% nurse monitoring documented P2

% within Target Range P3

Outcome measure, monthly

MDT presentation

Stickers V1

Stickers V2

Structured ward round

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Oxygen Outcome Measure, Ward 54 WGH

Overall compliance

Median

Target

What has worked well

•Multidisciplinary team involvement in this project •Regular audit cycles •Regular feedback to all team members via respiratory lunchtime meetings •Staff engagement across all disciplines • Using easily printable sticker template- available on all wards

What we learnt along the way

•Keep it simple • Sometimes taking a leap is better than small tests of change •Overhauling a system takes time and effort •The less choice the better for target saturations • There is no room for complacency- the hardest part is yet to come!

Moving forward

• Roll out to MAU and potentially other sites

– Update drug chart

• Trial for 1 week and adapt

• Print 1000 copies of new chart for roll out

– Ongoing data collection

– Meet with MAU staff groups to discuss

– Presentation at Lothian respiratory meeting

Moving forward

• Staff Questionnaire about training needs and beliefs around oxygen

– Develop training plan based on results for staff

– Ongoing training of new medical trainees and new ward staff

• Explore NEWS2 charts

• Ongoing sustainability and monitoring

• Publication

Data collection

Discussion

Ambivalence is unacceptable

Respiratory will be to be the driving force behind this change across Lothian

Electronic prescribing is coming- and oxygen prescribing will be incorporated

With thanks to... Crichton Ramsay, Douglas McCabe, Laura

Thompson, Jill Gill, Clem Nehil, Adeline Tan, Ruth Aldridge and all the Ward 54 staff

Questions?