Addenbrooke’s Hospital Implementation of the BTS 2008 Emergency Oxygen Guidelines – the story so far Caroline Owen Respiratory Nurse Specialist Addenbrooke’s Hospital, Cambridge

Where have we been? 1990’s – 2005 – aimed at education 2005-2008 – reviewed process – stickers in charts 2008 – BTS guidelines aimed to simplify and improve oxygen administration 2009 – NPSA alert No prescription Poor monitoring of the patient Incorrect administration – confusing air and oxygen flow meters Equipment – empty cylinders 2010 – Addenbrooke’s guideline 2012 – Never event 2014 – E-hospital

Implementation posters

BTS Oxygen Audit 2013 - Summary of data collected in comparison to National data and previous data collected Data Assessed Ad’brooke 2013 National 2012 2011 Nationally 2010 % of patients using oxygen with a prescription with a target range 94% 55% 46% 75% 48% 72% % of signatures to drugs rounds 87% 21% 76% 20% 61% 32% % of observations to rounds 123% 100% 106% 108% 96% % of patients within target range 74% 64% 78% 57% 67%

Challenges Signing drug chart Oxygen titration (audit poor to identify) ED Ambulance Services – ‘Alert’ cards Surgery Resuscitation guidelines & Oxygen guidelines Airflow meter confusion

Air Flow Meter’s Concerns over confusing oxygen and air flow meters 2011 audit - 384 beds checked – 106 air meters in-situ – majority not being used STANDARD REQUIRED: Air flow meters should be taken out of the wall when not in use Air flow meters should be kept in a dedicated place Air flow meters need high-lighting they are air and not oxygen Airflow meter covers

BEWARE! DON’T CONFUSE OXYGEN AND AIR FLOW METERS! REMOVE WHEN NOT IN USE KEEP IN A SPECIAL ALLOCATED PLACE IN YOUR AREA OXYGEN FLOW METERS KEEP IN THE WALL IN CASE OF EMERGENCIES IT’S BLACK AND LABELLED “AIR” IT’S WHITE AND LABELLED “O2” A new cover to help remind you it is air

Electronic Hospital Mandatory for all trusts by 2020 to be paperless Addenbrooke’s introduced an electronic system using Epic software in October 2014 Other hospitals have chosen different software We no longer use paper and all communication, charting and prescribing is done on the computers Access from inside the hospital and outside; on laptops, smart phones and i-pads

E-hospital considerations for oxygen prescribing What requirements must be fulfilled? Highlight these early on in the design When should oxygen be prescribed – on arrival into ED or later when patient is fully assessed? What should it look like? Should all patients be allocated a target saturation? What alerts may you want to add? Early days – trying different prescribing option…. When – difficulties of on arrival – many screens – good education required for initial care – improving with liaison with ambulance services Look like – discuss our approaches with ordering – on a ‘drug chart’ or an ‘order’ – pro’ and con’s for both - current – target sats for all patients Best practice alerts – aiming for type 2 alert

E-hospital considerations for nurse administration How should they see the oxygen prescription or order? How frequently should they ‘sign’ for it? Who should sign for it? Vital sign frequency can be ‘ordered’ Which measures can be applied to improve safety? Currently nurses have a worklist which will remind them to check and document the saturations for the patient HCA’s and students complete a flow sheet which the registered nurse may access Debate who should sign these? Registered nurses must cosign all HCA and student work – does it make it safer having all staff aware of target saturations – previously only on drug chart…. Measures – ideally changing colour if out of saturation range, not currently available - reminder comes up that they have documented a saturation out of range and they should address this

Audit Run a report for patients on oxygen Adapt to needs of the BTS audit criteria

Potential Advantages No paper – changes can be made without altering previous charts Better record keeping – neater! Easy access Visual reminders for doctors to write up; nurses to sign for. If out of range – alerts staff to address Easy audit Best practice alerts

Potential Disadvantages Adapting to a new way of working Many screens leads to information overload Requires good data input

Conclusion Any questions? Oxygen guidelines are now common place Audit results are exceptional No never events It is the challenge of E-hospital to maintain and continue to improve processes Any questions?