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

2. Where have we been? 1990’s – 2005 – aimed at education
– 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

3. Implementation posters

4. BTS Oxygen Audit 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%

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

6. Air Flow Meter’s Concerns over confusing oxygen and air flow meters
2011 audit 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

7. 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

8. 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

9. 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

10. 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

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

12. 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

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

14. 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?