Clinical Director of Pharmacy

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1 Guideline Title: Ref No: 2251 Version: 1 Document Author: Ratified by: Patient Transport Team Leader Care and Clinical Group Clinical Director of Pharmacy Date 20/12/2017 Date: 20/12/ /09/2017 Review date: 05 January 2021 CONTENTS 1. Introduction.Page 2 2. Oxygen Basics Page 2 3. Transportation of the Oxygen Dependent Patient..Page 5 4. Use of Oxygen in Emergency Situations.Page 7 5. Oxygen in the Community.Page 9 Appendix 1 BOC leaflet: Medical Oxygen Version 1 (January 2018) Page 1 of 10

2 1. Introduction This document has been created to outline the correct techniques regarding the usage of compressed medical oxygen, and the responsibilities of all trained crew members whilst on and off any NHS trust site. It is the responsibility of each crew member to read and understand these guidelines. 2. Oxygen Basics 2.1 What is Compressed Medical Oxygen (CMO)? Compressed medical oxygen is quite simply pure gaseous oxygen supplied in high pressure cylinders that is used for medicinal purposes. This can only be prescribed by a healthcare professional and is used to treat a variety of different ailments, usually caused by a debilitating lung condition. CMO is also used to provide vital oxygen to patients in an emergency situation, and can be administered by anyone trained to do so, as described in Section BOC Cylinders and the Types we Use BOC provide 15 different types of oxygen cylinder, all varying in size, construction, type of valve or outlet pressure. However, at Patient Transport, we only have to remember 2 of these. Displayed in the tables below are the estimated running times for both sizes of cylinder at different flow rates, and the amount of gas in the cylinder shown as a percentage. CYLINDER SIZE: CD "CD" SIZE CYLINDER WHEN FULL CONTAINS 460 LITRES Flow 100% 100% 75% 75% 50% 50% 25% 25% Rate Minutes Hrs/Mins Minutes Hrs/Mins Minutes Hrs/Mins Minutes Hrs/Mins CYLINDER SIZE: HX "HX" SIZE CYLINDER WHEN FULL CONTAINS 2300 LITRES Flow 100% 100% 75% 75% 50% 50% 25% 25% Rate Minutes Hrs/Mins Minutes Hrs/Mins Minutes Hrs/Mins Minutes Hrs/Mins Version 1 (January 2018) Page 2 of 10

3 2.3 How to Operate Cylinder/Preparations for Use When you have been allocated a particular patient who requires CMO, make sure you have prepared the cylinder for use by adhering to the following stages: Prior to use: Take the bottle from the cylinder housing and check the content is sufficient for the job you re completing. (If it is a new bottle the needle should read in the green zone.) Check the expiry date on the batch label. Turn the black open/close hand-wheel until it is open fully. (If it is a new bottle, remove the grey tamper evident cover first) Pull down the grey hinged door covering the fir tree outlet and attach tubing, ensuring a tight seal is made. Administer the prescribed flow rate by rotating the flow selector dial. After use: Turn flow selector dial to 0 Remove oxygen tubing from cylinder and connect to the next piece of oxygen delivering equipment. Turn black hand-wheel to off, making sure to turn completely. Place cylinder back into secure holding. Complete oxygen report form (refer to Section 3.5). Only those trained to do so should operate compressed oxygen cylinders 2.4 Oxygen store procedure Take the labelled oxygen store key from the key locker in the crew room. Disarm the alarm with the grey fob by placing it against the black box on the wall. A light should appear green. Version 1 (January 2018) Page 3 of 10

4 Go to the door on your right and unlock the 3 locks. Replace the empty cylinder with a full one. Relock the door and re-arm the alarm by placing the fob against the black box twice. The light should turn from green to red and a buzzer should sound. Return the oxygen store key to the key box 2.5 Oxygen safety/warnings There are a number of safety precautions to observe when handling oxygen cylinders. Despite its seemingly harmless nature, there are some properties that make its misuse potentially very dangerous. Whether in use or not, keep all cylinders away from any sources of ignition. Although compressed oxygen is not flammable, it is a very strong oxidant and will fiercely support and intensify combustion. Smoking is prohibited anywhere in or near the vehicles. When compressed oxygen and hydrocarbons such as oil and grease are combined, they have the potential to react violently and may ignite spontaneously with explosive violence. Never allow oil or grease to come into contact with a cylinder or its components. Oxygen enrichment, although highly unlikely, is a hazard everyone should be aware of when operating oxygen cylinders. Oxygen enrichment is a term used to describe a situation in which the oxygen concentration has risen above the normal composition for air. This may be caused by any of the following: Leaks from a damaged cylinder. Leaks from faulty equipment or poor connections. Not closing valves properly after use. Inadequate ventilation during CMO usage. Oxygen enrichment can enhance the potential of the previously mentioned hazards occurring, and should not be taken lightly. If you suspect oxygen enrichment, turn off all cylinders and ventilate the vehicle. Do not mistreat or drop the cylinders to avoid damaging or compromising their structural integrity. All types of fire extinguishers may be used when dealing with a fire involving medical oxygen cylinders. Version 1 (January 2018) Page 4 of 10

5 3. Transportation of the Oxygen Dependent Patient 3.1 Cylinder Storage When a vehicle check is performed, ensure that each cylinder on that vehicle is secured in either the correct housing or fastening. Two-man vehicles should be equipped with 2 cylinders only, located in either of the housings (inbetween the seats on the near side of the ambulance or by the back doors) or, if available, underneath the stretcher. At least one cylinder should be full, with the other above a quarter. Single-man vehicles should have one cylinder already equipped, that should be at least half full. The Bariatric vehicle should be equipped with one HX cylinder above a quarter full, and 2 CD cylinders; one full and the other above a quarter. If you find a cylinder with an unsatisfactory amount in, it must be replaced. If you do not have time to replace it before the end of your shift, leave a note for the next crew to inform them to do so. 3.2 How Many Prescribed Litres of Oxygen Can Patient Transport Service (PTS) Staff Administer? In the majority of instances, the maximum oxygen flow rate we would transport a patient on is 6 litres. Anything above this, the patient would be deemed as too high of a risk of deterioration. However, there are circumstances where we would review this limit, and authorise the transportation of a patient requiring more than 6 litres. Such circumstances include the transportation of imminent end of life or palliative care patients, in which they have been prescribed high flow oxygen to ease the symptoms of their condition. Another example, albeit rare, would be a patient who has been prescribed high-flow oxygen in order to facilitate their daily life. As this flow rate would be somewhat of a normality for this type of patient, we would class them as stable and not requiring the assistance of a paramedic crew. 3.3 Use of Cylinders in Transit Once the patient has been seated and fastened in, place the cylinder in the appropriate housing and secure tightly. Make sure there are no kinks in the tubing and that it is not restricted by the seatbelt. As previously mentioned, all cylinders should be adequately restrained at all times. If a patient is sat out of reach of the cylinder housing, it is reasonable to secure it with a seatbelt; ensuring the vehicle is stationary whilst doing so. If you swap stretchers with another crew, ensure you take your cylinder with you. To avoid oxygen enrichment, it is safe practice to provide ventilation during administration. Version 1 (January 2018) Page 5 of 10

6 (Refer to section 2.5) 3.4 Monitoring Oxygen Dependent Patients During Transfer The oxygen dependent patients we take have been prescribed a certain amount in order to keep them comfortable and stable. For this reason they do not require constant monitoring and a clinician will have deemed them fit enough to be taken by Patient Transport. The guideline is: 1 oxygen dependent patient per 1 crew member Therefore, single-man crews may take 1 oxygen dependent patient, and two-man crews can take Oxygen Report Forms These forms should be completed every time a patient requiring oxygen is transported. Oxygen report forms are a method vital in documenting the administration of compressed medical oxygen. These forms are kept on file for up to 2 years to be referred to as required. Version 1 (January 2018) Page 6 of 10

7 4. Use of Oxygen in an Emergency Situation This section includes procedural information in the event of an emergency involving any of our patients, not just those already receiving CMO. In an emergency situation an oxygen prescription is not required, therefore oxygen should be given to the patient immediately without a formal prescription, until the patient is stabilised and a senior medical assessment can be made. 4.1 Oxygen Administration Who and How Much? An emergency can arise any time, and it is our responsibility to act as quickly as possible. All of our staff receive resuscitation training during the mandatory annual training update, which allows us the skills to be able to begin CPR and administer the maximum available litreage of oxygen via bag and mask. Paramedics will require any information regarding initial first aid when they arrive at an incident, so it is important to keep track of what you have done and when. 4.2 Non-Rebreathe Mask/Bag and Mask Preparation Each vehicle is supplied with a non-rebreathe mask and a bag and mask, which should be contained within a sealed bag to avoid contamination. The date on these should be checked regularly. Bag and Mask Non-rebreathe mask As a rule of thumb, the non-rebreathe mask is for the conscious patient who is unable to breathe adequately, and requires oxygen to enrich the concentration in their blood. The bag and mask is designed to give rescue breaths to the unconscious patient when performing cardio pulmonary resuscitation. If you suspect your patient is in respiratory distress, remove the non-rebreathe mask and attach it to an oxygen cylinder. Turn the flow rate selector to the maximum and press your finger onto the valve inside of the mask, allowing the bag to inflate. Inform the patient before placing the mask onto their face, to avoid further angst. If your patient is unconscious; remove the bag and mask, connect an oxygen cylinder to the tubing and turn flow rate to 15. Hold the mask against your chest to allow the bag to inflate and then begin rescue breaths. Version 1 (January 2018) Page 7 of 10

8 4.3 Post Emergency Procedure Everyone reacts differently to emergency situations, and the surge of adrenaline experienced during an incident can often impair or mask other senses and feelings. After, it is important to take time and process the situation, allowing the come down to subside before doing anything else. Have a drink and something to eat to ensure your blood sugar level is sufficient, and inform Control or a Team Leader of the circumstances. Return to base and find somewhere to relax and further process your thoughts. A Team Leader will check on your welfare and enquire as to whether you would like to go home or feel ready to continue work. If you feel ready to return to work, ensure your oxygen is restocked and inform control you are clear. If at any point throughout the day you feel you need more time, inform a Team Leader who will instruct you to go home at your earliest convenience. 4.4 Treatment of a COPD (Chronic Obstructive Pulmonary Disease) Patient COPD is the name for a group of lung conditions that cause breathing difficulties. It includes conditions such as: Emphysema damage to the air sacs in the lungs Chronic bronchitis long-term inflammation of the airways Common symptoms of COPD include: Increasing breathlessness A persistent chesty cough Frequent chest infections Persistent wheezing The symptoms will usually worsen gradually and, over time, make daily activities increasingly difficult. Unlike most patients, it is widely suggested that the administration of high flow oxygen in the event of respiratory distress in a COPD sufferer, will actually impede recovery. If this situation were to arise on a Patient Transport ambulance, it is best practice to calmly explain to the patient that increasing their oxygen will only exacerbate their symptoms. Pull over, open the side door and advise them to utilise their inhaler if they have one. If the situation does not improve, dial 999. In the event of a cardiac arrest, follow the standard procedure, delivering rescue breaths as per your mandatory training. The most widely known exception to the rule of high-flow oxygen is the casualty with a Chronic Obstructive Pulmonary Disorder (COPD) such as bronchitis or emphysema. While it is not fully understood or agreed why COPD casualties respond better to low-flow oxygen is it universally accepted. Version 1 (January 2018) Page 8 of 10

9 NHS Unclassified Where a healthy person would typically have oxygen saturations of over 95% breathing normal air, COPD casualties would normally have saturations of 88-92%, as such we aim to oxygenate to that level. Moderating oxygen flow to a target saturation level titrating has been seen to reduce mortality by 58% compared to high-flow oxygen in COPD casualties. Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. (2010) Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomized controlled trial. British Medical Journal. Oct 18; 341: c Oxygen in the Community 5.1 Oxygen Concentrators Concentrators work by filtering oxygen from the air and condensing it into pure gaseous oxygen, creating an inexhaustible supply for continuous use around the home. Some of the patients we transport after discharge from a ward will have been prescribed CMO whilst in hospital, and will have had an oxygen concentrator delivered to their home. Although this will have been plugged in and the tubing set up, it is down to us to assist the patient in turning the machine on, and ensure it is functioning properly before leaving. The two main concentrators we come across look like the ones below. They work in the same way, and will require you to turn them on at the switch and ensure the flow rate gauge settles on the correct number. Check that the tubing is not kinked and advise the patient of the potential trip hazard. 5.2 Patient Personal Ambulatory Cylinders Each patient with a concentrator will also be equipped with portable cylinders in case of break downs or power cuts. If they are being transported to an appointment, they will have to take one with them to use whilst at the hospital. When you arrive at the hospital, inform the relevant department and enquire as to whether they have their own oxygen the patient could use. Inform control that the patient has been left on oxygen and that they may require a quicker than average collection to avoid them running out. Version 1 (January 2018) Page 9 of 10

10 NHS Unclassified Do not leave or swap a cylinder with a patient 5.3 Patient Queries Regarding Their Oxygen Therapy If a patient has any queries regarding their home oxygen therapy, invariably they will have been given a leaflet with all of the information they require. If they have mislaid it, direct them towards the NHS choices website that may provide them with the answers they need. The final port of call will be to call Dolby Vivisol on also listed on NHS choices. They are the supplier for the south of England that the relevant organiser will have ordered the equipment from. Amendment History Issue Status Date Reason for Change Authorised 1 Ratified 5 January 2018 New Care and Clinical Group Clinical Director of Pharmacy 1 26 January 2018 Review date extended from 2 years to 3 years Version 1 (January 2018) Page 10 of 10

11 NHS Unclassified Appendix 1 BOC Medical Oxygen Integral Valve Cylinders Linked to Healthcare Medical Oxygen Integral Valve Cylinders leaflet 06.indd Healthcare%20Medical%20Oxygen%20Integral%20Valve%20Cylinders%20leaflet% _ pdf?v=. (Last accessed ) Appendix 1 - Version 1 (January 2018) Page 1 of 1

12 NHS Unclassified The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. The Mental Capacity Act Version 1 (January 2018) Page 1 of 1

13 NHS Unclassified Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Patient Transport Oxygen Management Patient Transport Team Leader Version and Date 1 An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favourably than the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; Yes No convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Operational necessity outlined by the auditing body, the Care Quality Commission. Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below Yes No ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Patient Transport Team Leader Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net For Torbay and South Devon NHS Trusts, please call or pfd.sdhct@nhs.net This form should be published with the policy and a signed copy sent to your relevant organisation. Rapid Equality Impact Assessment Version 1 (January 2018) Page 1 of 1

14 NHS Unclassified Clinical and Non-Clinical Policies New Data Protection Regulation (NDPR) Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU New Data Protection Regulation (NDPR) in mind and therefore provides the reader with assurance of effective information governance practice. NDPR intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, NDPR requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. The most effective way of being open is through data mapping. Data mapping for NDPR was initially undertaken in November 2017 and must be completed on a triannual (every 3 years) basis to maintain compliance. This policy supports the data mapping requirement of the NDPR. For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our GDPR page on ICON. New Data Protection Regulation Version 1 (January 2018) Page 1 of 1