All Programs. CROSS REFERENCE: Initiation, Titration and Discontinuation of Oxygen Therapy for Adult Patients Medical Directive

Transcription

1 1 All Programs SUBJECT: Oxygen Standard of Care for the Adult Patient ISSUING BODY: Nursing Practice Council, Respiratory Therapy Services, Physiotherapy Practice Council and Occupational Therapy Practice Council CROSS REFERENCE: Initiation, Titration and Discontinuation of Oxygen Therapy for Adult Patients Medical Directive EFFECTIVE DATE: August 2001 REVIEW DATES: REVISION DATES: May 2002, October 2007, April 2013, November 2015 PURPOSE... 2 STANDARDS... 2 Initiation and Titration of Oxygen... 2 Oxygen Therapy During Nebulized Treatments... 4 Weaning... 5 Discontinuation of Oxygen... 5 Transport of Oxygen Dependent Patients... 6 DEFINITIONS... 8 ABBREVIATIONS... 8 REFERENCES... 9 REVIEWED & APPROVED BY Appendix A: Possible Patients with Hypoxic Drive Appendix B: Duration of Tank... 13

2 PURPOSE: 2 1. To ensure that patients receive a safe and therapeutic level of oxygen. 2. To outline the responsibilities of Nurses, Physiotherapists, Occupational Therapists, Respiratory Therapists and Anesthesia Assistants when initiating, titrating and discontinuing oxygen therapy. 3. To outline the management of adult patients requiring oxygen therapy, and expedite the weaning of patients off oxygen therapy. 4. To ensure the safe continuation of oxygen therapy while a patient is on transport within the Health Centre. STANDARDS: Initiation and Titration of Oxygen 1. Oxygen is a medication and therefore must be administered, monitored and documented accordingly. 2. There is a risk of oxygen toxicity thus weaning a patient off oxygen as soon as they are able is essential. Although there is no threshold upon which oxygen toxicity shall occur, the duration that a patient is receiving supplemental oxygen is a significant factor towards increasing the risk that this condition may occur. 3. For Occupational therapy (OT) and Physiotherapy (PT), the delegation of O2 administration will be restricted to the individuals who have met the educational requirements and have been certified by the Charge Respiratory Therapist or the Corporate Advanced Practice Clinical Educator as knowledgeable in this area. Recertification is a biannual requirement to maintain competence. 4. Report to the MRP/NP if patient presents with adventitious breath sounds and/or laboured breathing or with a respiratory rate less than 8 or greater than 30 breaths per minute. 5. The oxygen saturation (SpO2) should be monitored at a minimum of every minutes or more frequently as the clinical condition dictates after any increase or decrease in oxygen to ensure the patient remains within the prescribed saturation range. 6. Perform a thorough respiratory assessment as per unit or profession based standard of care. The assessment may include, but not limited to the following: i. Respiratory rate ii. SpO2 iii. Work of breathing iv. Presence of pallor and/or cyanosis v. Breath sounds via auscultation vi. Level of consciousness

3 8. O2 may be initiated when the patient is exhibiting one or more of the criteria as outlined in the Medical Directive Initiation, Titration and Discontinuation of Oxygen Therapy for Adult Patients. These signs and symptoms may include but are not limited to the following: i. Hypoxia defined as SpO2 is less than 90% or less than the prescribed SpO2 parameter. ii. Possible cardiac or neurological ischemia (i.e. chest pain, new onset confusion etc.). iii. Symptoms related to acute myocardial infarction. iv. Symptoms related to acute cerebral vascular accident (CVA) v. Low hemoglobin (less than 80 g/l). vi. Any medical emergency as defined by the Code Blue Standard of Care. 9. Oxygen administration is performed by the respective professions as outlined in the Medical Directive Initiation, Titration and Discontinuation of Oxygen Therapy for Adult Patients (See Appendix A). 10. Use the oxygen delivery device that is the most appropriate for the patient and their oxygen demands. Use the chart below as a guide: 3 Delivery Device Nasal prongs Simple mask (PACU only) Venturi mask Non-rebreather mask or HiOx mask Trach mask or Aerosol masks Oxygen Concentration Delivered Delivers 1-6 Lpm Approximate 24-40% Delivers approximately 35-50% O2 flow must be no less than 5 Lpm to decrease risk of CO2 re-breathing Fixed concentrations ranging from 24-50% depending on Venturi device being used The O2 must be set no less than the flow indicated on the Venturi device Delivers approximately 80-95% O2 flow must be no less than 10 Lpm to decrease the risk of CO2 re-breathing For oxygen concentration less than or equal to 40%, low humidity output nebulizer top is used (white top) For greater than 40%, high humidity nebulizer top is used (yellow top) Humidification Bubbler humidification should be considered when flow is greater than or equal to 4 Lpm and PRN Not applicable May be used with humidity if used in conjunction with the humidity collar Not applicable Always considered for patients with a tracheostomy or stoma

4 11. The least amount of O2 will be applied to keep SpO2 greater than or equal to 90% or the minimum amount of SpO2 prescribed by a physician. 12. Health care providers applying oxygen should do a full assessment to identify if any pre-existing health condition exists that may impact a patients hypoxic drive (ex. COPD). 13. Oxygen administration in patients with a hypoxic drive (See Appendix B) can result in a severe decrease in the patient s respiratory rate and level of consciousness. If the patient meets these clinical criteria, immediately page the RT or the REACT team and the MRP, Nurse Practitioner, or the physician on call. It may be necessary to obtain new SpO2 orders. Monitor patient continuously and do not leave the patient unattended. 14. During exertion, O2 can be titrated to remain within prescribed SpO2 parameters. If titrated by OT or PT, the nurse and physician must be informed of this titration on initial occurrence and with each subsequent titration required during activity. Post activity, the patient will be placed back on their baseline O2 level. 15. Documentation will be done on each professional s respective flowsheets, and will include: Reason for initiation Final O2 flowrate or concentration used to achieve minimal acceptable SpO2 Patient s current SpO2 Any other relevant clinical findings 16. Checking of all oxygen set-ups must be done at the beginning of every shift and assess for the following: Correct oxygen concentration. Correct flow meter setting. Use of the correct equipment and its integrity Adequate humidity output (if applicable) 17. Changing of all other oxygen set-ups must be done weekly or when it malfunctions or becomes visibly soiled. The RT will change humidified trach set ups weekly. 4 Oxygen Therapy During Nebulized Treatments: 1. Patients requiring nebulized treatments and are currently breathing room air, the nebulized treatment shall be run at a flow rate of 6 to 8 Lpm via medical air. 2. If a patient is requiring oxygen therapy via nasal prongs, the nebulized treatments shall be run at a flow rate of 6 to 8 Lpm via oxygen. 3. If a patient is receiving oxygen therapy via aerosol mask do the following:

5 5 a) If oxygen concentration is between 28 and 40%: remove humidity tubing and run nebulized treatment at a flow rate of 6 to 8 Lpm via oxygen. b) If oxygen concentration is greater than 40%, use oxygen T-piece adapter (which is obtained from the RT) and administer nebulized treatment at a flow rate of 6 to 8 Lpm via an additional oxygen source. Weaning 1. If the patient s oxygen concentration is less than or equal to 40% or 6 Lpm: a. The RN/RPN/OT/PT will monitor the patient s vitals as per unit based or profession specific Routine Standards of Care. b. If SpO2 is greater than or within the prescribed parameters, decrease oxygen concentration by decrements of 5 to 10% or by 1 to 2 Lpm. c. SpO2 readings will be done 15 to 20 minutes (or more frequently as the clinical situation dictates) after any oxygen concentration change. d. Any change in oxygen concentration will be relayed to the Nurse. 2. If the patient s oxygen concentration is greater than 40%: a. The RT will monitor and reassess O2 requirements at minimum once a shift and PRN. b. If SpO2 is greater than or within the prescribed parameters, RT or Nurse will decrease oxygen concentration by decrements of 5-10%. c. SpO2 readings will be done minutes (or more frequently as the clinical situation dictates) after any oxygen concentration change by RT. d. Any change in oxygen concentration will be relayed to the nurse. e. Once the oxygen concentration is less than or equal to 40%, the nurse will do the weaning and follow up. 3. Documentation of all weaning should be done on respective profession s flowsheets, and should include: a. Starting flow rate or FiO2 and correlating SPO2 b. Any respiratory assessment findings c. New flow rate or FiO2 and correlating SpO2 and vitals Discontinuation of Oxygen 1. Oxygen may be discontinued once the patient is on 2 Lpm via nasal prongs or 28% via aerosol mask. SpO2 reading is performed minutes after removal. If the patient s room air SpO2 is greater than 90% or minimum acceptable SpO2 prescribed by a physician with a stable respiratory and

6 cardiovascular status, the O2 will remain off 6 If the patient desaturates on room air, restart O2 at the last flow rate or concentrationof O2required to keep SpO2 greater than or equal to 90% or the minimum acceptable SpO2, or as prescribed by a physician. 2. Continue to wean the patient to room air every shift if they do not tolerate the initial weaning. 3. If the patient does not tolerate being on room air and is continually requiring supplemental O2 to maintain SpO2, the physician needs to be notified. 4. Tracheotomized patients with a trach mask must continue to receive humidity via medical air. 5. Documentation will be done on each professions respective flowsheets and will include: a. If patient tolerated O2 discontinuation and final room air SpO2, or b. Reasons and assessment findings of why the patient did not tolerate the wean. Transport of Oxygen Dependent Patients 1. Discontinue the use of humidity for the transport. 2. The Nurse will confirm the patient s oxygen concentration prior to the transport and choose the most appropriate O2 delivery device for the transport: a) If the patient s oxygen concentration is less than or equal to 50% or 6 Lpm use nasal prongs or a Venturi device to match the patient s current flow or FiO2. b) If the patient s oxygen concentration is greater than 50% place the patient on a non-rebreather or HiOx mask (if under airborne precautions), or over the tracheostomy, and attach to portable oxygen tank at appropriate flow to keep the bag inflated (12 to 15 Lpm) c) Trach mask use venturi device to match the patient s current oxygen concentration. If the tracheostomy patient is on Medical Air, place the patient on 24% via Venturi device. 3. The Nurse must place the patient on the proper O2 level just prior to leaving the unit and must ensure that the porter is equipped with the appropriate amount of O2 tanks to last the entire transport. (Refer to Appendix C) 4. Prior to transportation off the unit the Nurse must check SpO2 and vital signs. Check with MRP/NP if patient is on 50% or greater oxygen to ensure that transportation of this patient is appropriate.

7 5. On arrival at the receiving unit or service, the most appropriate regulated health professional (e.g. Diagnostic Imaging Technologist in CT scan area) must place the patient on the same O2 level that the patient was receiving before transport. 6. Upon return to the originating unit, the Nurse will assess the patient and place them back on the appropriate oxygen level and delivery device. They will also recommence humidity as appropriate. 7

8 8 DEFINITIONS: Hypoxemia: An arterial pressure (PaO2) of less than 60 mmhg via blood gas analysis. Hypoxia: Diminished availability of oxygen to the body tissues. This can be determined via pulse oximetry and physical assessment (cyanosis, confusion, clubbing, disorientation, aggressiveness, labored breathing) Hypoxic Drive: Low arterial oxygen pressure stimulus to breathe whereas the normal stimulus to breath is high Carbon Dioxide. Nurse: Refers to both Registered Nurse (RN) and Registered Practical Nurses (RPN) Oxygen Therapy: Is the administration of oxygen at concentrations greater than ambient air in order to treat hypoxia and/or hypoxemia, decrease work of breathing and decrease myocardial work. Oxygen Toxicity: A condition due to the excessive administration of oxygen that can result in pathologic tissue damage, such as retinopathy of prematurity and bronchopulmonary dysplasia in new borns. In adults, this can lead to the initiation of the inflammatory response, cause atelectasis, seizures, retinal damage, etc. RT: Refers to both Graduate and Registered Respiratory Therapists ABBREVIATIONS: FiO2: Fraction of inspired oxygen Hi-Ox: High Efficiency Oxygen Mask filtered HR: Heart rate Lpm: Litres per minute MRP Most Responsible Physician NP: Nurse Practitioner O2: Oxygen OT: Occupational Therapist PCM: Patient Care Managers PT: Physiotherapist PRN: As needed REACT: Rapid Evaluation and Acute Care Team RR: Respiratory rate RT: Respiratory Therapist SpO2: Saturation via pulse oximetry

9 9 REFERENCES: 1. AARC Clinical Practice Guideline. Oxygen Therapy for Adults in the Acute Care Facility Revision and Update. 2. British Thoracic Society. Emergency Oxygen Use in Adult Patients Guideline. Reviewed in College of Respiratory Therapists of Ontario. Oxygen Therapy Clinical Best Practice Guideline, November Egan's fundamentals of respiratory care. RM Kacmarek, JK Stoller, AH Heuer Kane, B. et al. Emergency oxygen therapy: from guideline to implementation. European Respiratory Journal. Published June 1, Saskatoon Health Region. Oxygen Administration. Revised June 5,

10 Developed in consultation with: 10 REVIEWED & APPROVED BY: (as applicable, see Policy) Corporate Advanced Practice Clinical Educator September 2015 Nursing Practice Council September 30, 2015 Interprofessional Advisory Committee: November 17, 2015 Pharmacy and Therapeutics November 2015 Medical Advisory Committee: November 16, 2015

11 FiO2 greater than 0.4 FiO2 less than or equal to Appendix A: Professional Guidelines for Oxygen Therapy Administration RN/RPN RT/AA OT/PT Initiate and titrate O 2 up to 6 Lpm OR FiO Must discuss changes in patient s condition with Nurse Follow up and weaning to be done by Nurse Initiate and titrate O 2 up to 6 Lpm OR Fraction of inspired O 2 (FiO 2) 0.4 If the patient s SpO 2 remains less than 90% or as ordered, the RT must be paged Initiate and titrate O 2 up to 6 Lpm OR FiO Must discuss changes with oxygen demands with the patient s Nurse If the patient s SpO2 remains less than 90% or as ordered, the treatment must be discontinued, and the RT must be paged RN/RPN RT/AA OT/PT Initiate and titrate O 2 up to FiO 2 1 Follow up to be done by RT BID until FiO 2 is weaned back down to less than or equal to FiO Page RT In case of a Code Blue or medical emergency, apply a nonrebreather mask with O 2 set to flush Page RT Physiotherapists may pre-oxygenate at FiO 2 1, if suctioning is being performed In case of a Code Blue or medical emergency, apply a non- rebreather mask with O 2 set to flush

12 12 Appendix B: Possible Patients with Hypoxic Drive Patients who may have a hypoxic drive to breathe and normally require lower saturation parameters: Chronic hypoxic lung disease COPD Severe Chronic Asthma Bronchiectasis / Cystic Fibrosis Chest wall disease Kyphoscoliosis Thoracoplasty Neuromuscular disease Obesity hypoventilation Also consider patients with a significant smoking history.

13 13 Appendix C: Duration of Tank NOTE: A full E-sized cylinder contains 2200 pounds per square inch (psi) of oxygen. Duration of full tank (minutes) O2 flow rate setting (Lpm) Duration of full tank (hours)