South Staffordshire and Shropshire Healthcare NHS Foundation Trust

South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: Administration of Oxygen Policy YELLOW - Clinical New or Replacing: Document Reference: Replacing 2005 version C/YEL/cm/02 Version No. v2.0 Implementation Date: September 2010 Author: Approving body: Diane Hughes Quality, Effectiveness & Risk Committee Approval Date: 13 th August 2009 Ratifying body: Trust Board Ratified Date: 26 th August 2010 Committee, Group or Individual Monitoring the Document: Clinical Policy Group Review Date: August 2012

ADMINISTRATION OF OXYGEN POLICY CONTENTS 1. SCOPE OF THE POLICY 2 2. POLICY STATEMENT 2 3. ORGANISATIONAL RESPONSIBILITIES 2 Trust Board The Chief Executive Executive/Clinical Directors Managers and Supervisors Employees 4. INTRODUCTION 2 5. STORAGE 3 6. TRANSPORT 3 7. LONG-TERM O2 THERAPY (LTOT) 4 8. SHORT BURST O2 THERAPY 4 9. PRN (As required) O2 THERAPY 5 10. ASSESSMENT FOR O2 THERAPY 5 11. CHILDREN AT HOME OR IN COMMUNITY SETTINGS (including Special Schools) 6 12. PRESCRIBING OXYGEN 6 13. NURSING ASSESSMENT OF O2 NEEDS (including PRN) 6 14. PROTOCOL FOR USE OF OXYGEN CYLINDERS 7 15. GUIDELINES FOR ADMINISTRATION OF O2 THERAPY 8 16. REFERENCES 10 Administration of Oxygen Policy (C/YEL/cm/02) Page 1 of 11

1. SCOPE OF THE POLICY This document applies to all employees of South Staffordshire and Shropshire Healthcare NHS Foundation Trust. 2. POLICY STATEMENT The purpose of this policy is to provide guidance on administration of oxygen within the healthcare setting and in the community. 3. ORGANISATIONAL RESPONSIBILITIES 3.1 The Trust Board The Trust Board will ensure that the Policy is implemented. The Chief Executive The Chief Executive will ensure that this Policy is implemented in all areas and will ensure that the effectiveness of this Policy is continually reviewed. Executive/Clinical Directors Executive and Clinical Directors have the responsibility for the co-ordination of Health and Safety activities and for ensuring that decisions are implemented in accordance with this Policy and associated guidelines. Managers and Supervisors Managers and Supervisors have a responsibility to ensure staff adherence to the Policy and that they understand their responsibilities and receive appropriate training. Employees All employees have a responsibility to abide by this Policy and associated guidelines and any decisions arising from their implementation. This Policy is enforceable through Health and Safety Legislation and Trust Disciplinary Procedures. If employees are aware that the Policy or associated guidelines are not being complied with they must first raise their concerns at the time of observation with the person concerned if they feel able to do so, then take the issue to their line manager and if the problem is not resolved they must take it to the next line of management. 4. INTRODUCTION: 4.1 The need for oxygen therapy arises when oxygen transport to the tissues is insufficient due to a breakdown in either the respiratory or circulatory systems. 4.2 The aim of oxygen therapy is to maintain tissue oxygenation at a functional level, to eliminate detrimental compensatory responses to hypoxaemia (reduced oxygen concentration in arterial blood), which may cause serious or irreparable damage to vital organs and tissues. Administration of Oxygen Policy (C/YEL/cm/02) Page 2 of 11

4.3 The amount of oxygen delivered is measured as a percentage, with 100% pure oxygen given in emergency situations this is achieved by using high flow oxygen (12-15l/min) with a high concentration non-rebreathe mask. For therapeutic uses, the range tends to be between 24% and 60%. Oxygen may also be measured and prescribed as a measure of litres per minute (l/min), in this case the percentage delivered will vary depending upon the mask/delivery system used. If no percentage value is specified then a standard low/medium concentration mask should be used. 4.4 For general use, oxygen can be administered via nasal cannulae/specs, face masks, oxygen tents or via mechanical ventilation devices. 4.5 Oxygen must be prescribed by a doctor on the patient s drug treatment card, indicating the percentage required, flow rate, frequency of administration and delivery method, e.g. nasal cannulae 4.6 When administering oxygen it is the nurse s responsibility to check the treatment card and ensure that flow rate and concentration is as prescribed and initial the chart to indicate that treatment administered 4.7 In emergency situations, nurses may administer oxygen in the absence of a prescription via the Oxygen PGD. In these circumstances, the amount given, for how long and clinical justification should be documented in the patient s notes as directed by the PGD for oxygen. The patient must then be reviewed and assessed by a Medical Officer as soon as practicable, but certainly within 4 hours. 5. STORAGE Oxygen is a very combustible material so it is important that it is stored safely and correctly Keep away from extremes of temperature, e.g. do not store close to windows or radiators Store in a well ventilated area Cylinders should be secured in a cylinder trolley, rack or with a chain Keep away from combustible materials Keep away from naked flames e.g. fires, cookers Ensure NO SMOKING anywhere in the vicinity of Oxygen cylinders When being transported, oxygen cylinders should be secured in the vehicle, preferably using a dedicated restraint system, but if not possible, store on back seat of vehicle restrained by the seatbelt, especially in van/minibus type vehicles. In a normal car, if this is not possible, the cylinder should be stowed in the rear foot well of the vehicle 6. TRANSPORT: If a patient is requiring Oxygen therapy and needs to be transferred between Trust sites, transport by ambulance must always be the first choice. If the patient is acutely unwell, transport by ambulance is essential, even if that means a lengthy wait until suitable transport is available. Administration of Oxygen Policy (C/YEL/cm/02) Page 3 of 11

If patient has a chronic condition and is on long-term oxygen therapy, an ambulance is still preferable, but if necessary, transport via car or taxi may be considered. When transferring a patient via car/taxi, staff must ensure that portable Oxygen cylinder is available with sufficient oxygen to complete the journey safely. Patient s Oxygen saturations must be monitored throughout the journey using a battery operated pulse oximeter and the patient must be escorted by a member of staff who is proficient in the use of Oxygen and the monitoring equipment. A warning sticker must be displayed in the car window at all times, advising that Oxygen is being carried. These can be obtained by ordering through stores or by contacting the Resuscitation Officer. If a taxi is being booked, please check with the control that the driver is happy to carry Oxygen; if not other arrangements will need to be made. When in use, Oxygen cylinder must be securely strapped in the vehicle, ideally with a bespoke restraint, but in a normal car it is sufficient to place it on the back seat next to the patient, strapped in securely with the car s seatbelt system. Alternatively, it should be stowed in the rear foot well of the car 7. LONG-TERM O2 THERAPY (LTOT): This refers generally to the use of continuous O2 therapy at home for a minimum of 15 hours daily (including night time use). Conditions that may precipitate the need for LTOT are listed below: 1. Chronic Obstructive Pulmonary Disease (COPD) 2. Severe chronic/brittle asthma 3. Interstitial lung disease 4. Cystic fibrosis 5. Bronchiectasis 6. Pulmonary vascular disease 7. Primary pulmonary hypertension 8. Pulmonary malignancy 9. Chronic heart failure 10. Secondary polycythaemia 11. Nocturnal hypoventilation due to obesity, neuromuscular/spinal/chest wall disease, obstructive sleep apnoea (with CPAP therapy) 12. Palliative use for relief of dyspnoea (difficulty in breathing) 13. Babies and children with chronic lung disease 8. SHORT BURST O2 THERAPY: Short burst O2 therapy refers to the intermittent use of supplementary O2 for those patients already on Long-term O2 Therapy, for the following reasons: 1. Pre-oxygenation before exercise 2. Breathlessness during recovery after exertion 3. Control of breathlessness at rest 4. Palliative care use for the ease of symptoms Administration of Oxygen Policy (C/YEL/cm/02) Page 4 of 11

5. Exacerbation of COPD to bridge the requirements during assessment of need for LTOT 6. Interstitial lung disease 7. Heart failure 8. Pre-oxygenation prior to nursing interventions Normally, this type of therapy will only be prescribed if there is documented evidence that there is an improvement to the breathlessness during this therapy. 9. PRN (as required) O2 THERAPY: Oxygen may be administered for more acute conditions, or to treat the immediate symptoms of hypoxaemia. The aim in these instances is to decrease the work of breathing, thereby reducing the myocardial load. Some of the indications for short-term therapy include: 1. Cardiac or respiratory failure 2. Hypotension 3. Shock 4. Respiratory distress 5. Angina 6. Myocardial Infarction 7. Anaphylaxis 8. Seizures In these emergency life-threatening conditions, High Flow oxygen may be administered as part of resuscitation, as a life-saving measure, without the need for a prescription. In emergency life-threatening situations, critically ill patients should receive high concentration oxygen immediately, at 15 L min via a high concentration reservoir mask. For patients with long term chronic conditions such as COPD or other risk factors for Type II respiratory failure, where high concentration of oxygen is usually contraindicated, when critically ill they should be treated as above in the emergency phase with arterial blood gas analysis as soon as practicable to decide future management. 10. ASSESSMENT FOR O2 THERAPY: There must be a clinical diagnosis of the disorder causing hypoxaemia, whether it be acute or chronic For long-term oxygen therapy there must be optimum medical management of the condition and stability for five weeks before assessment Arterial Blood Gases (ABG s) must be measured during the assessment period A patient will normally require a referral to a specialist Respiratory Medicine physician/consultant Oxygen is a drug and as such, should be prescribed accordingly; in the way that other medication is prescribed, on treatment sheets. Administration of Oxygen Policy (C/YEL/cm/02) Page 5 of 11

11. CHILDREN AT HOME OR COMMUNITY SETTINGS INC. SPECIAL SCHOOLS: The patient s care plan will contain detailed information as to the circumstances in which oxygen is to be delivered When children are discharged from hospital back into the community setting, a predischarge home visit check is made to ensure that all the oxygen equipment is installed correctly and that the parents/carers are fully conversant with its use. Prior to discharge, the responsible Clinician will have set parameters for the child s oxygen levels and oxygen therapy prescribed accordingly. Parents/carers will receive Basic Life Support training (if appropriate) prior to the child s discharge from hospital Parents/carers will be given clear instructions on who to contact in the event of equipment failure or a change in the child s condition. Individualised school care plan will have detailed information about safe administration, storage and transport of oxygen. 12. PRESCRIBING OXYGEN Oxygen should be regarded as a drug, and prescriptions/ treatment and administration cards should detail concentration (unless via nasal cannulae where concentration is not controlled), mode of delivery (e.g. face mask or nasal cannulae), flow rate, frequency and duration of therapy. It may be prescribed as a regular drug for long-term oxygen therapy or as an as required drug when used e.g. for short-burst oxygen therapy. If oxygen is being delivered from cylinders, the usual flow rates are medium, 2 litres per minute and high, 4 litres per minute. As part of discharge planning, arrangements should be made to ensure that oxygen will be available in the home/care environment, there are robust arrangements at interface to ensure continuity of supply, and appropriate arrangements are made for transport (see section 6). Emergency use of oxygen can be administered, without prescription, using the Trust s Patient Group Direction, as long as nurses meet the professional competencies stated. 13. NURSING ASSESSMENT OF O2 NEEDS, INCLUDING PRN: 13.1 Effectiveness of breathing This is done by monitoring the patient s chest movement, air entry and oxygen saturation. Chest movement should be equal, bi-lateral and symmetrical. The depth of inspiration and any changes in rate should be recorded on an observation chart. Air entry should be assessed by observation of chest and auscultation with a stethoscope. Breath sounds should be audible and equal in all lung zones. Arterial oxygen saturations should be monitored by pulse oximetry (Sats monitor). 13.2 Work of breathing Work of breathing should be spontaneous, with quiet breath sounds and minimal effort. Signs of increased breathing effort include: Administration of Oxygen Policy (C/YEL/cm/02) Page 6 of 11

Increased respiratory rate Noisy respirations Use of accessory muscles Paradoxical/see-saw breathing (abdomen rises as chest falls and vice versa) 13.3 Further measurement of respiratory status can be done through Arterial Blood Gas analysis. This allows for more detailed information relating to respiratory status, including Carbon Dioxide levels and ph. Acid base balance will show chemical reactions in the body, dependant on a balance of acids and bases to maintain a ph of 7.35 7.42. These measurements are more easily obtained and analysed during a hospital admission. 13.4 Other useful observations that may be monitored during assessment of respiratory function include: Rate and depth of respiration (as mentioned previously) Patient s colour (any cyanosis/flushing present) Body temperature Blood Pressure 13.5 Alterations to breathing pattern/effort should be followed by immediate assessment by appropriate medical staff, to allow for consideration of O2 therapy. 13.6 Information gathered through relevant assessment will allow a suitable medical professional to prescribe oxygen as a percentage rate, with a range, stating the maximum rate that is appropriate for that individual. This will allow nursing staff to titrate the amount of oxygen delivered, according to the assessment of need and following the specific treatment levels prescribed for that patient. 13.7 Nurses are in the ideal position to be able to explain the need for treatment and provide reassurance during O2 therapy. They must also document treatment and effect as part of the continual reassessment process, to ensure effectiveness and appropriateness of treatment. 14. PROTOCOL FOR USE OF OXYGEN CYLINDERS To be used in conjunction with the patient s specific care and support plans 14.1 When not in use, oxygen cylinders should always be stored with the cylinder valve closed and the flow metre turned to the off position. The gauge will then usually be showing as empty 14.2 Turn the knob or key (depending upon the type of cylinder) fully to open the cylinder valve, the gauge should now show an accurate guide to amount left in the cylinder. 14.3 Ensure there is sufficient oxygen remaining in the cylinder for what you require if showing less than ¼ full always ensure that an alternative supply is immediately to hand 14.4 Turn flow metre to desired setting as prescribed, and ensure that the gas is flowing freely Administration of Oxygen Policy (C/YEL/cm/02) Page 7 of 11

14.5 If using a flow metre with a floating ball, rather a dial with specific numbers, the floating ball should be sitting just above and resting on, the desired setting 14.6 Check the gauge regularly whilst in use to ensure that there is always sufficient remaining in the cylinder 14.7 When finished using an oxygen cylinder, please always observe the following procedure Turn off the flow metre Turn off the cylinder valve The cylinder valve now needs to be vented to empty any remaining gas from inside the valve Switch the flow metre back on, to a high setting briefly until all gas has been expelled The gauge should now usually be reading empty again The cylinder is now ready to be stored safely, according to local protocols and Trust Policy and guidance 15. GUIDELINES: ADMINISTRATION OF OXYGEN (O2) THERAPY Oxygen is a prescribed drug and as such, must be prescribed by an appropriately qualified medical practitioner. The amount of O2 to be administered must be prescribed clearly, with full instructions, including any variations allowed in the amount to be administered and under what circumstances these variations may be made. As from April 2005, community patients may have their long-term oxygen prescribed directly by their respiratory consultant, rather than via their GP. The only circumstances under which it is appropriate to administer oxygen without a physician s prescription, is in an emergency situation. Oxygen is a life-saving treatment that may be administered in an emergency as a life-saving measure, without a prescription. However, this must be assessed as soon as is practicable (certainly within 4 hours) by a suitably qualified healthcare professional, and a prescription obtained if it s use is likely to be required beyond the immediate resuscitation period. It is the responsibility of individual managers to ensure that all members of staff who are likely to be administering O2 therapy have received appropriate training and are fully aware of the prescription and instructions for use of oxygen for that patient. The patient s O2 requirements should be assessed on a regular basis and the effectiveness of such therapy recorded. The frequency of reassessment will vary, dependant upon clinical need/situation/individual patient. Any variation of the patient s condition and/or O2 requirements must be communicated to the prescriber or a suitable colleague. When choosing a suitable delivery method, e.g. mask or nasal cannulae, as well as clinical indications, attention should be paid to patient choice, especially in respect to any fears/concerns regarding having their face covered or having something up their nose etc. Administration of Oxygen Policy (C/YEL/cm/02) Page 8 of 11

It is important to ascertain whether or not all users have a sufficient understanding of the English Language to fully understand all information and safety instructions. It may be necessary to use an interpreter or to have the information translated; however, it must not be presumed that a person who speaks a particular language will also necessarily be able to read the same. If the person receiving the oxygen therapy is a child or has learning disabilities, extra attention must be paid to ensuring that they understand what is being given to them and why and any fears or concerns dealt with. If oxygen is to be used in the patient s home, consideration must be made to their ability to safely handle the equipment and understand all of the safety and storage issues and help must be provided to overcome any issues surrounding this. EQUIPMENT: 1. Appropriate administration set; i.e. face mask, nasal specs, tubing and spares 2. Oxygen source as appropriate Piped or cylinder 3. Bactericidal alcohol hand rub 4. Sphygmomanometer (dependant on clinical need) 5. Oxygen saturation monitor (dependant on clinical need) 6. Thermometer (dependant on clinical need) 7. Appropriate source of humidification if required PROCEDURE: Action 1. Explain and discuss procedure with patient 2. If possible, ensure patient is in a comfortable position, preferably sitting, supported by pillows if necessary 3. Give further explanation to family/ next of kin especially in the case of children, as to why O2 therapy is required 4. Wash hands according to Trust policy and apply alcohol hand rub 5. Check O2 prescription, administer according to prescription, using appropriate giving set 6. Continuously monitor respiratory function: skin colour, breathing pattern, effort of breathing, rate, depth etc. Monitor O2 saturations if appropriate. Rationale To ensure that the patient understands the procedure and gives his/her valid consent. This will also reduce patient s anxiety To promote comfort and compliance and to optimise lung expansion To relieve anxiety and enlist their help in obtaining/maintaining patient s compliance To minimise risks of cross infection/contamination To ensure that the O2 is administered correctly and safely, according to Trust policy To assess effectiveness of treatment and to identify any deterioration/improvement in patient s condition. To ensure that the patient is maintaining Administration of Oxygen Policy (C/YEL/cm/02) Page 9 of 11

adequate respiratory function 7. Offer regular drinks if patient able, otherwise offer ice cubes to suck, mouth washes or oral toilet as appropriate to patient needs 8. Consider using humidified oxygen if therapy is to be used for any substantial length of time 9. Ensure the O2 administration set is appropriate to the patient and well fitting 10. If patient is confined to bed/chair during treatment, encourage or assist them to change their position frequently 11. Offer continued reassurance and explanations to the patient and relatives. Keep them informed of the progress of the therapy and ensure that the patient is comfortable at all times 12. Observe patient and the O2 delivery system at all times, to ensure no equipment failure occurs and to ensure that the patient s condition remains stable To reduce the risk of dry mouth due to the very drying effects of O2, especially at high flow rates. Thereby reducing the risk of mouth ulcers etc. developing To minimise the drying effects of the O2 on the respiratory passageways/mouth and nose If not appropriate, patient may not tolerate it well. If poorly fitting, may cause soreness to eyes, nose, ears and other areas of the face Patients requiring O2 therapy may have compromised skin integrity, increasing their risk of pressure sores, particularly to extremities, e.g. elbows, heels and sacrum To reduce anxiety and maintain compliance with treatment To ensure maintenance of the equipment and consistency of treatment and to ensure patient safety at all times N.B. If O2 is being administered in the community, and there is a clear deterioration in respiratory function: 1. Follow prescriptive guidelines for the O2, giving emergency O2 if appropriate 2. Call 999 for a paramedic ambulance 3. Monitor patients colour and saturations until help arrives 4. Perform Basic Life Support if indicated 5. Inform significant family member and senior nursing/medical staff once emergency situation has been resolved and help is at hand 16. REFERENCES: Alexander, F. Fawcett, J. Runciman, P. (1999) Nursing Practice: Hospital and Home The Adult. Churchill Livingstone, 4 th Ed. London. p68 Administration of Oxygen Policy (C/YEL/cm/02) Page 10 of 11

Bateman, NT. Leach, RM. (1998) ABC of oxygen: Acute oxygen therapy. British Medical Journal. 25 th July, 1-4. British Medical Association (2001) British National Formulary. The Pharmaceutical press, Wallington. British Thoracic Society (2004) Clinical Components for the home oxygen service in England and Wales. British Thoracic Society Emergency Oxygen Guideline Group (October 2008) Guideline for emergency oxygen use in adult patients. Thorax an International Journal of Respiratory Medicine, Vol63, Supplement VI Chandler, T. (2001) Oxygen administration, Paediatric Nursing. 13(80, 37-42. East Kent NHS (2002) Care pathway for patients with COPD. Jevon, P. Ewens, B. (2001) Assessment of a breathless patient. Nursing Standard. 15(16), 48-53. Mallet, J. and Dougherty, L. (2000) Manual of Clinical Nursing Procedures. 5 th Ed. Blackwell Science, Oxford. Administration of Oxygen Policy (C/YEL/cm/02) Page 11 of 11