POLICY ON THE SAFE USE OF OXYGEN IN ADULTS WITHIN DORSET COMMUNITY HEALTH SERVICES

POLICY ON THE SAFE USE OF OXYGEN IN ADULTS WITHIN DORSET COMMUNITY HEALTH SERVICES Policy Number: 885 Date of Issue: August 2010 Date of Review: August 2012

PREFACE This policy sets out a framework to ensure that oxygen is handled, stored, prescribed, administered and maintained safely within all hospitals and departments of Dorset Community Health Services 2

DOCUMENT HISTORY Document Status: Developed by: Policy Number ID 885, Version 1.0 Date of Policy August 2010 Next Review Date August 2012 Sponsor Approved by / on Clinical Policy review group 27 th July 2010 Approved by / on Clinical Governance 28 th July 2010 Version Date Comments By Whom 1.0 August 2010

Evidence Base References O Driscoll B R, Howard L S, Davidson A G.BTS guideline for emergency oxygen use in adult patients. Thorax 2008; 63:Supplement VI Summary guideline for prescribing emergency oxygen in hospital Available on BTS website: www.brit-thoracic.org.uk/emergencyoxygen Summary of prescription, administration and discontinuation of oxygen therapy. Available on BTS website: www.brit-thoracic.org.uk/emergencyoxygen The National Patient Safety Agency (NPSA) Rapid Response report rrr006 oxygen safety in hospitals The Department of Health, Estates and Facilities division s guidance on medical gases The medicines and Healthcare Products Regulatory Agency (MHRA) one liners issue 67 www.mhra.gov.uk/publications/safetyguidance/oneliners/con046617 The MHRA publication Oxygen cylinders and their regulators: top tips on care and handling. Advice for healthcare professionals. www.mhra.gov.uk/publications/postersandleaflets/con014865 NPSA Rapid response alert NPSA/2009/RRR 006: Oxygen safety in hospitals 2010 2010 2010 Date (29th Sept 2009) 2001 May 2009 April 2008 Sept 2009 www.nrls.npsa.nhs.uk/alerts Associated Documents Date PEWS policy Mandatory Training policy 2008 2010

Contents 1. INTRODUCTION... 7 2. PURPOSE... 7 3. DEFINITIONS... 7 4. MAINTENANCE... 8 5. STORAGE... 8 6. SAFE HANDLING... 8 7. MEDICAL GAS CYLINDERS THAT REQUIRE THE TRANSFER OF REGULATORS... 9 8. LEAK TESTING... 9 9. FAULTY/SUSPECT EQUIPMENT... 9 10. EQUIPMENT... 9 11. MONITORING... 9 12. PRESCRIBING, ADMINISTERING AND MONITORING OXYGEN... 10 13. TRANSFER AND TRANSPORTATION OF PATIENTS RECEIVING OXYGEN... 11 14. PERI-OPERATIVE AND IMMEDIATELY POST OPERATIVELY... 12 15. IMPLEMENTATION... 12 16. RESPONSIBILITIES & DUTIES... 12 17. COMMITTEE WITH THE OVERARCHING RESPONSIBILITY FOR SUBJECT... 13 18. OTHER COMMITTEES/GROUPS WITH RESPONSIBILITIES FOR SUBJECT... 13 19. INTERNAL COMMUNICATION... 13 20. TRAINING... 14 21. MONITORING ATTENDANCE OF TRAINING... 15 22. MONITORING COMPLIANCE WITH THIS POLICY... 16 APPENDIX A... 22 INDICATIONS, CONTRA-INDICATIONS & PRECAUTIONS FOR OXYGEN THERAPY... 22 APPENDIX B... 25 OXYGEN ADMINISTRATION AND WEANING PROTOCOL... 25 APPENDIX C... 27 PROCEDURE FOR ADMINISTERING ACUTE OXYGEN THERAPY... 27 APPENDIX D... 29 EQUIPMENT USED IN THE DELIVERY OF OXYGEN (CHOOSE THE APPROPRIATE DELIVERY DEVICE)... 29 APPENDIX E... 35 PROCEDURE FOR PATIENTS ON OXYGEN THERAPY... 35 APPENDIX F... 36 HUMIDIFICATION... 36

APPENDIX G... 37 OXYGEN: HEALTH AND SAFETY... 37

POLICY ON THE SAFE USE OF OXYGEN IN ADULTS WITHIN DORSET COMMUNITY HEALTH SERVICES 1. INTRODUCTION 1.1 Oxygen is indicated in many critical and chronic conditions and can save lives by preventing severe hypoxemia. However, there is a potential for serious harm and even death if it is not administered and managed appropriately. 1.2 Dorset Community Health Services (DCHS) aim to provide high quality and safe oxygen therapy to patients. It recognises that in order to achieve this safe robust systems and procedures must be in place including the provision of appropriate medical gas safety training for key personnel, relevant to their particular roles and activities 1.3 Dorset Community Health Services recognises its responsibility under the Health & Safety at Work Act, 1974 to ensure the safe storage and use of Oxygen cylinder gases. To this end, it aims to provide information to all employees with regard to the safe storage, handling and transferring of oxygen cylinders and regulators with training relevant to their role. 1.4 Wards/Teams are strongly encouraged to order and use smaller, portable cylinders with fixed regulators that deliver up to 15 litres of oxygen per minute. There is a reduction of risk during safe handing and the cylinders do not require the removal of the regulator. Responsibilities relating to storage and changing of regulators are not relevant to these portable cylinders. Where oxygen is used on a regular basis, the large cylinders (with fixed regulators) should be used. 1.5 This policy has been developed in accordance with the following national guidance and is reflective of best practice standards. 1.6 This policy only applies to the hospitals and departments within DCHS and is intended for use by all staff involved with oxygen. 2. PURPOSE 2.1 The purpose of this policy is to; 2.2 Ensure that guide staff caring for patients in the safe and appropriate use of oxygen. Guidance from this policy will be available to staff via standing and project groups, matrons, senior nurses and medical staff, and to all staff attending inpatients and outpatients. 2.3 The policy will be available in each unit and available on the DCHS intranet website. 3. DEFINITIONS 3.1 Definitions of terms used within the context of this document. The following list is a guide only and is not exhaustive:. Hypercapnic respiratory failure Abnormally high levels of circulating carbon dioxide, see Respiratory Failure, below. Some patients with lung disease rely on elevated levels of carbon dioxide to maintain respiratory drive. Removal of this drive will cause respiratory failure. COPD : Chronic Obstructive Pulmonary Disease

Hypercapnia: Abnormally high arterial blood concentration of carbon dioxide Hypoxemia: An abnormal deficiency of oxygen in the arterial blood Hypercapnic: A greater than normal amount of carbon dioxide in the blood Respiratory acidosis: An abnormal condition characterised by increased arterial PCO2, excess carbonic acid MGPS: Medical Gas Pipeline System Hypoxia: Abnormally low blood concentration of oxygen Pulse Oximetry: Measurement of circulation oxygen concentration using a finger probe Respiratory Failure: The respiratory system fails to maintain adequate gas exchange which results in abnormal levels of oxygen and carbon dioxide Pao2: partial pressure of oxygen in the blood FiO2: is the fraction of inspired oxygen in a gas mixture 4. MAINTENANCE 4.1 The Estates and Facilities Team will arrange for routine maintenance and testing of medical gas regulators by a competent contractor. 5. STORAGE 5.1 Cylinder supply and stockholding in Trust buildings is the responsibility of the respective Ward/team manager. 5.2 Large cylinders should be stored in an oxygen trolley, if not they must be chained to the wall 5.3 Data sheets must be available for this product. These are available from BOC Medical. 5.4 Where cylinders have to be stored inside the building they should be either stored in trolleys or kept in designated parking areas. The area should be signed to indicate its purpose, all staff should be aware of the location; storage should be kept to a minimal level. 5.5 External storage should be constructed in accordance with HTM 02-01 (medical gas pipeline systems standards) 6. SAFE HANDLING 6.1 Safe medical gas cylinder handling shall be included in the recorded moving and handling assessments where appropriate, with staff trained accordingly.

6.2 The correct size and type of trolley should always be used for the safe transportation of medical gas cylinders 7. MEDICAL GAS CYLINDERS THAT REQUIRE THE TRANSFER OF REGULATORS 7.1 Only staff that have received training in the Storage and Handling of Medical Gas Cylinders should transfer regulators, ensuring leak free connections on medical gas cylinders 8. LEAK TESTING 8.1 Cylinders /Regulators - after changing a cylinder/regulator and at any other time when the equipment is to be used an audible test should be made to ensure a gas tight connection. 9. FAULTY/SUSPECT EQUIPMENT 9.1 Leaks - If a leak is detected or suspected, staff must follow the BOC faulty equipment procedure. This is done by telephoning BOC Medical on 0800 111 333 (Check this is the correct contact number). 9.2 Fire - In the event of a fire, normal fire procedure must be followed. In addition, the fire service must be informed of the presence and location of any medical gas cylinders. The Fire Service will then offer evacuation advice. After the incident, the procedure for reporting faulty/incident cylinders should be followed, as below. 9.3 Cylinders - All faulty or incident (as above) cylinders must be returned to the approved supplier. This includes 'Date-expired' cylinders and cylinders with a missing batch and date labels. 9.4 Regulators - Faulty or suspect regulators should be taken out of use and reported to the Estates Department. 10. EQUIPMENT 10.1 Wards/Teams are encouraged to order and use smaller, portable cylinders with fixed regulators. Cylinder size information can be gained from the Hospital Hotel Services Manager. There is a reduction of risk during safe handing and the cylinders do not require the removal of the regulator. 11. MONITORING 11.1 Ward/Team Managers shall be responsible for implementing a routine inspection of gas cylinders. A written record of visual checks of equipment and their expiry dates will be kept along with a list of staff trained in the safe storage, handling and transferring of the cylinders/regulators. 11.2 They also have responsibility to ensure that staff working under their supervision use safe working practices when dealing with medical gas cylinders and their contents. 11.3 Health and Safety audits will monitor the written records.

12. PRESCRIBING, ADMINISTERING AND MONITORING OXYGEN Identifying appropriate target saturation 12.1 Oxygen should be prescribed to achieve a target saturation of 94-98% for most acutely unwell patients or 88-92% for those at risk of Hypercapnic respiratory failure. Guidance on identifying appropriate saturations for patients is provided for prescribers in British Thoracic Society Guidelines; Emergency Oxygen Use in Adult Patients; 2008). Prescribing Oxygen 12.2 Oxygen should be prescribed on the Trust s Oxygen Prescription, Administration and Monitoring Chart, which can be found in the clinical area. 12.3 The appropriate target saturation should be circled on the chart. 12.4 If target saturations are not indicated (for example in patients receiving oxygen as part of palliative care or patients on the end of life care pathway) the relevant box should be ticked. Administering Oxygen 12.5 A qualified registered Nurse, trained Health Support Worker, Doctor and Physiotherapist can administer oxygen. 12.6 Refer to Appendix B - D for guidance regarding the administration of oxygen and the most appropriate delivery system to reach and maintain target oxygen saturation. Monitoring and Recording Oxygen 12.7 All patients on oxygen therapy should have regular pulse oximetry measurements (except for those patients mentioned in 12.4). The frequency of oximetry measurements will depend on the condition being treated and the stability of the patient. As a minimum; oxygen saturations must be recorded 4 hourly if patient on continuous oxygen and 8 hourly if patient on intermittent oxygen. 12.8 The patient s oxygen saturations and oxygen delivery system and other physiological variables should be recorded in the appropriate section of the Trust s Oxygen Prescription, Administration and Monitoring Chart. 12.9 Patients should be monitored accurately for signs of improvement or deterioration (Refer to Appendix E). Oxygen saturations of less than 90%, with or without oxygen, noisy or laboured breathing or respiratory rate of less than 8 or more than 25 should be reported immediately to the medical team, according to the Trust s Patient Early Warning System (PEWS) Policy. Emergency Situations 12.10 In the emergency situation oxygen prescription is not required. Oxygen should be given to the patient immediately without a formal prescription or drug order but documented later in the patient s record. 12.11 All peri-arrest and critically ill patients should be given 100% oxygen (15 l/m reservoir mask) whilst awaiting immediate medical review. Patients with COPD and other risk factors for Hypercapnia who develop critical illness

should have the same initial target saturations as other critically ill patients pending the results of urgent blood gas results after which these patients may need controlled oxygen therapy or supported ventilation if there is severe hypoxemia and/or Hypercapnia with respiratory acidosis. 12.12 All patients who have had a cardiac or respiratory arrest should have 100% Oxygen provided along with basic/advanced life support. 12.13 A subsequent written record must be made of what oxygen therapy has been given to every patient alongside the recording of all other emergency treatment. 12.14 Any qualified nurse/ health professional can commence oxygen therapy in an emergency situation as indicated in the Trust s Patient s Early Warning System (PEWS) Policy. Specialist Areas 12.15 This policy is for general use within general wards and departments. Where specific clinical guidelines are required for oxygen administration within specialist areas, they must be approved via the appropriate Clinical Governance forum or Medical Gas Committee / Drugs & Therapeutics Committee. They should reflect wherever possible the principles within this policy. Patients transferring from specialist areas must be transferred with a prescription for their oxygen therapy utilising target saturation, if the clinical indication is ongoing. If a patient transfers from an area not utilising the target saturation system, their oxygen should be administered as per the transferring area s prescription until the patient is reviewed and transferred over to the target saturation scheme, which should occur as soon as possible. Nebulised therapy and Oxygen 12.16 When Nebulised therapy is administered to patients at risk of Hypercapnic respiratory failure, it should be driven by compressed air. If necessary, supplementary oxygen should be given concurrently by nasal prongs at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other specified target range. 12.17 All patients requiring 35% or greater oxygen therapy should have their Nebulised therapy by oxygen at a flow rate of >6 litres/minute. Humidification 12.18 Humidification may be required for some patient groups, especially neckbreathing patients and those who have difficulty in clearing airway secretions or mucus (Refer to Appendix F). 13. TRANSFER AND TRANSPORTATION OF PATIENTS RECEIVING OXYGEN 13.1 Patients who are transferred from one area to another must have clear documentation of their ongoing oxygen requirements and documentation of their oxygen saturation. If a patient transfers from an area not utilising the target saturation system (see specialist areas above) their oxygen should be administered as per the transferring areas prescription until the patient is reviewed and transferred over to the target saturation scheme, which should occur as soon as possible.

13.2 A trained member of staff should accompany patients requiring oxygen therapy whilst being transferred from one area to another wherever possible. If this does not occur, clear instructions must be provided for personnel involved in the transfer of the patient, which must include delivery device and flow rate. 13.3 Patients requiring oxygen should only be transported in an Ambulance and not in any type of Trust vehicle. 13.4 The person booking the transport needs to ensure that they identify oxygen requirements on the transfer form. 14. PERI-OPERATIVE AND IMMEDIATELY POST OPERATIVELY 14.1 The usual procedure for prescribing oxygen therapy in these areas should be adhered to, utilising the target saturation. If a patient is transferred back to the ward on oxygen therapy and is not on the target saturation system, the need for ongoing oxygen therapy should be reviewed as soon as possible. If oxygen therapy is to be continued, it should be prescribed using the target saturation scheme. Normal Oxygen Saturations: 14.2 In adults less than 70 years of age at rest at sea level 96%-98% when awake. 14.3 Aged 70 and above at rest at sea level greater than 94% when awake. 14.4 Patients of all ages may have transient dips of saturation to 84% during sleep 15. IMPLEMENTATION 15.1 (From BTS guideline) for info: 15.2 All nurses, nursing assistants and other healthcare professionals involved in prescribing or administrating oxygen should adhere to oxygen policy. Teaching aides are available on www.brit-thoracic.org/emergencyoxygen. A record of all those who have been taught will be kept. 15.3 All doctors should adhere to the oxygen policy. Teaching aids are available on the BTS website. Audits will be performed in all clinical areas. Audit Performa s are available on the BTS website. The hospital will participate in the national audits organised the BTS. 15.4 The BTS has appointed oxygen champions in all Trusts to help introduce the Guideline. 16. RESPONSIBILITIES & DUTIES Directors, Senior Managers and Unit / Managers and Team Leaders 16.1 All Directors, Senior Managers and Unit / Managers and Team Leaders are responsible for compliance with this Policy. 16.2 Team Leaders will be responsible for ensuring that when oxygen is required, this policy is implemented and monitored. This will include: 16.3 A collaborative approach, involving Staff, Team Leaders and Designated Nurse for oxygen where appropriate.

16.4 Documenting evidence of assessments undertaken, recommendations, action plans and rationale of decisions taken where appropriate 16.5 Are responsible for ensuring that all staff in their place of work have received the required training. All Trust Staff 16.6 All staff have a legal responsibility to adhere to those Policies that are put in place by the Trust for the Health, Safety and Welfare of their employees and patient care. In relation to this Policy, Staff will co-operate by: 16.7 Participating in the training process. 16.8 Keeping the organisation informed by completing an adverse incident form every time an incident or potential incident occurs and not assume somebody else has reported it. 16.9 Communicating a dangerous situation to anyone who could be at risk. 17. COMMITTEE WITH THE OVERARCHING RESPONSIBILITY FOR SUBJECT 17.1 The Medicines Management Group will retain overarching responsibility for this policy. 17.2 Responsibility for monitoring the completion of action plans within, or arising from this policy and the subsequent effectiveness of actions taken will be included within the remit of this group. 17.3 The Medicines Management Group will report to the DCHS Clinical Governance, Quality and Standards Group, who in turn report to DCHS Committee, Senior Management Team and the Trust Board on an annual basis. 18. OTHER COMMITTEES/GROUPS WITH RESPONSIBILITIES FOR SUBJECT 18.1 The Medical Devices Management Group will receive reports from the Medicines Management Group in order to be updated with issues relating to the devices necessary to dispense medical gases. 18.2 To ensure effective compliance with this policy, annual consultations/reviews of this policy will take place via: The Clinical Effectiveness and Audit Group, Best Practice Standards Group 19. INTERNAL COMMUNICATION 19.1 Medical gas training reports are distributed to all trust directors, in accordance with recognised system. this includes compliance with the NPSA Alert 19.2 The Directors cascade this data to their Line Managers and request that any non-compliant members of staff take the appropriate action to become compliant. 19.3 The Clinical Governance team will be informed of progress made via the quarterly exception reporting process.

19.4 Completed oxygen usage related AIRS forms are sent to the Medicines Management Department. 19.5 The medicines Management Manager will then identify AIRS that require follow up and forwarded to relevant line manager who will take appropriate action. 20. TRAINING 20.1 Each Community Hospital with piped and/or cylinder oxygen must have a Designated Nursing Officer (DNO) who will undergo specific face-to-face DNO training. The DNO will have specific responsibility regarding the management of the Medical Gas pipeline System (MGPS) in the event that supply is interrupted. 20.2 British Oxygen Company (BOC) will deliver this training via the Learning Centre. 20.3 Refresher training for this role must be three yearly as highlighted in the Mandatory Training policy (Appendix1). 20.4 All staff that change cylinders and transfer regulators must have attended the Trust Training Session "Storage and Handling of Medical Gas Cylinders". This session lasts approximately 1½ hours and includes the BOC video presentation - "Gas Safe in the Hospital. Staff who have attended this session and have been assessed will be identified as competent staff for the storage, handing and transferring medical gas cylinders and regulators. It is the responsibility of unit/team managers to ensure that sufficient numbers of staff receive training. As a minimum, all registered nurses on inpatient units must be trained in the Storage and Handling of Medical Gas Cylinders in order that a trained member of staff is on duty at all times. 20.5 This course will enable staff to help reduce accidents and incidents by: Distinguishing between normal and fault medical gas alarm indications Deal with damage to terminal units and serious gas leaks Emergency isolation of a medical gas supply Reacting correctly in the event of fire Reacting correctly in the event of total electricity supply failure Reacting correctly in the event of total or partial gas supply failure Identifying a contaminated gas supply Plan effective remedial actions to deal with shutdown or failure of Medical gas systems in order to maintain patient safety Permit isolation of a medical gas system in accordance with the MGPS permit-to-work system 20.6 Access to the BOC National e Learning package can be utilised during the intervening years. 20.7 Upon completion, staff will be trained to:

Define a medical gas, especially in the context of its role as a medicine List medical gases in common use Describe the dangers of medical gases and take appropriate precautions to ensure service user and staff safety during their use Identify a range of medical gas cylinders by size, valve type and colourcoding Handle, move and, where relevant, store medical gas cylinders safely Prepare a medical gas cylinder for use, connect it to a piece of medical equipment and, when empty, take the cylinder out of use, with due regard to any relevant local labelling requirements Identify faulty and incident cylinder and take appropriate action Transport of cylinders in vehicles Connect and operate demand valves, cylinders and terminal units 20.8 Porters who are involved with the storage transportation and replacement of oxygen cylinders must undergo face-to-face training annually. British Oxygen Company (BOC) will deliver this training via the Learning Centre. 20.9 Upon completion, staff will be trained to: List the properties and hazards Identify a range of medical gas cylinders by colour code, size and other labelling, and select cylinders in accordance with the needs of clinical/medical/engineering requirements Identify and describe the major components of pressurised gas systems and, in particular, a hospital MGPS Handle and transport pressurised gas cylinders safely Identify a range of patient-connected equipment requiring cylinder supplies of gas Connect and disconnect safely pressurised gas cylinders from plant, manifolds and user equipment Understand and respond to pressurised system alarms, hazards and emergencies, and observe local reporting procedures Replenish and operate (where directed) emergency reserve supply systems in accordance with local estates directives 21. MONITORING ATTENDANCE OF TRAINING 21.1 All Medical Gas training will be recorded using an attendance list which details the names of expected attendees and which identifies actual attendees in order to facilitate monitoring of non-attendance or inappropriate attendance.

21.2 Attendance records will be sent to the Learning Centre by the BOC trainer on the same day of the course-taking place. 21.3 Line Managers will be informed of non-attendance in writing within 5 working days of the course delivery. 21.4 Uptake of training is monitored via the Oracle Learning Management database (OLM) from which attendance reports can be provided upon request. 22. MONITORING COMPLIANCE WITH THIS POLICY 22.1 The DCHS Patient Safety Risk Group will be responsible for monitoring compliance with this policy. 22.2 Assurance will be provided to the Medicines Management Committee on an annual basis, in the form of a management report that sets out compliance by designated staff and medical gas training. Related minutes will be reported to the DCHS committee.

PART 1-Screening EQUALITY IMPACT ASSESSMENT FORM Department/Service area: Policy Sponsor: Name of the policy/protocol: (please attach a copy) Which target groups are affected by this policy/protocol (delete as appropriate) Please indicate if this affects staff, patients or both (delete as appropriate) If any groups are excluded please state why. Risk Management Team Chloe Finn POLICY ON THE SAFE USE OF OXYGEN IN ADULTS WITHIN DORSET COMMUNITY HEALTH SERVICES a) Gender/transgender b) Race c) Disability d) Sexual Orientation e) Age f) Religion/Belief a) Staff b) Patients c) Both Can the policy be implemented on a differential basis to any of the following target groups? Please tick yes or no and provide appropriate evidence. Equality Target Groups YES NO Evidence to support your decision (see Appendix for sources of evidence) Gender/transgender Race (BME communities) Disability Sexual orientation (lesbian, gay men or bisexual) Age (older people, young people/children) Religion/Belief

If you have identified evidence of an impact for any of the above target groups, consultation with the appropriate organisations should take place to identify if there is any differential impact from the service development or policy implementation. Equality Target Groups Gender/transgender Name of Appropriate Body EVIDENCE OF CONSULTATION Date Consulted Outcome/Agreed Action Race (BME communities) Disability Sexual orientation (lesbian, gay men or bisexual) Age (older people, young people/children) Religion/Belief If no evidence of differential experiences has been identified, the Equality Impact Assessment has been completed. If differential experience has been identified then Part 2 the full assessment should be completed. Signed by Writer/Reviewer: Name (print) C Finn Signed by Sponsor: Name (print) C Finn Date completed: Name (print) Date completed Date of next policy review: June 2010 Completed copies of Equality Impact Assessments should be sent to the nominated equality coordinator within the Human Resources and Workforce Development. A signed hard copy should be submitted with the policy or service development plan when it is presented for approval. A hard copy and an electronic copy should be kept within your department for audit purposes. PART 2 Full Assessment

Department/Service area: Person responsible for completing the assessment: Name of the strategy, policy, or service development: EQUALITY IMPACT ASSESSMENT FORM In part 1 (initial screening), which equality target group(s) were identified as being disadvantaged by the strategy/policy: a) Gender/transgender b) Race c) Disability d) Sexual Orientation e) Age f) Religion/Belief 1. Summarise the negative impacts for each group:

2. What previous consultation has taken place or will take place with each equality target group either externally or internally? Give details: Equality target Groups Summary of consultation carried out or planned Gender/transgender Race (BME communities) Disability Sexual orientation (lesbian, gay men or bisexual) Age (older people, young people/children) Religion/Belief QUESTION 3 MUST ONLY BE COMPLETED ONCE CONSULTATION AND RESEARCH HAS BEEN CARRIED OUT 3. Who was consulted and/or what research material was obtained? Please list: Equality target Title/type/details of report/research/statistics etc Groups Gender/transgender Race (BME communities) Disability Sexual orientation (lesbian, gay men or bisexual) Age (older people, young people/children) Religion/Belief 4. What does the consultation indicate about the negative impact of the strategy, policy, or service development?

5. What changes do you propose to make to the strategy, policy, or service development as a result of research and/or consultation? 6. Will the planned changes to the strategy/policy: Lower the negative impact? or Ensure that the negative impact is legal under anti-discriminatory law? Provide an opportunity to promote equality, equal opportunity and improve relations within equality target groups? i.e. a positive impact 7. What equality monitoring/evaluation/review systems have been set up to carry out regular checks on the effects of the strategy/policy? Give details: 8. When will the strategy/policy be reviewed?

EQUALITY IMPACT ASSESSMENT IMPROVEMENT PLAN Area of negative impact Changes proposed Lead Timescale Resource Implications Comments Signed by Writer/Reviewer: Signed by Sponsor:. Name (print).. Name (print). Date completed:.../. /... Name (print). Date completed. Date of next policy review: Completed copies of Equality Impact Assessments should be sent to the nominated equality co-ordinator within the Human Resources and Workforce Development. A signed hard copy should be submitted with the policy or service development plan when it is presented for approval. A hard copy and an electronic copy should be kept within your department for audit purposes. APPENDIX A INDICATIONS, CONTRA-INDICATIONS & PRECAUTIONS FOR OXYGEN THERAPY

(Taken from BTS guidelines 2008; Emergency Oxygen Use in Adult Patients) INDICATIONS The rationale for oxygen therapy is prevention of cellular hypoxia, caused by hypoxaemia (low PaO2), and thus prevention of potentially irreversible damage to vital organs. Therefore the most common reasons for oxygen therapy to be initiated are: Acute hypoxaemia (for example pneumonia, shock, asthma, heart failure, pulmonary embolus) Ischaemia (for example myocardial infarction, but only if associated with hypoxaemia (abnormally high levels may be harmful to patients with ischaemic heart disease and stroke). Abnormalities in quality or type of haemoglobin (for example acute GI blood loss or carbon monoxide poisoning). Other indications include: Pneumothorax Oxygen may increase the rate of resolution of pneumothorax in patients for whom a chest drain is not indicated. Post operative state (general anaesthesia can lead to decrease in functional residual capacity with in the lungs (especially following thoracic or abdominal surgery) resulting in hypoxaemia (Ferguson 1999). There is some evidence to suggest a decreased incidence of postoperative wound infections with shortterm oxygen therapy following bowel surgery. CONTRA-INDICATIONS There are no absolute contraindications to oxygen therapy if indications are judged to be present. The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest possible FiO 2. Supplemental O2 should be administered with caution in patients suffering from Paraquat poisoning (BNF 2005) and with acid inhalation or previous Bleomycin lung injury. CAUTIONS Oxygen administration and carbon dioxide retention In patients with chronic carbon dioxide retention, oxygen administration may cause further increases in carbon dioxide and respiratory acidosis. This may occur in patients with COPD, neuromuscular disorders, morbid obesity or musculoskeletal disorders. There are several factors, which lead to the rise in CO2 with oxygen therapy in patients with hypercapnic respiratory failure, and details are in the BTS guideline.

Other precautions/ Hazards/ Complications of oxygen therapy Drying of nasal and pharyngeal mucosa Oxygen toxicity Absorption atelectasis Skin irritation Fire hazard Potentially inadequate flow resulting in lower FiO 2 than intended due to high aspiratory demand or inappropriate oxygen delivery device or equipment faults

APPENDIX B OXYGEN ADMINISTRATION AND WEANING PROTOCOL (Taken from BTS guidelines 2008; Emergency Oxygen Use in Adult Patients) ACTION All patients requiring oxygen therapy will have a prescription for oxygen therapy recorded on the patients oxygen prescription, administration & monitoring chart. N.B exceptions- see emergency situations The prescription will incorporate a target saturation that will be identified by the clinician prescribing the oxygen in accordance with the Trust's oxygen guideline The prescription will incorporate an initial starting dose (i.e. delivery device and flow rate) The drug chart should be signed at every drug round Once oxygen is in situ the nurse will monitor observations in line with trust policy. All patients should have their oxygen saturation observed for at least five minutes after starting oxygen therapy. If a patient is receiving intermittent therapy they may be monitored at least 8 hourly. The oxygen delivery device and oxygen flow rate should be recorded alongside the oxygen saturation on the bedside observation chart. Oxygen saturations must always be interpreted alongside the patients clinical status incorporating the early warning score. If the patient falls outside of the target saturation range, the oxygen therapy will be adjusted accordingly The saturation should be monitored continuously for at least 5 minutes after any increase or decrease in oxygen dose to ensure that the patient acheives the desired saturation range. RATIONALE Oxygen should be regarded as a drug and should be prescribed. BTS National guidelines (2008). British National Formulary (2010). Certain groups of patients require different target ranges for their oxygen saturation, see Tables 1-4. Certain groups of patients are at risk of hyperoxaemia, particularly patients with COPD. To provide the nurses with guidance for the appropriate starting point for the oxygen delivery system and flow rate To ensure that the patient is receiving oxygen if prescribed and to consider weaning and discontinuation To identify if oxygen therapy is maintaining the target saturation or if an increase or decrease in oxygen therapy is required To provide an accurate record and allow trends in oxygen therapy and saturation levels to be identified. To identify early signs of clinical deterioration, e.g. elevated respiratory rate To maintain the saturation in the desired range.

ACTION RATIONALE 22.3 Saturation higher than target specified or >98% for an extended period of time. Step down oxygen therapy as per guidance for delivery Consider discontinuation of oxygen therapy 22.4 Saturation lower than target specified Check all elements of oxygen delivery system for faults or errors. Step up oxygen therapy as per protocols in appendix (i). Any sudden fall in oxygen saturation should lead to clinical evaluation and in most cases measurement of blood gases Monitor Early Warning Score and respiratory rate for further clinical signs of deterioration Saturation within target specified Continue with oxygen therapy, and monitor patient to identify appropriate time for stepping down therapy, once clinical condition allows A change in delivery device (without an increase in O2 therapy) does not require review by the medical team. Oxygen delivery methods The Trusts recommended delivery devices will be utilised to ensure a standardised approach to oxygen delivery, see Appendix (D) The patient will require weaning down from current oxygen delivery system. (See Appendix H) The patients clinical condition may have improved negating the need for supplementary oxygen In most instances a fall in oxygen saturation is due to deterioration of the patient however equipment faults should be checked for. To assess the patients response to oxygen increase, and ensure that PaCO2 has not risen to an unacceptable level, or Ph dropped to an unacceptable level and to screen for the cause of deteriorating oxygen level (e.g. pneumonia, heart failure etc) Patient safety (The change may be made in stable patients due to patient preference or comfort). Previous audits have demonstrated wide variations in delivery devices across clinical areas, potentially increasing the risk of adverse incidents

APPENDIX C PROCEDURE FOR ADMINISTERING ACUTE OXYGEN THERAPY (Taken from BTS guidelines 2008; Emergency Oxygen Use in Adult Patients) Action Ensure patency of airway The type of delivery system used will depend on the needs and comfort of to the patient. Most stable patients prefer nasal cannulae to masks. It is the nurse s role to assess the patient and use the prescribed system. Ensure oxygen is prescribed on prescription chart. In some situations a protocol may be in place to allow designated nurses to administer oxygen. The exception to this action would be during an emergency situation where the resuscitation guideline should be followed. In these cases the doctor must review the patients condition within the stated time and prescribe oxygen accordingly. Ensure that the oxygen dose is clearly indicated. If nasal cannula or reservoir masks are being used check that the flow rate is clearly indicated. Inform patient and or relative/ carer of the combustibility of oxygen Show and explain the oxygen delivery system to the patient. Give the patient the information sheet about oxygen. Assemble the oxygen delivery system carefully as shown in Appendix (D). Attach oxygen delivery system to oxygen source. Attach oxygen delivery system to patient according to manufacturers instructions Turn on oxygen flow in accordance with prescription and manufacturers instruction. Ensure patient has either a drink or a mouthwash within reach. Clean oxygen mask as required with general purpose detergent and dry thoroughly needed. Discard systems after use (Single use items) Rationale To promote effective oxygenation To provide accurate oxygen delivery To ensure a complete record is maintained and expedite patient treatment. In accordance with the administration of medicines policy. Oxygen supports combustion therefore, there is always a danger of fire when oxygen is being used. To obtain consent and cooperation To ensure oxygen is given as prescribed. To ensure oxygen supply is ready For oxygen to be administered to the patient. To administer correct % of oxygen. To prevent drying or the oral mucosa. To minimise risk of infection

APPENDIX D EQUIPMENT USED IN THE DELIVERY OF OXYGEN (CHOOSE THE APPROPRIATE DELIVERY DEVICE) (Taken from BTS guidelines 2008; Emergency Oxygen Use in Adult Patients) 1. Oxygen source (piped or cylinder) 2. Flow meter 3. Saturation monitor 4. Oxygen Delivery system - (see appendix j for advice on use of each device); I) Nasal cannula DEVICE DESCRIPTION PURPOSE Nasal Cannulae Nasal cannulae consist of pair of tubes about 2cm long, each projecting into the nostril and stemming from a tube which passes over the ears and which is thus selfretaining. Uncontrolled oxygen therapy Cannulae are preferred to masks by most patients. They have the advantage of not interfering with feeding and are not as inconvenient as masks during coughing and sneezing. It is not advisable to assume what percent oxygen (FI02) the patient is receiving according to the Litres delivered.this is not important if the patient is in the correct target range. ACTION RATIONALE 1. (When using nasal cannula). Position the tips of the cannula in the patient s nose so that the tips do not extend more than 1.5cm into the nose. Overlong tubing is uncomfortable, which may make the patient reject the procedure. Sore nasal mucosa can result from pressure or friction of tubing that is too long. 2. Place tubing over the ears and under the chin as shown above. Educate patient re prevention of pressure areas on the back of the ear. 3. Adjust flow rate, usually 2-4 l/min but may vary from 1-6 l/min in some circumstances. To allow optimum comfort for the patient. To prevent pressure sores. Set the flow rate to achieve the desired target oxygen saturation.

II) Fixed performance mask (Venturi mask and valve) DEVICE DESCRIPTION PURPOSE Venturi mask A mask incorporating a device to enable a fixed concentration of oxygen to be delivered independent of patient factors or fit to the face or flow rate. Oxygen is forced out through a small hole causing a Venturi effect which enables air to mix with oxygen. Controlled oxygen therapy This is a high performance oxygen mask designed to deliver a specified oxygen concentration regardless of breathing rate or tidal volume. Venturi devices come in different colours for % Blue = 24% White = 28% Yellow = 35% Red = 40% Green = 60% ACTION RATIONALE 1. (When using Venturi mask) Connect the mask to the appropriate Venturi barrel attached firmly into the mask inlet. To ensure that patient receives the correct concentration of oxygen 2. Fasten oxygen tubing securely. Correctly secured tubing is comfortable and prevents displacement of mask/cannulae. 3. Assess the patient s condition and functioning of equipment at regular intervals according to care plan. 4. Adjust flow rate. The minimum flow rate is indicated on the mask or packet. The flow should be doubled if the patient has a respiratory rate above 30 per minute. To ensure patient s safety and that oxygen is being administered as prescribed. Higher flows are required for patients with rapid respiration and high inspiratory flow rates. This does not affect the concentration of oxygen but allows the gas flow rate to match the patient s breathing pattern.

III) Simple face mask (variable flow) DEVICE DESCRIPTION Mask has a soft plastic face piece, vent holes are provided to allow air to escape. Maximum 50%-60% at 15ltrs/minute flow. PURPOSE This is a variable performance device. The oxygen concentration delivered will be influenced by: a. the oxygen flow rate( litres per minute) used, leakage between the mask and face; Simple face mask Variable Percentage (Delivers unpredictable concentrations that vary with flow rate) Nasal cannulae should be used for most patients who require medium dose oxygen but a simple face mask may be used due to patient preference or if the nose is blocked ACTION Uncontrolled Oxygen therapy RATIONALE b. the patient s tidal volume and breathing rate. NOT to be used for CO 2 retaining patients. (If using simple face mask) Gently place mask over the patient s face, position the strap behind the head or the loops over the ears then carefully pull both ends through the front of the mask until secure. Ensure a comfortable fit and delivery of prescribed oxygen is maintained. Check that strap is not across ears and if necessary insert padding between the strap and head. Adjust the oxygen flow rate. Must never be below 5L/min To prevent irritation. Flows below 5L/m do not give enough oxygen and may cause increased resistance to breathing and may also cause CO2 rebreathing due to the small mask size.

IV) Reservoir mask (non re-breathe mask) DEVICE DESCRIPTIO N Reservoir Mask Mask has a soft plastic face piece with flapvalve exhalation ports (Non-rebreathe Mask) which may be removed for emergency airintake. There is also a one-way valve between the face mask and reservoir bag. Uncontrolled oxygen therapy PURPOSE In non re-breathing systems the oxygen may be stored in the reservoir bag during exhalation by means of a one-way valve. High concentrations of oxygen 80-90% can be achieved at relatively low flow rates. NOT to be used for C02 retaining patients except in life-threatening emergencies such as cardiac arrest or major trauma. ACTION 1. (Non Rebreathe Reservoir Mask) Ensure the reservoir bag is inflated before placing mask on patient, this should be maintained by using 15 litres of oxygen per min. 2. Adjust the oxygen flow to the prescribed rate. RATIONALE To ensure the optimal flow of oxygen to the patient. Inadequate flow rates may result in administration of inadequate oxygen concentration to the patient. In disposable reservoir, oxygen flows directly into the mask during inspiration and into the reservoir bag during exhalation. All exhaled air is vented through a port in the mask and a one-way valve between the bag and mask, which prevents re-breathing.

V) Tracheostomy mask for patients with tracheotomy or laryngectomy DEVICE Tracheostomy mask Variable Percentage (Delivers unpredictable concentrations that vary with flow rate) DESCRIPTION Mask designed for neck breathing patients. Fits comfortably over tracheostomy or tracheotomy. Exhalation port on front of mask. Uncontrolled Oxygen therapy PURPOSE This is a variable performance device for patients with tracheostomy or tracheotomy. The oxygen concentration delivered will be influenced by: a. the oxygen flow rate (litres per minute) used. b. the patient s tidal volume and breathing rate. Use cautiously at low flow rates in CO2 retaining patients as there may be no alternative. ACTION RATIONALE Gently place mask over the patient s airway, position the strap behind the head then carefully pull both ends through the front of the mask until secure. Ensure a comfortable fit and delivery of prescribed oxygen is maintained. Most neck-breathing patients need humidified oxygen therapy. (refer Appendix F) To avoid drying of airways.

VI) Oxygen Flow Meter DEVICE DESCRIPTION Device to allow the patient to receive an accurate flow of oxygen, usually between 2 and 15 litres per minute. May be wall-mounted or on a cylinder. TAKE SPECIAL CARE IF YOUR TRUST USES A TWIN OXYGEN OUTLET OR IF THERE ARE AIR OUTLETS THAT MAY BE MISTAKEN FOR OXYGEN OUTLETS. PURPOSE To ensure that the patient receives the correct amount of oxygen. 3 2 1 Correct Setting for 2 l/min 3 2 1 Oxygen flow meter Delivers oxygen to the patient. ACTION RATIONALE Attach the oxygen tubing to the nozzle on the flow meter. To ensure that the patient receives the correct amount of oxygen. Turn the finger-valve to obtain the desired flow rate. The CENTRE of the ball shows the correct flow rate. The diagram shows the correct setting to deliver 2 l/min.

APPENDIX E PROCEDURE FOR PATIENTS ON OXYGEN THERAPY (Adapted from BTS guidelines 2008; Emergency Oxygen Use in Adult Patients) ACTION RATIONALE 1. Observe the following; In order to accurately monitor a. Monitor oxygen saturation levels the patient for signs of improvement using pulse oximetry or deterioration. b. Visual observations of skin colour for central cyanosis (blue lips). c. Respiratory rate. d. Any sign of respiratory distress should be reported immediately. 2. If the arterial oxygen saturation is above or below the target saturation the observer (often a Health Care Assistant) must inform the personnel who are qualified to administer oxygen (usually a trained Nurse) 3. Check the patient s mouth and nose and To identify signs of infection and behind the ears. pressure sores as soon as possible. 4. Record all observations on appropriate To ensure adequate record keeping. Chart 4 hourly if on continuous oxygen 8 hourly if on intermittent oxygen *Also see Trust s Patient Early Warning System (PEWS) Policy

APPENDIX F HUMIDIFICATION This should only be used if specifically requested by the doctor or physiotherapist in the following circumstances. 1. If the flow rate exceeds 4 litres per minute for several days 2. Tracheotomy or tracheotomy patients ( neck-breathing patients) 3. Cystic Fibrosis patients 4. Bronchiectasis patients 5. Patients with a chest infection retaining secretions Can be given by warm or cold humidifier systems (Warm humidifier systems are mainly used in critical care areas)

APPENDIX G OXYGEN: HEALTH AND SAFETY Oxygen supports combustion. There is always a danger of fire when oxygen is being used. It is potentially dangerous when in contact with sources of ignition and flammable material. Inform patients and carers about the combustibility of oxygen Oxygen should be stored in an area designated as no smoking Electrical appliances should be kept at least 5 feet away from the source of oxygen. Avoid grease or oil coming into contact with the apparatus Store unused cylinders in a dry well ventilated place.

POLICY APPROVED BY: JOB TITLE PRINTED NAME SIGNATURE DATE POLICY AUTHORISED BY AUTHORISING MANAGER (First) AUTHORISING MANAGER (Second) AUTHORISING MANAGER (Third)* DATE APPLICABLE PRINTED NAME SIGNATURE DATE REVIEW DATE PERSON RESPONSIBLE FOR REVIEW * IF APPLICABLE