Supply, Prescription, Administration and Storage of Emergency and Non- Emergency Oxygen

Policy: O3 Supply, Prescription, Administration and Storage of Emergency and Non- Emergency Oxygen This policy is associated to: M2 Medicines Policy Version: O3/02 Ratified by: Trust Management Team Date ratified: 16 th July 2014 Title of originator/author: Assistant Director of Primary Care Development Title of responsible Director Medical Director Governance Committee Medicines Management Date issued: 27 th July 2015 Review date: July 2017 Target audience: All staff Trust wide Disclosure Status B Can be disclosed to patients and the public EIA / Sustainability Implementation Plan Other Related Procedure or Documents: West London Mental Health NHS Trust _Page 1 of 22

Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust _Page 2 of 22

Version Control Sheet O3 - Protocol for Supply, Prescription, Administration & Storage of Emergency and Non-Emergency Oxygen Version Date Title of Author Status Comment O3/1.0 Jan 11 Assistant Director of Primary Care Developments O3/2.0 April 11 Assistant Director of Primary Care Developments New Protocol Under consultation Revised to incorporate comments received during consultation. O3/01 July 2011 Assistant Director of Primary Care Developments Present to Policy Review Group 28 th July 2011 approved as associated Policy to M2 Medicines Policy. O3/02 July 2014 Presented to July TMT for approval. Approved. Amendments throughout policy to reflect frequency of equipment checks West London Mental Health NHS Trust _Page 3 of 22

CONTENTS PAGE 1 Flowchart 5 2 Introduction 6 3 Scope 6 4 Aims 6 5 Responsibilities 6 6 Systems & Recording 7 7 7.1 7.2 7.3 7.4 7.5 Prescribing, Administering and monitoring oxygen Prescribing Oxygen Normal Oxygen Saturation Identifying appropriate target situations Administering prescribed Oxygen Monitoring and recording oxygen administered 8 8 8.1 Administering oxygen in an Emergency situation Preparing a high concentration non re-breathing oxygen mask for the use with the Oxygen cylinder. 9 Pulse oximetry 11 10 10.1 10.2 10.3 Indications Acute Hypoxaemia Ischaemia Nebulised Therapy and Oxygen 10 11 11 11.1 11.2 Contra-indications and cautions Contra-indications Cautions 12 12 Provision of Oxygen 12 13 Safety, Storage and Transport 13 14 Training 17 15 Monitoring 17 16 Fraud Statement 18 17 References (external Documents) 18 18 Supporting Documents (Trust Documents) 18 19 Glossary of Terms / Acronyms 18 Appendix 1 TPR-MEWs Chart 19 Appendix 2 Guidance for preparing a high concentration non re-breathing oxygen mask for the use with the oxygen cylinder West London Mental Health NHS Trust _Page 4 of 22 20

Appendix 3 Monitoring Template 21 1.0 FLOWCHART West London Mental Health NHS Trust _Page 5 of 22

O3 - Supply, Prescription, Administration & Storage of Emergency and Non-Emergency Oxygen OXYGEN THERAPY REQUIRED EMERGENCY TREATMENT MANAGEMENT OF RESPIRATORY CONDITION OXYGEN PRESCRIPTION IS NOT REQUIRED. OXYGEN SHOULD BE GIVEN TO THE PATIENT IMMEDIATELY Prescribe oxygen on prescription chart in the regular or PRN section. Include: Target saturation Starting device Flow rate Frequency of O 2 sats monitoring RECORD DECISION TO PRESCRIBE AND ABOVE DETAILS IN PATIENT NOTES NURSE: Administer oxygen in line with prescription Monitor of O 2 sats in line with prescription and record on observation chart Ensure patient has a drink within reach Inform doctor if O2 sats fall below the level indicated on the prescription chart PHARMACIST: When screening oxygen check that it is prescribed in line with Trust policy. 2.0 INTRODUCTION HIGH FLOW OXYGEN (15 litres with non-rebreather mask) ADMINISTERED BY QUALIFIED NURSE OR HEALTHCARE PROFESSIONAL CONTINUOUS PULSE OXIMETRY DOCUMENT IN PATIENT NOTES INDICATION FLOW RATE 0 2 SATS FREQUENCY OF MONITORING AND REGULAR READINGS OXYGEN CYLINDERS, MASKS AND PULSE OXIMETERS MUST BE CHECKED AND RECORDED ON A DAILY BASIS AS PART OF THE CLINIC ROOM EQUIPMENT CHECKS REPLACEMENT OXYGEN CYLINDERS SHOULD BE REQUESTED THROUGH PHARMACY West London Mental Health NHS Trust _Page 6 of 22

2.1 Oxygen is a gas which is essential for our bodies to function. Certain breathing disorders can result in a lack of oxygen. Oxygen may also be essential in acute medical presentations. 2.2 Failure to administer oxygen appropriately can result in serious harm to the patient. Under-use is extremely dangerous as it exposes critically ill patients to the risk of hypoxic organ damage Overuse can also be harmful, especially for vulnerable patients such as those patients with chronic obstructive pulmonary disease (COPD) 2.3 The National Patient Safety Agency (NPSA) has issued guidance on oxygen safety in hospitals and this policy has been written in accordance with their guidance as well as the guidance of the British Thoracic Society (BTS). 2.4 Medical gas cylinders are classified as Dangerous Goods under various Dangerous Goods legislation: The Carriage of Dangerous Goods and use of Transportable Pressure Equipment Regulations 2009; The Carriage of Dangerous Goods and use of Transportable Pressure Equipment (Amendment) Regulations 2011; and The European Agreement concerning -the International Carriage of Dangerous Goods by Road 2015 (ADR 2015). 3.0 SCOPE 3.1 The policy relates to oxygen prescribing and administration to patients in the Trust. 4.0 AIMS The aims of the document are to ensure that: 4.1 All patients who require supplementary oxygen therapy receive therapy that is appropriate to their clinical condition and in line with National Guidance (BTS Guideline: Thorax 2008). 4.2 Oxygen will be prescribed according to a target saturation range. The system of prescribing target saturation aims to achieve a specified outcome, rather than specifying the oxygen delivery method alone. 4.3 Those who administer oxygen therapy will monitor the patient and ensure that saturation is kept within the target saturation range. 5.0 RESPONSIBILITIES 5.1 Chief Executive West London Mental Health NHS Trust _Page 7 of 22

The Chief Executive has the overall statutory responsibility for the safe and secure handling of medicines within the Trust with ultimate responsibility for the implementation and monitoring of policies in use in the Trust. This responsibility may be delegated to an appropriate colleague. 5.2 Accountable Director The Medical Director is the Executive Director responsible for pharmacy and medicines management and has Trust Board responsibility for all aspects of medicines management and is responsible for development, management and implementation of this policy at trust level. They are also responsible for ensuring all medical staff are trained to carry out the tasks required of them in the prescribing and management of medicines. The Medical Director is supported by the Trust s Medicines Management Committee and the Chief Pharmacist. 5.3 Specific Staff for Policy Safe implementation of oxygen therapy with appropriate monitoring is an integral part of the Healthcare Professional s role All qualified nurses, medical staff, pharmacy staff should be familiar with the contents of this policy. 5.4 Managers Managers are responsible for ensuring policies are communicated to their teams / staff. They are responsible for ensuring staff attend relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are implemented and audited. 5.5 Estates staff Estates staff who are involved in the storage and transport of oxygen must ensure they are familiar with the contents of the policy. 5.6 All staff Staff are required to complete an incident report (IR1) in the event of any incidents or near misses involving oxygen. 6.0 SYSTEMS AND RECORDING Where Recorded: Prescription Chart West London Mental Health NHS Trust _Page 8 of 22

Oxygen Saturation on TPR MEWS Chart (Appendix 1) Patient Record (RiO) Recorded by (name/title): Prescriber Nurse When recorded (date): At point of prescribing During course of treatment 7.0 PRESCRIBING, ADMINISTERING & MONITORING OXYGEN Oxygen is essential for the management of a wide range of clinical conditions. 7.1 Prescribing Oxygen Oxygen is a medicines and must always be prescribed except in emergency conditions. Oxygen should be prescribed in the relevant section of the prescription chart (regular or PRN). The prescription must include all the relevant details including. Target saturation Starting device and flow rate Whether PRN or continuous use 7.2 Normal Oxygen Saturation In adults less than 70 years of age at rest at sea level 96% - 98% when awake. Aged 70 and above at rest at sea level greater than 94% when awake. Patients with certain conditions including chronic lung disease, congenital cyanotic heart disease and chronic neuromuscular conditions may have saturations well below the normal range even when stable West London Mental Health NHS Trust _Page 9 of 22

7.3 Identifying appropriate target saturations In summary 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. The Responsible Consultant may also wish to seek advice from the physical health team as appropriate. 7.4 Administering prescribed oxygen Failure to administer appropriately can result in serious harm to the patient. Action 1. Ensure oxygen is prescribed on prescription chart. 2. Ensure that the oxygen dose is clearly indicated. 3. Inform patient and or relative/ carer of the combustibility of oxygen. 4. Show and explain the oxygen delivery system to the patient. 5. Assemble the oxygen delivery system carefully. 6. Attach oxygen delivery system to patient according to manufacturer s instructions. 7. Turn on oxygen flow in accordance with prescription and manufacturer s instructions. 8. Ensure patient has a drink within reach. 9. Clean oxygen mask as required with general purpose detergent and dry thoroughly. Discard systems after use. Rationale To ensure a complete record is maintained and expedite patient treatment. The exception to this action would be during an emergency situation where, B4 Basic Life support policy or A15g Managing Acute Medical Presentations should be followed. 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 co-operation. To ensure oxygen is given as prescribed. For oxygen to be administered to patient. To administer correct % of oxygen. To prevent drying or the oral mucosa. To minimise risk of infection (Single patient device) 7.5 Monitoring and Recording Oxygen administered Oxygen saturation should be recorded on the TPR MEWS Chart (Appendix 1) which should then be scanned into the patients electronic record. West London Mental Health NHS Trust _Page 10 of 22

All patients on oxygen therapy should have regular pulse oximetry measurements. The frequency of oximetry measurements should be recorded on the observation chart and will depend on the condition being treated and the stability of the patient. Pulse oximetry must be available at each location where oxygen will be used; stable patients on prescribed low flow oxygen should have their saturation recorded at least once a day. 8. ADMINISTERING OXYGEN IN AN EMERGENCY SITUATION In an emergency situation an oxygen prescription is not required. Oxygen should be given to the patient immediately without a formal prescription or medicine order but documented later in the patient s record. To maximise the chances of survival for a person who is in respiratory or cardio-respiratory arrest, it is essential to maintain adequate ventilation and circulation. All patients who have had a cardiac or respiratory arrest should have high flow oxygen provided along with basic/advanced life support. A subsequent written record must be made of what oxygen therapy has been given to the patient alongside the recording of all other emergency treatment. Any qualified nurse/health professional can commence oxygen therapy in an emergency situation. 8.1 Preparing a high concentration non re-breathing oxygen mask for the use with the Oxygen cylinder. When administering oxygen, it is essential that staff trained in Basic Life Support (BLS) techniques know how to prepare the high concentration non-re-breathing oxygen mask by adhering to the following steps; Appendix A provides a picture flow chart of the process. Clinical Managers should laminate a copy of this and place it in close proximity to the oxygen cylinder for staff reference. Make sure that the oxygen tubing is connected both to the mask and the cylinder outlet. Make sure that the lock at the side of the cylinder is in the 'open' position. The flow meter is at the top of the cylinder, turn this on to the clinically appropriate flow rate (this is 15 litres per minute in the event of a cardiac arrest/respiratory emergency situations (Non-re-breather masks must always be used with 15 litres O2) or as prescribed by a doctor if the patient is receiving oxygen therapy. West London Mental Health NHS Trust _Page 11 of 22

Inflate the bag at the end of the mask by blocking off the valve inside the mask with your fingers. When the bag is inflated, place the mask on the patient s face. Gently pull the strap ends until the mask is secure and fits snugly, then squeeze the metal strip across the nose to ensure a tight seal. Observe the bag and ensure that it expands and contracts as the patient breathes in and out.. 9. PULSE OXIMETRY Pulse oximeter should be available in all locations where oxygen is used. Pulse oximeters are available either in the BLS bag or treatment room. ECT suites must have pulse oximeters 10. INDICATIONS The rationale for oxygen therapy is the prevention of cellular hypoxia, caused by hypoxaemia (low Pa02), anaemia (reduced or abnormal haemoglobin) or ischaemia (reduction in blood flow), and thus prevention of potentially irreversible damage to vital organs. Therefore the most common reasons for oxygen therapy to be initiated are as follows: 10.1 Acute hypoxaemia for example pneumonia, asthma, heart failure, pulmonary embolus, etc. 10.2 Ischaemia for example myocardial infarction 10.3 Nebulised Therapy and Oxygen When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure (ie. respiratory failure caused by an abnormally high concentration of carbon dioxide in the blood) it should be driven by compressed air. If necessary, supplementary oxygen should be given concurrently to maintain an oxygen saturation of 88-92% 10.4 Other precautions/ Hazards/ Complications of Oxygen Therapy Drying of nasal and pharyngeal mucosa Oxygen toxicity Absorption atelectasis (the failure of part of the lung to expand) Skin irritation West London Mental Health NHS Trust _Page 12 of 22

Fire hazard 11. CONTRA-INDICATIONS AND CAUTIONS 11.1 Contra-indications There are no absolute contra-indications to oxygen therapy. 11.2 Cautions 11.2.1 COPD In patients with chronic carbon dioxide retention, oxygen administration may cause a further increase in arterial carbon dioxide (PaCO2) and worsening respiratory acidosis. 11.2.2 Asthma A reduced Ventilation/perfusion ratio (VQ) can occur following bronchoconstriction in asthma restricting adequate air supply to the lungs, resulting in increased Oxygen requirements.. 12. PROVISION OF OXYGEN 12.1 All inpatient wards will have a supply of oxygen. Other teams/departments within the Trust may have a supply of oxygen and this will be agreed on an individual basis. 12.2 All medical oxygen cylinders used within WLMHT will be either CD or HX in size. Both these cylinders have built in regulators. 12.3 Only ONE (1) CD size portable medical oxygen cylinder will be supplied. These contain approximately 440 litres and deliver 30 minutes of oxygen at 12 litres per minute. This is sufficient for emergency situations. The oxygen cylinder must be stored in close proximity to the basic life support (BLS) bag. 12.4 Wards will not keep spare cylinders for just in case. Any patient requiring oxygen other than in an emergency must have been prescribed on a Trust prescription chart. 12.5 Primary Health Care Centre at Broadmoor, ECT suites and Older Peoples wards as standard will have a supply of the HX size cylinders (approximately 4000 litres). These may be provided to other wards when there is a clinical need. 12.6 Replacement cylinders must be requested via your local Pharmacy service only. West London Mental Health NHS Trust _Page 13 of 22

12.7 Replacement cylinders will only be supplied on the return of a used and empty cylinder. 12.8 All cylinders have an expiry date. Wards and departments must check these on a daily basis whilst doing the clinic room equipment checks. A record of this daily check must be held in the area by completion of the orange Grab Bag Medical Equipment Contents Check Book under the entry stating please also check expiry dates and replace items as necessary or, where in use, a local checklist. These checks should include the oxygen cylinder expiry date. Where cylinder dates have expired or where stickers have fallen off or been removed, cylinders must not be used and must be replaced at the earliest opportunity. Pharmacy should be contacted to arrange replacement of oxygen cylinders. Pharmacy will arrange for cylinders which are expired or do not have an expiry date to be returned to the supplier regularly. Image to show cylinder expiry date sticker on small cylinders. 12.9 All medical oxygen cylinders are rented from BOC by West London Mental Health Trust. These cylinders must not be returned or lent to any other organisation. 12.10 BOC provide cylinders that have met relevant construction, inspection and testing requirements in accordance with their duties under ADR 13 SAFETY,STORAGE AND TRANSPORT 13.1 Safe handling of gas cylinders In general, using gas cylinders is safe. There is however, the potential for a serious accident if the gas cylinder or the attachments are not treated properly. Incorrect handling of heavy, awkward cylinders can cause personal injury; particularly to the back, neck or arms. The risks involved in moving cylinders will differ depending on the area of work. West London Mental Health NHS Trust _Page 14 of 22

keep cylinder stocks to the necessary minimum for your volume of trade only use cylinders filled by a reputable gas supplier who fills and regularly tests cylinders in accordance with current safety regulations return gas cylinders to the supplier you purchased them from and to no-one else Use a suitable purpose designed trolley of the correct size to transport large HX size cylinders. Any stationary cylinder trolley in a ward area should be fixed in place to prevent it falling over. wear suitable protective footwear such as toetectors when transporting gas cylinders (unless the cylinder is small) Anyone transporting cylinders must have undertaken manual handling training unless the cylinder is small and light. Ensure a warning sign indicating oxygen is placed on the door to any room where oxygen is used or stored Keep oxygen equipment clean. Contamination by particulate matter, dust, sand, oils, greases or general atmospheric debris is a potential fire hazard. Portable equipment is particularly susceptible to contamination and precautions should be taken to keep it clean Use clean hands or gloves when handling cylinders and assembling oxygen equipment e.g. attaching the pressure regulator, making connections. carry small cylinders close to the body. Large cylinders must not be carried Ensure the cylinder is set up and tested before placing near the patient. Always use an appropriately designed cylinder support to hold the cylinder whilst in use adjacent to the patient where available. place the cylinder on the patient s bed unless there is no suitable alternative for retaining the cylinder. hang anything on the cylinder. Keep it clear at all times. fill one gas cylinder from another - this is extremely dangerous carry gas cylinders in a car or other closed vehicle. Only secure vehicles used for transport of patients may store oxygen. connect gas cylinders to any equipment other than the primary regulator drop, throw or mishandle cylinders use cylinders for anything other than storing and delivering dispense gas oil or lubricate cylinder valves. Do not use oil or grease (or any oilbased products which includes hand creams) in the vicinity of an oxygen cylinder. lift a cylinder over 25kg in weight by yourself; this can cause West London Mental Health NHS Trust _Page 15 of 22

muscle strain or back injury lift cylinders above chest height reach for and lift cylinders from behind stacks of crates or kegs; this can cause strain or injury use any materials which contain ammonium or chlorine compounds if you need to clean a cylinder. 13.2 Storage 13.2.1 Outside oxygen stores The outside cage, where cylinders are stored and handled, should be checked periodically to make sure it is a safe working environment. The following should be adhered to: Store cylinders in a secure enclosure Restrict entry to the oxygen cage, allowing only trained persons to enter and work there. The door or gate must be kept locked when not in use display appropriate warning signs and safety procedures ensure the cage is adequately ventilated clean up spillages immediately to prevent slipping hazards ensure the cage has adequate lighting secure cylinders safely, whether in use or not Keep EMPTY cylinders separated from FULL cylinders store and secure the cylinder in an upright position return all empties to the gas supplier you purchased them from store full cylinders in an area away from cylinders in use store cylinders where they may come into contact with water Store cylinders next to a direct heat source; e.g. radiators, coolers stack objects in front of cylinders. Reaching over objects to lift cylinders can cause back injury stand cylinders on uneven floors. The cylinder may fall, causing injury or damage obstruct access to or from the cellar, which can prevent escape in the event of an emergency 13.2.2 Storage of oxygen inside buildings Store oxygen cylinders in a secure room display appropriate warning signs and safety procedures ensure cylinders are secured to a wall or trolley West London Mental Health NHS Trust _Page 16 of 22

Ensure cylinders are stored and used in well ventilated areas, kept clean and dry ensure the cage has adequate lighting secure cylinders safely, whether in use or not Keep EMPTY cylinders separated from FULL cylinders store and secure the cylinder in an upright position return all empties to the gas supplier you purchased them from store full cylinders in an area away from cylinders in use Inform pharmacy when you have an empty or expired cylinder Use equipment at the correct flow rate, set to zero before opening the valve, open the valve slowly by turning it anti-clockwise and set the flow meter at the flow rate prescribed. Check for leaks on the connections after opening the valve. The flow can be checked by placing the end of the tube in a glass of water and watch for bubbles. Ensure that there is an adequate supply of gas in the oxygen equipment by checking the gauge on the cylinder valve or on the vessel. Never allow the oxygen cylinder to completely empty Close the cylinder valve when the supply is not in use Check your oxygen cylinder on a daily basis store cylinders where they may come into contact with water Store cylinders next to a direct heat source; e.g. radiators, coolers etc. stack objects in front of cylinders. Reaching over objects to lift cylinders can cause back injury stand cylinders on uneven floors. The cylinder may fall, causing injury or damage Store cylinders in corridors, stairways or exit doors or protected fire escape routes. keep large quantities of combustible material (i.e. paper, cardboard) near your oxygen supply 13.3 Transport of Oxygen Cylinders For stock supply of oxygen WLMHT only transport oxygen cylinders within the boundaries of each main site. WLMHT do not transport oxygen between sites. Cylinders must be properly secured when being moved and, if transported in a van, precautions must be taken to avoid a build-up of gas which might affect the driver Off sites that require oxygen will have direct delivery from BOC. West London Mental Health NHS Trust _Page 17 of 22

Secure vehicles that transport patients may store and carry oxygen. Transport of oxygen cylinders in vehicles comes under the Transport of Dangerous Substances Act or the Carriage Regulations only if 1000 litres or more (measured by the water capacity of the cylinder) is carried at any one time. Secure Vehicles are therefore exempt from this as long as they only carry the small portable cylinders however normal health and safety requirements will still apply (see below). Health and Safety Executive guidance for safe use of oxygen cylinders is as follows: o All cylinders must be secured appropriately so they cannot move in transit (includes portable cylinders). o No smoking in the vicinity of cylinders. o Cylinders must be checked regularly for obvious signs of leakage. o Cylinders must be kept out of direct sunlight. o Green warning triangle compressed gas should be displayed on the vehicle. o Cylinders should never be lifted by the neck. o They should only be changed by suitably trained personnel. o They should be checked daily for expiry and to ensure they have sufficient content. 13.4 Fire 13.4.1 Oxygen is a colourless, odourless and non-flammable gas and is essential for life. It is however, classified as an accelerator meaning that if there is a fire and oxygen is present, the fire will burn 13.4.2 Some materials which do not normally burn in air will burn in an atmosphere of oxygen, nitrous oxide or gas mixtures containing more than 21% oxygen. These gases do not burn themselves, but strongly support combustion, and therefore special attention should be directed to the hazards associated with smoking and naked flames. When using medical gas cylinders it is most important that no part of the cylinder valve or equipment is either lubricated or contaminated with oil or grease. This is due to the risk of spontaneous combustion that can occur with high pressure gases in the presence of hydrocarbons 13.4.3 Should there be a fire in an area where cylinders are stored, only attempt to shut off or move cylinder if it is absolutely safe to do so. Otherwise shut the door and try to ensure that other staff are well away from the area. 13.4.4 Electronic cigarettes are an ignition source and should not be used anywhere near an oxygen cylinder. There have been reports of them causing fire resulting in burns injuries. 13.4.5 New recommendations regarding the use of oxygen cylinders have recently been published by BOC and have been endorsed by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). It is now recommended that oxygen cylinders are, West London Mental Health NHS Trust _Page 18 of 22

whenever possible, placed in specially designed brackets attached to the patient s bed, rather than being laid on the bed itself. 14 TRAINING 14.1 All staff providing or managing care or treatment are responsible for their own practice including keeping their knowledge up to date, participating in supervision and seeking appropriate training. 14.2 Employees who work with those who use oxygen must receive instruction in the safe use of oxygen and be made aware of the content of this document and safe procedures must be in place. A risk assessment must be in place for the establishment or clients homes to ensure safe practice is in place. Should a fire occur in any premises this must always be reported. 15 MONITORING 15.1 The monitoring of the oxygen policy will be carried out by the Trusts Medicines Management Group. 15.2 Outcomes from monitoring of the oxygen policy will be reported to the Clinical Effectiveness & Compliance Committee. 15.3 Compliance with the oxygen policy will be monitored through a number methods including audit as outlined in the monitoring template. 15.4 Where poor compliance is highlighted the lead for that ward/department will be required to develop and action plan to address these areas which will need to be reported to the Medicines Management Group. 15.5 Incidents involving oxygen will be reported via the Trust Incident Reporting System. 15.6 Incidents relating to oxygen will be reviewed annually at the Medicines Management Group. 16. FRAUD STATEMENT Not applicable to this policy (N/A) 17. REFERENCES (EXTERNAL DOCUMENTS) This policy should be read in conjunction with the following: West London Mental Health NHS Trust _Page 19 of 22

National Patient Safety Alert (NPSA/2009/RRR006) Oxygen Safety in Hospitals Guideline for emergency oxygen use in adult patients. British Thoracic Society (BTS) https://www.britthoracic.org.uk/guidelines-and-quality-standards/emergencyoxygen-use-in-adult-patients-guideline/ Transporting and Storing Gas Cylinders. www.boconline.co.uk Safe Anaesthesia Liaison Group. Promoting fire safety on intensive care and in theatres. SALG RECOMMENDATIONS June 2013 18. SUPPORTING DOCUMENTS (TRUST DOCUMENTS) M2 - Medicines Policy B4 - Basic Life Support Policy A15g Managing Acute Medical Situations Guideline 19. GLOSSARY OF TERMS / ACRONYMS BTS PRN BLS ECT COPD WLMHT British Thoracic Society Pro re nata Basic Life Support Electro Convulsive Therapy Chronic Obstructive Pulmonary Disease West London Mental Health Trust Appendix 1 MEWS-TPR chart.pdf West London Mental Health NHS Trust _Page 20 of 22

1 Appendix 2 For use in Emergencies only Oxygen Cylinder (O2) With High Concentration (HC) Non-rebreathing oxygen mask 2 Ensure the O2 tubing is attached to the outlet, open the lock below the flow meter and turn the flow meter to the clinically appropriate flow rate. Inflate the bag initially by blocking off the valve inside the mask with your fingers 3 Inflated bag West London Mental Health NHS Trust _Page 21 of 22 Place the mask on the patient`s face. Gently pull the strap ends until the mask is secure. Mould the metal strip on the mask to fit the face 4

APPENDIX 3 MONITORING TEMPLATE POLICY / PROCEDURE: O3 - Protocol for Supply, Prescription, Administration & Storage of Emergency and Non-Emergency Oxygen MONITORING TEMPLATE Minimum Requirement to be Monitored Where described in policy WHO (which staff / team / dept) HOW MONITORED (Audit / process / report / scorecard) - list details HOW MANY RECORDS (No of records / % records) FREQUENCY (monthly / quarterly / annual) REVIEW GROUP (which meeting / committee) Storage of oxygen Cylinders Section 13 Managers Audit All areas Two yearly Medicines Management Group Review of Oxygen Incidents Section 5.6 All Staff IR1 reports All Annually Medicines Management Group OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) Action plan managed through local clinical governance Escalated to Clinical Effectiveness Committee as required Action plan managed through local clinical governance Escalated to Clinical Effectiveness Committee as required West London Mental Health NHS Trust _Page 22 of 22