How the rational use of oxygen can improve patient safety, health outcomes and reduce waste

1. How the rational use of oxygen can improve patient safety, health outcomes and reduce waste Craig Davidson Oxygen lead for London Respiratory Team, NHS London

2. Two faces of oxygen therapy

3. Oxygen use in England >85,000 people receive oxygen at home It costs C £120, 000,000 (2011) • (30% up on 2006, 10% total cost COPD) Historically service/cost placed in community Patients often do not understand why provided or how to use • 23-43% don’t use or don’t need (Commissioning toolkit, DH) • Up to 51% continue to smoke (v < 15% Canada)

4. Rationale of home oxygen • Long term oxygen therapy (LTOT) • primarily to extend life • improve QOL (cognition & sleep) • c 15 hrs/day, downside :dependency & reduced mobility • Other forms of Home oxygen service (HOS) • for alleviation symptoms • primarily hypoxia and breathlessness on exertion • better ambulatory devices new contract • potentially expensive

5. LTOT use to prolong life Long time ago • before recognition overlap syndromes (OSA/OHS & COPD) and treatment (CPAP/NIV) • not stratified for smoking • benefit small, delayed & limited number of patients (<300) • no benefit in less severe hypoxia Goreka 1997 MRC

6. Responsible prescribing : smoking and LTOT Smoking cessation as treatment • 2 in 3 domestic fires in homes with O2 result of smoking • 1 in 4 die • Risk can be predicted • Better to not start than to remove

7. BTS Guideline for emergency oxygen use in adult patients • 35% patients receive O2 in ambulance/ED • 18% ward patients treated with O2 • prescribing rare • adjusting and removing even rarer • Development raised PCO2 increases mortality

8. Oxygen is a drug and must be prescribed It should be prescribed to a specific saturation range Device and flow rate should be adjusted to achieve target > 1 increase in oxygen dose requires medical review Oxygen is not indicated unless patient hypoxaemic or in an emergency For most acutely ill patients the target range is 94-98% For patients at risk of CO2 retention the target is 88-92% Disorders which increase risk of CO2 retention: COPD Cystic fibrosis Bronchiectasis Chest wall deformity Neuromuscular disease Obesity hypoventilation Prescribing Oxygen In an emergency all patients should receive high flow oxygen Reference: www.brit-thoracic.org.uk Designed by the Oxygen Steering Group July 2009

9. Oxygen & hypercapnic RF 2011 BTS audit : 2500 cases hypercapnic respiratory failure receiving NIV Respondents asked was hypercapnia O2 induced • Overall 21% oxygen toxicity • Ambulance 29% v in hospital 62% • Only 10% took action to prevent in future • eg O2 alert card, person specific protocol (PSP)

10. LAS already implemented change

11. Delivery devices

12. Targeted O2 in AECOPD • Mortality 9% in usual care v 2% controlled therapy NNH 14 (RR 0.42) • High flow increases • Mortality (2-4,000 avoidable deaths per year) • LOS • Need for NIV • HDU admission Campbell 1967, Denniston 2002, Joosten 2007, Robinson 2001, Plant 2000, Wijesinghe 2009 National Patient Safety Awards 2011 Patient Safety in Clinical Practice Award (Health Service Journal and Nursing Times)

13. London Clinical Oxygen Network 2012 City & Hackney Tower Hamlets Hounslow Newham • Christine Mikelsons (Royal Free Hospital) • Glenda Esmond (Central London Community Healthcare) • Karen Spooner (Community Pharmacy NCL) • Debbie Roots • (St Georges Hospital) • Anne Crawford (ONEL) • Belinda Krishek (Chief Pharmacist ONEL) Enfield Waltham Forest Redbridge Barnet Havering Harrow • Irem Patel (Imperial College Hospitals) • Beryl Bevan (Chief Pharmacist ONWL) • Will Man (Brompton & Harefield) Barking & Dagenham Haringey Brent • Matthew Hodson (Homerton Hospital) • loren.Ateli (PCT) • Barbara Brese (Chief Pharmacist EL&C) Camden Isling- ton Ealing Hammer smith & Fulham West- minster Kensing ton & Chelsea Hillingdon South- wark Greenwich Bexley Lewisham Lambeth Richmond & Twickenham Wandsworth NHS London • Jim Pursell (HOS Lead) • Craig Davidson (COG Chair, London Respiratory Team) • Sonia Colwill (Director of Quality and Prescribing Bromley BSU) • Lynn McDonnell (Ambulatory lead) • Sally Hickman (Greenwich & Bromley) Bromley Kingston • Tuck-Kay Loke (Croydon University Hospital) • Nikki Davies (Croydon) • Neil Roberts (Primary care Contracting SWL) Sutton & Merton Croydon

14. BTS medical leads for O2 LRT has (so far) enrolled 23 consultants across London Work with them • Universal prescription of O2 • Leadership in protecting patients • Push to develop quality O2 assessments • Support RNS & therapists who, most often, involved in initiation of LTOT • (70% following admission) • Link with GPs, CCGs & community services

15. One of aims LCON : promote coordination between hospitals and community Graham Delves

16. Summary Hospitals need to take a lead in • protecting patients • supervising new starters • reaching out to community • controlling waste

17. (Lack of) Effect of palliative oxygen in relief of breathlessness in patients with refractory dyspnoea Lancet. 2010 376 :784-93