Addenbrookes Hospital Implementation of the BTS 2008 Emergency

Addenbrooke’s Hospital Implementation of the BTS 2008 Emergency Oxygen Guidelines – the story so far Caroline Owen Respiratory Nurse Specialist Addenbrooke’s Hospital, Cambridge

Where have we been? Ü 1990’s – 2005 – aimed at education Ü 2005 -2008 – reviewed process – stickers in charts Ü 2008 – BTS guidelines aimed to simplify and improve oxygen administration Ü 2009 – NPSA alert Ü Ü No prescription Poor monitoring of the patient Incorrect administration – confusing air and oxygen flow meters Equipment – empty cylinders Ü 2010 – Addenbrooke’s guideline Ü 2012 – Never event Ü 2014 – E-hospital

Implementation posters

BTS Oxygen Audit 2013 - Summary of data collected in comparison to National data and previous data collected Ad’brooke Data Assessed 2013 National Ad’brooke 2013 2012 2011 % of patients using oxygen with a prescription with a target range 94% 55% 94% 46% % of signatures to drugs rounds 87% 21% 76% % of observations to rounds 123% 100% % of patients within target range 74% 64% Nationally Ad’brooke 2011 2010 75% 48% 72% 20% 61% 20% 32% 106% 100% 108% 100% 96% 78% 57% 75% 67% 61%

Challenges Ü Signing drug chart Ü Oxygen titration (audit poor to identify) Ü ED Ü Ambulance Services – ‘Alert’ cards Ü Surgery Ü Resuscitation guidelines & Oxygen guidelines Ü Airflow meter confusion

Air Flow Meter’s Ü Concerns over confusing oxygen and air flow meters Ü 2011 audit - 384 beds checked – 106 air meters in-situ – majority not being used Ü STANDARD REQUIRED: Ü Air flow meters should be taken out of the wall when not in use Ü Air flow meters should be kept in a dedicated place Ü Air flow meters need high-lighting they are air and not oxygen Ü Airflow meter covers

BEWARE! DON’T CONFUSE OXYGEN AND AIR FLOW METERS! AIRFLOW METERS • • REMOVE WHEN NOT IN USE KEEP IN A SPECIAL ALLOCATED PLACE IN YOUR AREA IT’S BLACK AND LABELLED “AIR” A new cover to help remind you it is air OXYGEN FLOW METERS • KEEP IN THE WALL IN CASE OF EMERGENCIES IT’S WHITE AND LABELLED “O 2”

Electronic Hospital Ü Mandatory for all trusts by 2020 to be paperless Ü Addenbrooke’s introduced an electronic system using Epic software in October 2014 Ü Other hospitals have chosen different software Ü We no longer use paper and all communication, charting and prescribing is done on the computers Ü Access from inside the hospital and outside; on laptops, smart phones and i-pads

E-hospital considerations for oxygen prescribing Ü What requirements must be fulfilled? Ü Highlight these early on in the design Ü When should oxygen be prescribed – on arrival into ED or later when patient is fully assessed? Ü What should it look like? Ü Should all patients be allocated a target saturation? Ü What alerts may you want to add?

E-hospital considerations for nurse administration Ü How should they see the oxygen prescription or order? Ü How frequently should they ‘sign’ for it? Ü Who should sign for it? Ü Vital sign frequency can be ‘ordered’ Ü Which measures can be applied to improve safety?

Audit Ü Run a report for patients on oxygen Ü Adapt to needs of the BTS audit criteria

Potential Advantages Ü No paper – changes can be made without altering previous charts Ü Better record keeping – neater! Ü Easy access Ü Visual reminders for doctors to write up; nurses to sign for. Ü If out of range – alerts staff to address Ü Easy audit Ü Best practice alerts

Potential Disadvantages Ü Adapting to a new way of working Ü Many screens leads to information overload Ü Requires good data input

Conclusion Ü Oxygen guidelines are now common place Ü Audit results are exceptional Ü No never events Ü It is the challenge of E-hospital to maintain and continue to improve processes Ü Any questions?