Can we improve the prescribing and delivery of oxygen on a respiratory ward in accordance with new British Thoracic Society oxygen guidelines?

Abstract

The British Thoracic Society recommends oxygen delivery to achieve target oxygen saturation range between 94% and 98% for medically unwell adult patients, and 88% to 92% in patients at risk of hypercapnic respiratory failure. Interviews with our medical and nursing staff suggested that oxygen was sometimes being given to patients without a valid order and there was a failure to titrate oxygen to the stated oxygen saturation range. Our aim was to improve appropriate oxygen delivery to 90% of our patients on a 30-bedded respiratory ward within 3 months. We identified several key steps to safe oxygen delivery on our ward. These include the recording of target oxygen saturation range, the prescribing of an oxygen order on drug chart and the correct bedside delivery of oxygen to the patient. To help improve compliance of these key steps, the following plan-do-study-act (PDSA) interventions were undertaken: (1) Educational announcements at board rounds. (2) A communication oxygen poster. (3) Highlighting improvement progress to teams via email. (4) Pharmacist review of inpatient drug chart. (5) Display of target oxygen saturation range at patient bedside. At baseline, only 50% of drug charts had a recorded oxygen order and 60% of drug charts had a set target oxygen saturation range. Following PDSA interventions, both measures improved to 93%. Our main outcome measure of appropriate oxygen delivery to the patient improved from a baseline of 20% to 80% on completion. Our quality improvement programme has shown simple interventions can improve oxygen prescribing and appropriate delivery of oxygen to the patient. The most effective PDSA interventions were sharing our measurements via email and displaying target oxygen saturation ranges by the patient bedside. We aim to provide future oxygen educational sessions at induction to our staff and scale our quality improvement programme to other wards including our acute medical unit.

Keywords: control charts/run charts; patient safety; quality improvement.

Figure 1

Current oxygen prescription area on drug chart and National Early Warning Score (NEWS) nursing observation chart at Barking, Havering and Redbridge University Hospitals NHS Trust.

Figure 2

Schematic process steps for oxygen prescribing quality improvement programme. The boxes in red are the emergent plan-do-study-act (PDSA) cycles that were implemented during the programme.

Figure 3

Driver diagram to improve oxygen prescribing and recording of target saturations on acute respiratory wards.

Figure 4

Pareto chart highlighting frequency of missing key steps for the delivery of appropriate oxygen to the patient at bedside. Data are taken from the first six measurement cycles (n=90). The first three bars on graph account for 85% of the effect.

Figure 5

Process and balancing measures for oxygen prescribing quality improvement programme over a 3-month period between 09 May 2017 to 28 July 2017. Data measurement points 1–6 were twice weekly. Data measurements 7–14 were once weekly. The baseline measurements are calculated from the median value of the first six measurements for each run chart.

Figure 6

Main outcome measure with annotation for each plan-do-study-act (PDSA) intervention.