Oxygen prescription: improving compliance using methods fromBMJ Open Qualityjournal

Abstract

Oxygen is an important drug frequently used in the management of acutely unwell hospital patients. However, oxygen overuse can have fatal side effects particularly for those patients at risk of iatrogenic hypercapnia. British Thoracic Society Guidelines state that oxygen must be prescribed for all patients, with target saturations stipulated on the prescription for patient safety. A quality improvement project was undertaken with the aim to improve the oxygen prescription rate across the respiratory ward at a district general hospital, over a period of 3 months. Quality improvement methods were implemented based on data analysis at each stage, following discussion with senior doctors and specialist nurses, and after reviewing previous quality improvement projects published on BMJ Open Quality. The initial interventions of poster reminders and multidisciplinary team education failed to significantly improve the rates of oxygen prescription. Use of a targeted intervention where stickers were placed above oxygen taps significantly improved prescription rate from 20% in the non-targeted group to 60% in the targeted group. This was based on a BMJ Open Quality published improvement method. The current guidelines from the British Thoracic Society, and hospital’s own guidelines, advise good oxygen prescribing. However, these recommendations alone are ineffective at achieving compliance among prescribers. Further targeted interventions have shown improvements in oxygen prescriptions and could lead to better clinical practice, patient care and safety.

Acute oxygen use in hospitalised patients with chronic obstructive pulmonary disease is guideline discordant

“…Electronic medical record based initiatives have promise, and may be an effective way to improve prescription. 13 In aggregate, a multi-layered approach to acute oxygen use may be required. This could involve risk controls at patient level (for instance by electronic medical record alerts and automated oxygen titration systems 14 ), administrative controls (such as prescription guidelines), health systems interventions (such as education and society guidelines) and most importantly, a cultural shift in how oxygen is regarded.…”

“…Lessons from educational initiatives 12 suggest that more than one educational intervention may be required, and that the involvement of medical staff at all levels and nursing staff facilitates better prescription rates. Electronic medical record based initiatives have promise, and may be an effective way to improve prescription 13 …”

Rationalising oxygen usage in a level II special newborn care unit in Madhya Pradesh, India

“…In the first PDSA cycle, we assessed the feasibility of the intervention in a small set (n=30) of neonates and later scaled up to all eligible neonates in the second phase. We observed a significant reduction in oxygen consumption (from median (IQR) 8 (7-8) to 3 (3)(4) cylinders per day) that can lead to a direct saving of 590 000 Indian rupees (US$9000) per year. There was a significant reduction in the number of neonates on oxygen support on a given day.…”

Improving documentation of prescriptions for as-required medications in hospital inpatients

“…The use of passive interventions such as posters to prevent erroneous behaviours has been successful 30 31 ; however, evidence shows it is more effective when done in combination with an active intervention. 32 33 Qualitative interviews with ward staff were a strength of our project; by examining the contrasts and similarities between doctors and nurses on the ward, we had the opportunity to understand the views of our stakeholders. Solutions were also offered by interviewees such as providing more space to write in the Kardex.…”