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Home Oxygen Prescribing: Risk Evaluation and Management

This discussion focuses on the risk evaluation and management for prescribing home oxygen. Topics include the benefits, potential risks, and appropriate timing for prescription. Case scenarios will be analyzed to shed light on best practices and the role of respiratory physicians in supporting nurses in this area.

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Home Oxygen Prescribing: Risk Evaluation and Management

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  1. Oxygen matters2012 HOS contract/future commissioning Jim Pursell, SL CSU Responsible oxygen prescribing Craig Davidson, Clinical lead O2 LRT Ambulatory oxygen Cassie Lee, LCON lead AO Audience involvement Facilitated discussion

  2. Responsible oxygen prescribingHOS >90% COPD, ILD, CWD or PHT4% children & paediatrics4% cardiac, CNS or palliative careDH “Commissioning toolkit” 30% patients derive no benefit20% don’t receive who would get benefit

  3. 2010 • O2 in pre hospital care in AECOPD • Nasal prongs 88-92% v 8-10 L non rebreath • 405 patients, COPD confirmed in 214 • Mortality 9% high v 4% titrated • Mortality 9% v 2% COPD confirmed • NNT 14 (RR 0.42)

  4. Why do we prescribe home oxygen? • To prolong life (LTOT) Poor quality evidence May improve cognition & QOL PR & stopping smoking more important • To reduce symptoms 85% severe COPD breathless 55% LTOT users have cylinders Most not used for ambulation Few get AO assessment AO costs > LTOT

  5. LTOT in chronic hypoxaemia NOTT 1980 MRC 1981 Goreka 1997 Long time ago before recognition OSA not stratified for smoking limited other therapy small numbers ineffective moderate hypoxaemia

  6. Commissioning of HOSARs failed in London service reliant on nursing good will other responsibilities medically poorly supported limited knowledge new equipment often poor dialogue acute & community

  7. Risk evaluation is part of new HOOF • Incidence smoking & O2 related fire unknown • 70% burn injuries related to smoking • 12% result in need for ICU admission • When FSS involved 1 in 4 results in death, 1 in 3 in serious injury

  8. Group work case scenarios • Two patient stories • Please discuss each as a group • Time limit 5 mins for each case.

  9. Bill 65 yrs AECOPD admission Day 6 recovering but PaO2 7.4, PaCO2 5.1 Oxygen specialist nurse asked to arrange LTOT She contacts community COPD team who raise concerns about home oxygen as, despite professing to have given up smoking, team have noticed evidence of smoking in home. Wife mild dementia and smoker.

  10. Bill (2) Medical team complete HOOF as consider Bill genuine in intention to stop smoking. You are the oxygen nurse specialist/ward manager. Would you take any specific action re LTOT? If so what?

  11. Bill (3) Nursing staff call for MDT including gas supplier, FSS and community COPD team Fire risk agreed to be high Reason for not prescribing LTOT explained to Bill and GP informed. At review at home Bill told nurses he did not want the worry of having home oxygen. Better to delay and review than start and remove

  12. Sally 72 yrs old Admitted with confusion relating to UTI. Heavy smoker with recurrent admissions AECOPD Nursing staff on EC ward note SaO2 87% ABGs : PaO2 6.9, PaCO2 7.2 Nasal oxygen 1L/min prescribed and LTOT ordered prior to discharge. Sally warned she must not smoke when wearing oxygen. Discharged before COPD team can see on ward.

  13. Sally (2) Discuss management issues raised in this case Consider steps that ideally should have been pursued.

  14. Sally (3) Discuss management issues raised in this case Could respiratory failure be cause of confusion, risk of oxygen causing further CO2 retention, need for multi-disciplinary management plan List steps that ideally should have been pursued. Need to review investigations/management during previous admissions, involve COPD team, ascertain risk of home oxygen, delay decision making, discuss management with potential care givers such as GP and son.

  15. Sally (4) One week later son calls to find home engulfed in smoke. Calls 999 Attempts to rescue mother : falls and breaks leg Sally intubated on arrival (PaCO2 15.1, CO 12.1) Fails to regain consciousness. Extubated and dies day 3

  16. Discussion areas When is risk of not providing home oxygen greater than risk of doing so? Are there any circumstances where oxygen prescription is urgent? Should there be national guidance on risk evaluation/prescribing to committed smokers? Can or should respiratory physicians offer support to nurses running HOS-AR (de facto or commissioned?)

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