Implementing an evidenced based guideline for oxygen use in hospitalised adults.

Randomized time series pilot study. Two clinical wards will be randomized to one of two intervention groups (single intervention or multi-component intervention group). Both wards will receive the intervention in parallel. Medical record audits will allow us to assess the differences between prescribing practices between wards. These outcomes will be compared. Patients will not be enrolled in the study. Single intervention group (ward) Time Point 1: Weeks 1-2 Preparation of staff: Staff informed that a study will be commencing regarding the prescription of oxygen therapy. Researchers to demonstrate the prescribing facility in MedChart and provide background. Initial information sessions to raise awareness and to answer staff questions. (Session to be conducted via group in-service sessions 2 x 30 minute training sessions, in week 1 and week 2. In-service sessions will be run by a member of the research team to allow any questions raised to be answered) Time Point 2: Weeks 3-5 Inform staff of oxygen prescribing: Staff will be informed of the prescribing intervention via ward meetings and inservices during ‘Time Point 2’ (Session to be conducted via group in-service sessions 2 x 30 minute training sessions or more frequently at the request of clinical staff or clinical managers, i.e. nursing unit manager). These sessions will allow clinical staff to ask questions about the oxygen prescription facility in Medchart. This will include informing medical officers, particularly junior medical officers. Oxygen prescription: The online medication prescription chart (Medchart) will be modified to allow prescription of oxygen therapy. The oxygen prescribing ability will be available to clinicians from ‘Time Point 2.’ Oxygen will be able to be prescribed by medical officers and nurse practitioners as a regular/routine medication. Registered nurses will be able to prescribe oxygen therapy as a nurse initiated medication as per the ‘HNELHD Nurse/Midwife Initiated Medication Protocol’. Oxygen prescription for all clinicians are categorised for two patient groups. Those ‘at risk’ of hypercapnoea (COPD, obesity, and neuromuscular disorders as per the patient diagnosis or as noted in the patient history) and those ‘not at risk’ of hypercapnoea, as per the evidence based guidelines (Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults) . Oxygen prescriptions that are available to medical officers and nurse practitioners on Medchart are outlined below: • Oxygen Gas for those NOT at risk of hypercapnoea o Dose 0.5 to 4L/min via Nasal Prongs (4 hourly) to be commenced if SpO2 < 92% and titrate to minimum dose to achieve SpO2 92-96%. o Dose 0.24 to 0.5 FiO2 via Venturi Mask (4 hourly) to be commenced if SpO2 < 92% and titrate to minimum dose to achieve SpO2 92-96%. (Consider clinical review if max dose required) • Oxygen Gas for those AT RISK of hypercapnoea o Dose 0.5 to 4L/min via Nasal Prongs (4 hourly) to be commenced if SpO2 < 88% and titrate to minimum dose to achieve SpO2 88-92%. (Consider clinical review if max dose required) o Dose 0.24 to 0.4 FiO2 via Venturi Mask (4 hourly) to be commenced if SpO2 < 88% and titrate to minimum dose to achieve SpO2 88-92%. (Consider clinical review if max dose required) Oxygen prescription that are available to registered nurses on Medchart as per the ‘HNELHD Nurse/midwife Initiated Medication Protocol’ and are available for acute deterioration and emergency use only (whilst awaiting urgent clinical review): • Oxygen Gas for those NOT at risk of hypercapnoea o Dose 1-15L/min, Stat. To be commenced if SpO2 < 92% and titrated to minimum dose to achieve SpO2 of 92-96% • Oxygen Gas for those AT RISK of hypercapnoea o Dose 1-15L/min, Stat. To be commenced if SpO2 < 88% and titrated to minimum dose to achieve SpO2 of 88-92% Time Point 2 to 5: Weeks 3-16 • Only oxygen prescription to remain insitu until completion of study Multi-component intervention group (ward) As per the ‘Single Intervention Ward’ for weeks 1-2 and 3-5 with the addition of the following interventions introduced at various ‘Time Points’ during the study. Time Point 2: Weeks 3-5 • Inform staff of intervention group (single or multi-intervention group) • Introduce local leader/champion to act as a resource person/oxygen leader and be available to answer questions regarding oxygen therapy. Time Point 3: Weeks 6-8 • Introduce targeted education (to be delivered by a member of the research team). Targeted education as informed by expert reference group and will include o Week 6: Oxygen package stickers – oxygen stickers will be placed on outer oxygen packaging. Packaging will be checked once per week by a member of the research team to ensure outer packaging has a sticker in place. Oxygen stickers will read "has this oxygen been prescribed" o Week 6: Informational posters placed in patients’ rooms/bedside near the oxygen flow meter. Poster colour will be changed at ‘Time Point 4’ – week 9. There will be 2 posters at each bedside reading: POSTER 1."Titrate oxygen 'up arrow' and 'down arrow' to maintain an SpO2 88-92% as per prescription, for all patients which COPD or those at risk of hypercapnoea. Patients at risk include: COPD/Obese/neuromuscular disorders" POSTER 2. "Titrate oxygen 'up arrow' and 'down arrow' to maintain an SpO2 92-96% as per prescription, for all patients without risk factors for hypercapnoea." o Week 6: Informational posters placed in prominent locations. (Staff room, staff bathrooms, above handwash basins, around computer terminals) Poster will contain the following information in different sections: "Oxygen therapy. Has your patient's oxygen been prescribed? Aim for SpO2 88-92%. Those at risk of hypercapnoea including COPD/Obese/Neuromuscular disorders. Actively titrate oxygen therapy to achieve a saturation between 88-92%. Aim for SpO2 92-96%. Most medical patients ONLY require an oxygen saturation between 92-96%. Actively titrate oxygen therapy to achieve a saturation between 92%-96%. Prescribe oxygen based on patient assessment and to achieve a specified saturation range. Alter call criteria to match the prescription chart." o Week 7: Fast facts at safety huddle to be delivered about oxygen therapy. To be delivered by the nursing unit manager or nurse in charge, one day each week. o Week 8: Pre-existing online eLearning package. ‘My Health Learning’ education module regarding acute oxygen use in adults. 3 hour pre-existing spaced eLearning module to be completed at any time during week 8-12. The eLearning package delivers 2 questions to participants every 2 days with participants allowed up to 3 attempts to complete all questions. Time taken to answer each question will vary depending on the participant completing the question, it is not envisaged that it would take more than 15 minutes to complete each question. Completion of the module may qualify the participants for up to 1.0 hr of Continuous Professional Development (CPD). The module explores decision-making processes and is based on the TSANZ oxygen guideline and complements the NSW Health policy directive ‘PD2020_018 Recognition and management of patient who are deteriorating.’ The module is designed for NSW Health Clinicians in non-critical care areas caring for patients requiring oxygen therapy. • REDcap software will be used to email clinical staff the details of the online ‘My Health Learning’ education module and encouraged to enroll, to improve their knowledge around the administration of oxygen therapy. Time Point 4: Weeks 9-11 • Introduce weekly email communication (via REDcap software) to ward clinical staff outlining the progress of the study to date. Highlighting areas where adherence is high and areas for improvement) Withdrawal: Weeks 12 – 14 inclusive • Email invitations to participate in qualitative interview to be sent by nursing unit managers, pharmacy manager and allied health manager. • Qualitative interview invitation posters to be placed in the staff room. • Oxygen prescription facility in Medchart to remain insitu • Researcher presence and activity will be withdrawn. This includes withdrawal/removal of: o Oxygen stickers on oxygen packages o Informational posters in patient rooms and at all previously placed staff locations o Cessation of oxygen fast facts during safety huddle o Cessation of weekly progress emails NB: as the ‘My Health Learning’ education module can be accessed by any NSW clinical staff at any time, with a valid log in, access will still be possible for clinical staff if they should wish to continue or repeat this education module. Time Point 5: Week 15-16 • Qualitative interviews will occur face to face or via telephone/internet as requested by the participants.