- Title
- Prescription of acute oxgyen therpay in patients at risk of type II respiratory failure
- Creator
- Cousins, Joyce Lucille
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2023
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Background: Oxygen is essential for life, and oxygen therapy has been used in clinical practice for centuries, typically to correct hypoxaemia. The dangers associated with the indiscriminate use of oxygen therapy for patients at risk of type II respiratory failure have been well known for decades. Robust randomised controlled trials examining the use of high-flow oxygen against titrated oxygen have more recently confirmed the risks in this cohort. This has prompted international and national respiratory societies to advocate for the prescription of oxygen therapy and titration of oxygen therapy between specific saturation targets aiming to maintain optimal saturations for appropriate patient populations to prevent hypoxaemia and hyperoxaemia. While there is agreement between the British Thoracic Society and the Thoracic Society of Australia and New Zealand (TSANZ) on the optimal saturation range for patients at risk of type II respiratory failure, their upper and lower targets differ for those not at risk. Despite evidence-based guideline availability in the United Kingdom since 2008 and Australia since 2015, challenges remain in changing ingrained practices associated with the prescription and administration of oxygen therapy. How best to facilitate ongoing practice change remains unknown, especially within Australia, where established practices continue to place patients at risk of adverse clinical outcomes. Aims: The overall aim of this research was to translate an evidence-based guideline into clinical practice to improve patient outcomes. Particularly for those at risk of type II respiratory failure. Design/Methods: Three separate, inter related studies were undertaken to address the overarching aim; Study One: Understanding Clinicians’ Perceived Barriers and Facilitators to Optimal Use of Acute Oxygen Therapy in Adults: A national cross-sectional survey was conducted using convenience sampling. The survey consisted of 3 sections: Introduction and participant characteristics; opinion/beliefs, knowledge and actions about oxygen therapy and other drugs; and barriers and facilitators to use of the TSANZ guideline. A paper-based survey was distributed at the TSANZ Annual Scientific Meeting. An online survey was emailed to the TSANZ membership and to the clinical staff of John Hunter Hospital. Snowballing was also used to help with wider dissemination of the survey. Study Two: Management of acute COPD exacerbations in Australia: do we follow the guidelines?: Data from a prospective clinical audit of COPD hospital admission from five tertiary care hospitals in five states of Australia were analysed to assess concordance to the COPD-X guidelines for patients admitted with an acute exacerbation of COPD. Variable included; basic demographic and discharge data, forced expiratory volume in one second (FEV1), blood gas measurement, chest X-Ray, oral corticosteroids, antibiotic therapy, oxygen therapy, prescription of oxygen therapy, ventilatory assistance, pulmonary rehabilitation referral and general practitioner follow up. Post-discharge follow-up was conducted by phone to assess for readmission and health status. Study Three: Does an oxygen prescription improve practice? A 2-arm Pilot Implementation Trial: A pilot implementation trial was carried out over 16 weeks in two medical wards in a large tertiary referral hospital. Wards were randomly assigned to one of two intervention groups (a single intervention ward versus a multi-intervention ward). Multicomponent interventions were implemented at various time points during the study period and were aimed at clinical personnel who administer or prescribe oxygen therapy for patients. The electronic medication prescription chart was modified to allow for oxygen prescription and was available on both the multiple intervention and single intervention (as a comparator) wards. Oxygen prescription was categorised into two patient groups, ‘not at risk’ of hypercapnia: and ‘at risk’ of hypercapnia according to the evidence-based guidelines. Basic demographic and discharge variable were recorded along with relevant medical history and data related to the prescription of oxygen therapy and delivery of oxygen therapy in addition to any alterations made to the call criteria. Results: In the national cross-sectional survey, responses were received from 133 clinicians: 52.6% nurses, 30.1% doctors; and 17.3% other clinicians. More than a third (37.7%) were unsure/ unaware of the oxygen guideline’s existence. Most (79.8%) believe that oxygen is a drug and should be treated as one. Most (92.4%) stated that they only administered it based on clinical need. The knowledge assessment demonstrated that optimal oxygen saturation was identified in only one of the four hypothetical cases by the majority of participants. Several facilitators and barriers were identified when asked about practising in accordance with the TSANZ guideline. The guideline itself and several clinician characteristics were considered facilitators, while the lack of equipment, getting doctors to prescribe oxygen, the assessment of oxygen by nurses and oxygen being treated differently to other drugs were considered barriers. For the national audit, data were recorded for 207 admissions for acute exacerbation (171 patients; mean 70.2 years old; 50.3% males). Readmission rates at 28 days were 25.4%, with one (0.6%) death during admission and eight (6.1%) post-discharge within 28 days. Variation to the COPD-X guidance was noted. Areas of high concordance where: blood gases collected when FEV1<1L in 81.1%, chest X-Ray performed in 99.5%, prescribed systemic corticosteroids prescribed in 95.1%, antibiotic therapy was prescribed in 95%, oxygen therapy administered in 89.1% and 92.6% when PaO2<80 mmHg, 65.6% received ventilatory assistance when pH<7.35 but 76.8% had general practitioner follow-up arranged. Areas where improvements to recommendations were needed included the prescription of oxygen therapy which occurred in only 27%, performance of spirometry occurred in only 22.7% and referral to pulmonary rehabilitation which occurred in only 32.4%. The pilot implementation trial examined 151 patient admissions where oxygen therapy (17.2%) was delivered within 24 hours after admission to the wards. Most (96.4%) had a record of oxygen saturation assessment at admission. In patients with COPD, 55.3% had their peripheral oxygen saturation assessed on room air on admission. Oxygen prescription occurred for 9.9% of those on oxygen therapy; most prescriptions (87%) occurred on the multi-intervention ward and peaked during week 9 of the intervention. Call criteria were amended according to the prescription on the multi-intervention ward only; less than half reflected the prescribed oxygen amount. Post hoc analysis of all oxygen saturations revealed that 43.6% of the entries aligned with the TSANZ guidelines; over administration was most common 53.2%. When a prescription was present versus not, appropriate administration was seen in 54.9% versus 43.3% (p=0.011), and over administration decreased (40.6% versus 53.5%; p=0.005). Conclusion: This research has increased our knowledge of clinician attitudes and behaviours towards the prescription and administration of oxygen therapy. It is clear that most believe that oxygen therapy should be treated like other drugs, however, it identifies that clinicians do not treat oxygen the same as other drugs and there is a disconnect between beliefs and actions with regard to oxygen therapy. It identified that national practice towards the prescription of oxygen therapy was poor overall, when compared to other recommendations from peak bodies. More focus is needed to encourage doctors to prescribe this therapy in line with other medications. Attempts to improve practice in both prescribing and administration at one site were challenging due to the outbreak of the novel Corona virus. Despite these challenges, valuable knowledge has been gained. Improvements in prescribing rate are possible in the presence of multiple interventions to improve practice, which lead to improvements in administration practices. This knowledge can inform future studies and be utilised to base further interventions for improving practice in this area.
- Subject
- oxgyen therpay; type II respiratory failure; prescription; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1492093
- Identifier
- uon:53242
- Rights
- Copyright 2023 Joyce Lucille Cousins
- Language
- eng
- Full Text
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