From the 2022 HVPA National Conference
Jopher Bernal MD (UCF/HCA Healthcare GME, Greater Orlando, FL Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL Orlando VA Medical Center, Orlando, FL), Gizem Gokalp MD, Guru Chinnaraj MD, Ramez Massoud MD, Michael Del Zoppo DO, George Alvarez DO, Joshua Shultz MD, Ashwini Komarla MD, Nicole Brenner MD
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Since the advent of oxygen therapy in healthcare, it has remained one of the most important and often used drugs. A “more is better” culture regarding oxygen use persists among healthcare providers and hospitals despite proven risks of excessive oxygen therapy use. Hyperoxia-induced hypercapnia among COPD patients is a well-studied phenomenon leading to respiratory acidosis, increased mortality, morbidity, and length of stay. Directed oxygen treatment guidelines have been implemented by the British Thoracic Society, who recommend that patients at risk of hypercapnic respiratory failure receive oxygen with a saturation goal of 88%-92%
The goal of our Quality Improvement (QI) project is to minimize the use of supplemental oxygen without proper indication, thus reducing the risk of patient harm incurred by providing excess oxygen, especially in patients at risk of hypercapnic respiratory failure.
We reviewed patients receiving oxygen therapy via nasal cannula on Graduate Medical Education (GME) teams, determined whether there was an appropriate order for oxygen, whether goal saturation parameters were listed and identified patients at high risk for oxygen-induced harm, such as those with COPD. We excluded patients with active COVID-19 infection. In addition, we surveyed residents and nurses to assess their awareness on oxygen order set and oxygen parameters. Interventions included implementation of oxygen order set in the electronic medical record, resident and nurse training, and door signs with goal O2 parameters.
The proportion of the patients on nasal cannula oxygen with a proper oxygen order increased from 28% to 55% after combining a new oxygen and weaning oxygen order in the admission order set. Despite this intervention, follow up resident surveys revealed that 44% of residents were still not aware of the oxygen order set and almost 99% of patients with COPD did not have desired oxygen parameters listed. Post-intervention nursing surveys revealed that just over 50% of the nurses were aware of an oxygen order set, had witnessed patients outside the indicated parameters, and had placed patients on oxygen without an order. Currently, we are working on nursing education, putting signs on patients’ doors with proper oxygen parameters, oxygen algorithm in supply rooms next to nasal cannulas. Post-intervention data is pending.
Our QI project employed a multi-disciplinary approach to reduce the excess use of oxygen. Through the above-mentioned measures and continued interventions, we hope to see a significant increase in proper ordering of oxygen and proper use of oxygen within goal parameters.
Reduce patient harm by excess oxygen, reduce oxygen burden on the hospital while at the same time reducing costs.