Standard Operating Procedure for Administration and use of Emergency and Non-Emergency Oxygen in Lincolnshire Community Health Services Community Hospitals

Reference No:

G_CS_24

Version:

1.2

Ratified by: Date ratified:

LCHS Trust Board 25th March 2014

Name of originator/author:

Jill Anderson /Jo Stones/ Michelle Webb

Name of responsible committee/individual:

Quality Scrutiny Group

Date Approved by committee/individual:

23rd January 2014

Date issued:

October 2016

Review date:

November 2016

Target audience:

Registered Ward Staff

Distributed via:

Website

Lincolnshire Community Health Services NHS Trust Standard Operating Procedure for the Administration and use of Emergency and Non-Emergency Oxygen in Lincolnshire Community Health Services Community Hospitals Version Control Sheet Version/Description of Amendments

Date

Author/Amended by

1 1.1

New SOP Extension agreed

Jan 2014 May 2016

Audit Committee

1.2

Extension agreed

Oct 2016

Version

Section/Para/ Appendix

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

2

Corporate Assurance Team

Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

Lincolnshire Community Health Services NHS Trust Administration and use of Emergency and Non-Emergency Oxygen in Lincolnshire Community Health Services Community Hospitals Standard Operating Procedure Statement

Background

The purpose of this guidance is to provide a unified clinical approach to the administration and care of patients requiring supplemental oxygen therapy and to ensure that oxygen is prescribed safely and appropriately with appropriate monitoring and equipment in place.

Statement

A concise and full standard operating procedure will help to provide all Ward staff with the knowledge and skills to monitor the use of oxygen therapy

Responsibilities

All employees on the Wards and Urgent Care Services will have the responsibility to follow the guidance. Authors of the guidance will have the responsibility to undertake appropriate consultation during development of the guidance, and any subsequent amendments.

Training

Matrons / Clinical Leads have a responsibility to ensure all Registered Ward staff are aware of the guidance and have access to appropriate training. Registered Ward Staff have responsibility to ensure all new staff are included in this process at induction.

Dissemination

Via e-mail. Introduction at staff meetings. On induction of new staff. Standard operating procedure files.

Resource implication The operating procedure has been developed to provide a framework / guidance for staff who are working in the Community Hospitals / Urgent care services to ensure safe, appropriate management of oxygen therapy. Consultation

North East Business Unit Clinical Governance Meeting Quality Scrutiny Group All Adult Business Units Respiratory Team

3 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

Lincolnshire Community Health Services NHS Trust Administration and use of Emergency and Non-Emergency Oxygen in Lincolnshire Community Health Services Community Hospitals Contents Section i ii 1 2 3 4 4 4.1 4.2 4.3 5 6 7 Part One 8 Fig. 1 Fig 2. Fig 3. Fig 4. Part Two 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Appendix 1 Appendix 2

Version control sheet Operating procedure statement Introduction. Aims and Objectives Scope Roles and Responsibilities Indications’ for prescribed Oxygen in LCHS Community Hospitals General Managers and Heads of Clinical Services Practitioners All Clinical professionals Review Evidence Base Risk Management Administration of Emergency Oxygen Emergency situations Critical illness requiring high levels of supplemental oxygen. Maintaining oxygen saturation levels Serious illness requiring moderate levels of supplemental oxygen if the patient is hypoxaemic COPD and other conditions requiring controlled or low dose oxygen therapy Administration of Non-Emergency Oxygen Indications for prescribing Oxygen in LCHS Community Hospitals Assessing and Monitoring Inpatients Patients Requiring Oxygen Therapy Identifying appropriate target saturations Contra-indications Prescribing oxygen Types of equipment to administer oxygen therapy Administering Oxygen Nebulised therapy and oxygen Humidification Prescribing and Monitoring Transfer and Transportation of patients receiving oxygen Weaning and Discontinuation Infection Prevention and Control Training Monitoring and recording Oxygen Summary Oxygen Administration protocol (and weaning protocol) Audit Oxygen Devices References CHS 78 Administer Oxygen Safely and Effectively (Skills for Health Competencies) Oxygen Audit in Community Hospitals NPSA/2009/RRR006 Equality Impact Assessment Audit and Monitoring

Page 2 3 5 5 6

7 8 9 10 11

12

13 14

15 16 14 17 18 23 24 26 30 32

4 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

1

Introduction

1.1 The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions; however oxygen is a drug and therefore requires prescribing in all but emergency situations. Failure to administer oxygen appropriately can result in serious harm to the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the clinician’s role. 1.2 Oxygen is a colourless, odourless and tasteless gas which makes up 21% of the atmosphere. Within all community hospitals there are two varieties of oxygen administration namely piped and portable cylinders. Both of these systems are supported by portering staff from within the facilities team, who have a day to day responsibility for changing cylinders, monitoring usage and availability of supplies. They also order replacement stock. 2

Aims and Objectives

2.1 The aim of this service operating procedure (sop) is to provide a unified clinical approach to the administration and care of patients requiring oxygen therapy, within LCHS community hospitals. The use of supplementary oxygen is considered to be a medicine and should be managed in the same way as all other medicines in its method of administration.   

All patients who require emergency / supplementary oxygen therapy receive therapy that is appropriate to their clinical condition and in line with national guidance (British Thoracic Society Guideline; Thorax, 2008). Oxygen will be prescribed according to a target saturation range. The system of prescribing target saturation aims to achieve a specified outcome, rather than specifying the oxygen delivery method alone. Those who administer oxygen therapy will monitor the patient and keep within the target saturation range.

2.2 This sop outlines the administration and use of oxygen within community hospitals and Urgent Care services. The clinical steps which should be taken by registered clinicians before administering oxygen to patients. It also outlines equipment which should be used to administer oxygen therapy and the roles and responsibilities of staff caring for patients receiving oxygen. Where appropriate, it should be read in conjunction with Policy for Use of Pulse Oximetry in Adults (P_CIG_09). 3 Scope 3.1 Minimum standards expected from clinical professionals in the administration of emergency and non-emergency oxygen, are provided. 3.2 This sop applies to all areas within the Community Hospitals and Urgent Care Services of Lincolnshire Community Health Care Services NHS Trust where oxygen is administered. Responsibility lies with registered healthcare professionals who in order to administer oxygen safely must understand:     

The indications for oxygen The hazards associated with oxygen therapy Oxygen and humidification systems in use Potential side effects of usage Safe storage of Oxygen 5 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

 How to initiate home Oxygen therapy  The referral process for the Community Respiratory Team 4

Roles and Responsibilities The Chief Executive has overall responsibility for the strategic and operational management of LCHS NHS Trust, including ensuring that the organisations policies and procedures comply with all legal, statutory and good practice requirements.

4.1 General Managers and Heads of Clinical Service Responsible for identifying and implementing polices relevant to their area of responsibility. They are also responsible for ensuring that all staff have access to and are made aware of policies that apply to them. All staff are responsible for the implementation of LCHS polices and procedures as part of their core duties 4.2 Practitioners It is the responsibility of these individuals to ensure that they are competent to administer oxygen and record the appropriate clinical observations. They should be competent in the use of equipment for the delivery of oxygen, in the case of any evident or suspected malfunction or inaccuracy of equipment this should be reported to a senior member of staff and appropriate action taken. 4.3 All Clinical Professionals Who are involved in the administration of oxygen should be aware of this sop and its principles. Documentation and communication are pivotal to minimising risks for patients and all actions should be documented contemporaneously or as soon as possible after the event. 5

Review This sop will be reviewed annually by the Medicines Management Committee and approved by the Quality Scrutiny Group.

6

Evidence Base See references Section 27

7

Risk Management

7.1 The NHSLA risk management standards 2012-2013 (NHS Litigation Authority) outline the requirements for Medical Devices Training (5.5) and Medicines Management (5.10). 7.2 The NPSA (2009) Oxygen safety in hospitals - Rapid Response Report – from reporting to learning NPSA/2009/RRR006, aims to ensure that safe systems are in place to treat patients needing oxygen. An audit tool based on this guidance is detailed in Appendix 3.

Part One Administration of Emergency Oxygen 6 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

8

Emergency Situations

8.1

In the emergency situation an oxygen prescription is not required. Oxygen should be given to the patient immediately, without a formal prescription or drug order, but documented in the patient’s record. All patients who have a cardiac or respiratory arrest should have 100% oxygen provided, along with basic / advanced life support.

8.2 All critically ill patients should be given 100% oxygen (15l/m reservoir mask), immediately (see fig.1), the aim should to stablilise the patient and then to achieve normal or nearnormal oxygen saturations for all acutely ill patients, apart from those at risk of hypercapnic respiratory failure or those receiving terminal palliative care. Fig.1 Critical illnesses requiring high levels of supplemental oxygen 

The initial oxygen therapy is a reservoir mask at 15 l/m



Once stable, reduce the oxygen dose and aim for a target saturation range of 94-98%



Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients pending the results of blood gas measurements, after which these patients may need controlled oxygen therapy or supported ventilation if there is severe hypoxaemia and / or hypercapnia with respiratory acidosis.

Cardiac arrest or resuscitation

Shock, sepsis, anaphylaxsis, major pulmonary haemorrhage

Additional comments Use bag-valve mask during resuscitation Aim for maximum possible oxygen saturation until the patient is stable. Also give specific treatment for the underlying condition

Major head injury

Early intubation and ventilation if comatose

Carbon monoxide poisoning

Give as much oxygen as possible using a bag-valve mask or reservoir mask. Check carboxyhaemoglobin levels. A normal or high oximetry reading should be disregarded because saturation monitors cannot differentiate between carboxyhaemoglobin and oxyhaemoglobin owing to their similar absorbances. 2 The blood gas PaO will also be normal in these cases (despite the presence of tissue hypoxia). (British Thoracic Society guideline, 2008)

* * Th e a b o ve p a t i e nt s w i l l r e q ui r e e m er g e n c y t r a n s f er t o a c u t e c a r e e x c e p t w h e r e a d va n c e d d i r e c t i ves a r e i n pl a c e * * See also: Fig. 3 (page 9) Fig. 4 (page 10)

Serious illnesses requiring moderate levels of supplemental oxygen if the patient is hypoxaemic COPD and other conditions requiring controlled or low-dose oxygen therapy

8.3 Oxygen should be prescribed to achieve a target level saturation of 94-98% for most acutely ill patients or 88-92% for those at risk of hypercapnic respiratory failure (see Fig. 7 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

2). The target saturation should be written on the drug chart. ** some normal subjects, especially people aged > 70 years, may have oxygen saturation measurements below 94% and do not require oxygen therapy when clinically stable.** Maintaining Oxygen Saturation

Fig 2.

Titrate oxygen up or down to maintain the target oxygen saturation. The table below shows available options for stepping dosage up or down. The chart does not imply any equivalence of dose between Venturi masks and nasal cannulae. Allow at least 5 minutes at each dose before adjusting further upwards or downwards (except with major and sudden fall in saturation). Once your patient has adequate and stable saturation on minimal oxygen dose, consider discontinuation of oxygen therapy.

Seek medical advice if patient appears to need increasing oxygen therapy or if there is a rising National Early Warning Score (NEWS)

Venturi 24% 2-4 l/min

Nasal cannulae 1 l/min

Venturi 28% 4-6 l/min

Nasal cannulae 2 l/min

Venturi 35% 8-10 l/min

Nasal cannulae 4 l/min

Signs of respiratory Deterioration  Respiratory rate (especially if >30)  O2

Blue

White

All patients should have ABG Within 1 hour of requiring increased oxygen



 NEWS score  C O2 retention  Drowsiness  Headache  Flushed face 

Yellow Venturi 40% 10-12 l/min

or simple face mask at 5-6 l/min

Venturi 60% 12-15 l/min

or simple face mask 7-10 l/min

Red Where ABG is required, transfer to Acute care should be considered, send ABG to lab as directed by medical staff. Ensure continued monitoring of SPO2

oxygen dose needed to keep Spo2 in target range

Tremor Green

Seek medical advice

Reservoir mask at 15l/min oxygen flow

If reservoir mask required, seek Senior medical input immediately



For venturi masks, the higher flow rate is required if the respiratory rate is >30

Patients in a peri-arrest situation and critically ill patients should be given maximal oxygen therapy via a reservoir mask via reservoir mask or bad-valve mask whilst immediate medical /paramedic help is arriving (except for patients with COPD with known oxygen sensitivity recorded in patient’s notes and drug chart: keep saturation at 88-92% for this subgroup of patients) (British Thoracic Society guideline, 2008)

8.4 Oxygen should be given by staff who are trained in oxygen administration, using appropriate devices and flow rates in order to achieve the target saturation. Any qualified nurse / health professional can commence oxygen therapy in an emergency situation. 8.5 Oxygen is a treatment for hypoxaemia, not breathlessness (oxygen has not been shown to have any effect on the sensation of breathlessness in non-hypoxaemic patients). However, a sudden reduction of more than 3% in a patient’s oxygen 8 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

saturation within the target saturation range should prompt fuller assessment of the patient (and oximeter signal) because this may be the first evidence of an acute illness. 8.6 Oxygen saturation should be checked by pulse oximetry in all breathless and acutely ill patients, urgent blood gas analysis should be undertaken when necessary (transfer should be consider for all acutely ill patients). The inspired oxygen concentration should be recorded on the observation chart with the oximetry result. 8.7 The other vital signs of pulse, blood pressure, temperature and respiratory rate, should also be recorded. All acutely ill patients should be assessed and monitored using the National Early Warning Score (NEWS). Fig 3.

9 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

Fig 4. Table 3 COPD and other conditions requiring controlled or low-dose oxygen therapy (section 8.12)  Prior to availability of blood gases, use a 28% Venturi mask at 4 Vmin and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis. [Grade D]  Adjust target range to 94-98% if the Paco2 is normal (unless there is a history of previous NW or IPPV) and recheck blood gases alter 3060 min [Grade D]  Aim at a prespecified saturation range (from alert card) in patients with a history of previous respiratory acidosis. These patients may have their own Venturi mask. In the absence of an oxygen alert card but with a history of previous respiratory failure (use of NIV or IPPV), treatment should be commenced using a 28% oxygen mask at 4 Vmin in prehospital care or a 24% Venturi mask at 2-4 Vmin in hospital settings with an initial target saturation of 88-92% pending urgent blood gas results. [Grade I))  If the saturation remains below 88% in prehospital care despite a 28% Venturi mask, change to nasal cannulae at 2-6 Vmin or a simple mask at 5 Vmin with target saturation of 88-92%. All at-risk patients with alert cards, previous NIV or IPPV or with saturation 50 years who are long-term smokers with a history of chronic breathlessness on minor exertion such as walking on level ground and no other known cause of breathlessness should be treated as if having COPD for the purposes of this guideline. Patients with COPD may also use terms such as chronic bronchitis and emphysema to describe their condition but may sometimes mistakenly use "asthma". FEV, should be measured on arrival in hospital if possible and should be measured at least once before discharge from hospital in all cases of suspected COPD. [Grade D]  Patients with a significant likelihood of severe COPD or other illness that may cause hypercapnic respiratory failure should be triaged as very urgent and blood gases should be measured on arrival in hospital. [Grade 0]  Blood gases should be rechecked after 30-60 min (or if there is clinical deterioration) even if the initial Paco, measurement was normal. [Grade D]  If the Paco, is raised but pH is {[H1 6 kPa or 45 mm Hg) and acidotic (pH 45 nmo1/1) consider non-invasive ventilation, especially if acidosis has persisted for more than 30 min despite appropriate therapy. [Grade A]

Additional comments

Grade of recommendation

COPD

May need lower range if acidotic or if known to be very sensitive to oxygen Grade C therapy. Ideally use alert cards to guide treatment based on previous blood gas results, Increase flow by 50% if respiratory rate is >30 (see recommendation 32)

Exacerbation of CF

Admit to regional CF centre if possible; if not, discuss with regional centre or manage according to protocol agreed with regional CF centre

Grade D

Ideally use alert cards to guide therapy. Increase flow by 50% if respiratory rate is >30 {see recommendation 32) Chronic neuromuscular disorders

May require ventilatory support. Risk of hypercapnic respiratory failure

Grade 1)

Chest wall disorders

For acute neuromuscular disorders and subacute conditions such as GuiIlain-Barre syndrome (see table 4)

Grade I)

Morbid obesity

Grade I)

CF, cystic fibrosis; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; IPPV, intermittent positive pressure ventilation; NIV, non-invasive ventilation; Patoz, arterial carbon dioxide tension; Booz, arterial oxygen saturation measured by pulse oximetry.

10 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

Part Two Administration of Non-Emergency Oxygen 9

Indications for prescribed Oxygen in LCHS Community Hospitals

9.1 Oxygen therapy is used for a variety of clinical conditions but primarily where the patient is unable to maintain their own oxygen levels. Within the community hospitals, patients requiring oxygen may fall into the following clinical groups       

Cardiac failure Respiratory failure/distress Palliative care Chronic obstructive Pulmonary Disease Asthma Post myocardial infarction Pneumonia

(This list is not exhaustive and is intended as a guide only to clinicians)

10 Assessing and Monitoring Patients Requiring Oxygen Therapy 10.1 On admission to hospital patients should have baseline observations of Temperature, Pulse, Respirations, Blood Pressure and Oxygen saturation levels recorded using a pulse oximeter.

11 Identifying Appropriate Target Saturations 11.1 The normal range for peripheral saturation (SpO2) levels is 94 -98%. The exceptions are patients at risk of hypercapnic respiratory failure (usually patients with moderate or severe COPD, severe chest wall or spinal disease, neuromuscular disease or severe obesity) for this group the target is oxygen saturations set at 88 to 92 per % ( until arterial blood gases have been interpreted). Where patient’s oxygen saturations are lower than this further assessment of their health and referral to any recent recordings should be made. It is not acceptable that the first response is the application of oxygen (except in an emergency) as in the case of a patient with Chronic Obstructive Pulmonary Disease (COPD) this may be very harmful. 11.2 10 -15% of patients with COPD have type II respiratory failure (Bateman and Leach 1998) and for these patients a falling oxygen level is their drive to breathe. These patients need to have their hypoxia corrected but the dose of oxygen given needs to be carefully administered and monitored, this should be reviewed as a potential issue when oxygen therapy is considered. 11.3 Clinical signs of inadequate oxygenation to consider when making an assessment are:

     

Is the patient’s SpO2 below 94%? Does the patient have a raised pulse rate? Does the patient have a raised respiratory rate? Does the patient have altered skin colour? Is there cyanosis? Are there signs of agitation, confusion or an altered level of consciousness? Are they using their accessory muscles when breathing?

Consideration should be given to: 11 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

     

Optimisation of medication and inhalers Compliance against prescription Inhaler technique Evidence of or diagnosis of anaemia Is treatment for COPD ( saturations will be lower) Pre existing respiratory conditions

12 Contraindications 12.1 There are no absolute contraindications to oxygen therapy if indications are judged to be present. The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest possible rate of administration. 12.2 Other Precautions/ Hazards/ Complications of Oxygen Therapy     

Drying of nasal and pharyngeal mucosa Oxygen toxicity Skin irritation Fire hazard Potentially inadequate flow resulting in lower oxygen absorption than intended (equipment fault should be considered).

13 Prescribing Oxygen 13.1 Oxygen should be prescribed in the designated section of the hospital prescription card and the appropriate target saturation should recorded on the chart and on the National Early Warning Score Chart.

14 Types of equipment to administer oxygen therapy 14.1 All staff involved in the provision and administration of oxygen should be able to demonstrate competency with the equipment in use within their clinical area of work. Where cylinders are in use staff should understand the process for changing the flow meters (usually undertaken by Facilities Team).

12 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

14.2 All equipment should be regularly checked and stocks of masks readily available and accessible. Where there is both a supply of piped air and oxygen the regulators should be clearly distinguishable and where necessary labelled. 14.3 Piped oxygen will be the main source of supply, the use of cylinders should be kept to a minimum. Where the use of oxygen cylinders is unavoidable systems should be in place to ensure that supplies are readily available, accessible and checked on a regular basis( during intentional rounding) when in use. In addition there needs to be clear segregation of full and empty cylinder supplies. There should be clear distinction between oxygen and piped air. When piped air is not required flow meters should be removed but readily available for use. 14.4 Following admission any patients requiring non emergency oxygen therapy should be reviewed by a doctor! non-medical prescriber at the earliest opportunity and a prescription for oxygen together with the desired oxygen saturation range clearly documented on the inpatient prescription chart, and National Early Warning Score (NEWS). The correct oxygen administration device can then be selected. 15 Administering oxygen 15.1 Once the target saturation has been identified and prescribed, guidance regarding the most appropriate delivery system to reach and maintain the prescribed saturation is provided below: 15.2 Oxygen administration devices are many and variable. For emergency situations where a high percentage oxygen is required the mask of choice for those who will tolerate a mask is a non rebreathe mask with reservoir This can be connected directly to the flow meter with a flow rate of 15 litres! minute (l!min) and deliver 85% oxygen. This product is only licensed for emergency situations and once stabilised an alternative mask should be used. Guidance from the British Thoracic Society states that in an emergency, oxygen should always be given immediately and documented later. 15.3 Nasal Speculum deliver a low range of oxygen between 24 – 35% and are connected directly to the oxygen with an oxygen flow rate of up to 4 l!min These are safe and easy to use, are comfortable and allow the patient to eat drink and talk. 15.4 Venturi devices come as individual colour-coded barrels that are attached to an aerosol mask. The system delivers a specific percentage of oxygen to the patient Different coloured barrels are selected depending on the percentage of oxygen required. The oxygen flow rate needed for the different barrels varies according to the manufacturer and this flow rate will always be stated on the device. (Section 23) 15.5 This is the device of choice when it is important to deliver an accurate percentage of oxygen (e.g. Type II respiratory failure). 15.6 Medium concentration (MC) masks deliver a medium range of oxygen, generally considered to be 35 - 60%. The mask is connected directly to the oxygen flow meter with a flow of 5 – 10 l!min. The oxygen flow should be adjusted according to the flow rate or the desired SpO2 range stated clearly. This mask is ideal for people who are suffering with Asthma, Pulmonary Embolism, Myocardial Infection, Pneumonia or other forms of type I respiratory failure. When using this type of mask flow rates should be maintained at 5 l!min or more as lower rates may result in re-breathing of exhaled air. This makes it difficult to achieve a low inspired oxygen concentration and so these masks are generally unsuitable for patients with type II respiratory failure.

16 Nebulised therapy and oxygen 13 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

16.1 When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure (retention of CO2), it should be driven by compressed air. If necessary, supplementary oxygen should be given concurrently by nasal cannulae at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other specified target range. 16.2 All patients requiring 35% or greater oxygen therapy should have their nebulised therapy by oxygen at a flow rate of >6 l/min and should have pulse oximetry for the duration of delivery. 17

Humidification

17.1 Humidification may be required for some patient groups, especially patients with a tracheostomy and those who have difficulty in clearing airway secretions or mucus. It is not routinely required. 18 Prescribing and Monitoring 18.1 The doctor, nurse practitioner or specialist nurse, is required to prescribe oxygen and this should be done at the earliest opportunity with guidance on the range of oxygen saturation levels required. The delivery device and flow rate should always be recorded on the physiological observations chart (BTS 2008) this is also in line with LCHS Trust policies and procedures. 18.2 Oxygen therapy will be adjusted to achieve target saturations rather than giving a fixed dose to all patients with the same disease. Nursing staff will be able to adjust the dose delivered (following discussion with a senior clinician competent in the prescription of oxygen / respiratory clinicians) this will be reflected on the prescription chart. The patient’s requirement for oxygen should be monitored at each drug round and their oxygen saturation levels recorded. If oxygen is still required the Registered Nurse must sign the prescription chart confirming the quantity of oxygen that is being administered. 18.3 The on-going requirement should be monitored to assess the patient’s progress and requirements for discharge. A Home Oxygen Order Form (HOOF) will need to be completed, signed by the prescribing clinician and faxed to the home oxygen supplier. This should be undertaken at least 24hrs prior to discharge. Part A of HOOF can only be completed by the ward, for Part B where portable cylinders may be required there is a need to contact the community oxygen nurse or secondary care. Oxygen is only required if SPO2