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• W3165154501 abstract "Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable condition characterised by persistent respiratory symptoms and chronic airflow limitation due to airway and/or alveolar abnormalities. Globally, COPD leads to considerable morbidity and mortality.1 People with COPD often experience episodes of acute worsening of respiratory symptoms (exacerbations) that require additional therapies. Severe exacerbations can lead to acute respiratory failure (with or without hypercapnia), requiring hospital admission and oxygen supplementation.1 While oxygen therapy is commonly used in the acute care setting to treat hypoxaemia, there has been increasing recognition over many years that oxygen therapy is often used inappropriately, including to treat the symptom of dyspnoea in patients who are not actually hypoxaemic, or to prevent hypoxaemia.2, 3 Importantly, over-oxygenation can lead to severe or fatal adverse effects including coronary vasoconstriction, and increased risk of reperfusion injury and mortality in patients with acute myocardial infarction.4 Indeed, a recent systematic review and meta-analysis, which included over 16 000 patients with various severe illnesses, identified that liberal oxygen therapy significantly increased in-hospital mortality when compared with a conservative oxygen approach.5 Furthermore, some people with chronic respiratory conditions (e.g. patients with COPD exacerbations or patients with chronic ventilatory failure) are more vulnerable to life-threatening hypercapnic respiratory failure due to excessive oxygen administration through mechanisms such as reduced minute ventilation, ventilation perfusion mismatch and the Haldane effect.6-9 Given the prevalence of oxygen therapy overuse and over-oxygenation of patients in the acute care settings,2, 10, 11 for some years national and international guidelines from respiratory societies1, 2, 12 have recommended that to safeguard patients all aspects of oxygen therapy should be prescribed in a written manner, targeted oxygen saturations set and the response to treatment must be monitored and acted on (titrating the oxygen prescription to saturations) according to the goals of treatment. Furthermore, patients who are at increased risk of oxygen associated complications must be identified, the risk highlighted and the target oxygen saturations adjusted (usually set to a lower level, e.g. 88–92%).1, 2, 12 However, an increasing body of evidence over some years has identified that adherence to these recommendations is poor.3 In this issue of the Internal Medicine Journal, three articles consider these issues further.13-15 Deshpande et al. report suboptimal adherence to acute oxygen use guidelines in a study of hospitalised patients with COPD.14 In this single-site, retrospective chart review, 557 admissions for 457 patients were included, with patients predominantly admitted for respiratory or cardiac conditions. Documentation of an oxygen prescription was variable (31.2 and 78.9% of ED and ward episodes respectively), and when oxygen prescriptions were documented, most were not guideline concordant.14 Furthermore, even when a guideline concordant oxygen prescription was documented, one third did not receive guideline-concordant oxygen therapy. In the absence of an oxygen prescription a significant proportion of patients did not receive guideline-concordant oxygen administration in both settings. The authors noted that adverse events occurred in 8% of episodes, all of whom received more oxygen than guideline recommendations. However, these events may have arisen due to any of several causes, of which over-oxygenation was only one possibility.14 Anderson et al. report findings from a similar study13 focussed on inpatients with COPD and hypercapnia (PaCO2 ≥45 mmHg) on admission. Of 1160 COPD admissions, hypercapnia was present on admission in 16%, with a final sample of 157 admissions (106 patients) included. The authors identified that oxygen prescriptions were well-documented in medical records (82%) but poorly recorded on prescription charts (13%).13 Over-oxygenation occurred in almost two-thirds of admissions and was significantly more likely to occur in patients admitted to non-respiratory wards or in the absence of an oxygen prescription. Adverse events were more prevalent in this study (22% of patients); however, while there was a trend towards an association between over-oxygenation and adverse events, this was not statistically significant.13 The third article in this issue of the Journal is by Nguyen et al. and reports the findings from a small, single-site study investigating the effectiveness of an oxygen therapy education programme for nursing and junior medical staff on respiratory, oncology and surgical wards.15 The programme comprised a 30-min education session regarding guideline recommendations for oxygen use in respiratory failure. No control group was included. A preliminary audit prior to the intervention found that oxygen therapy was used infrequently (28 of 175 patients) across medical and surgical wards and the ED.15 Baseline data demonstrated oxygen prescriptions documented for half (24 of 43) the patients using oxygen therapy on the target wards. The prescription rate increased (albeit not statistically significantly) to 75% at 3 months, and remained at 65% at 6 months. The authors identified that while documentation of oxygen saturations by nursing staff was high, no action was taken for any of the patients with oxygen saturations outside their treatment goals.15 The intervention did not include an audit and feedback approach, which may have provided additional opportunities for healthcare professionals to reflect on and improve their practice.16 While all three of these studies were relatively small, with two being retrospective medical audits, nevertheless, the fundamental message remains that acute oxygen therapy is still not well managed in hospitals with low adherence to guideline recommendations and patients who receive oxygen therapy are often over-oxygenated.13-15 Importantly, all three studies identified wide variability in acute oxygen management practices, with opportunities for improvement throughout the hospital environments. While patients cared for on respiratory wards received more guideline concordant oxygen therapy, even in those respiratory areas (where healthcare staff are more experienced and specifically trained to manage oxygen therapy), there were suboptimal oxygen management practices.13-15 While it was not possible in these studies to infer any causality between over-oxygenation and adverse outcomes, this has been well demonstrated in other studies.4, 5, 7-9 Importantly, the findings regarding suboptimal oxygen management are despite evidence over decades of the need for change and more recently guidelines that recommend specific practices to improve oxygen management and safeguard patients from oxygen associated harms.2, 3 These three studies, and others before them,10, 11 provide convincing evidence of an implementation failure, where guideline-mandated care is not consistently delivered. This issue affects multiple acute care settings, patients with many different acute illnesses and many different healthcare professionals. What we need now is a deeper understanding of why this implementation failure persists, and targeted strategies to address it. Implementation science has been defined as ‘the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services’.17 A key feature of implementation science approaches is the use of conceptual frameworks, which allow researchers to identify the factors that predict implementation success, design implementation strategies that target these factors and accurately measure their outcomes.18 Recent examples include use of the Theoretical Domains Framework to understand behavioural determinants of low referral rates to pulmonary rehabilitation by healthcare professionals19 and application of the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) Framework to evaluate an electronic medical record-based implementation strategy for lung protective ventilation in critical care.20 While this remains an emerging field, an American Thoracic Society research statement has called for a greater focus on implementation science to address evidence-to-practice gaps in respiratory medicine,21 of which over-oxygenation in acute care is an obvious example. These studies highlight the fundamental challenges in implementing guidelines and changing practice even over decades. How then can we go forward and bring about change? Education of all healthcare professionals (including senior medical staff) regarding safe acute oxygen therapy remains a priority. Nguyen et al.'s study confirms findings from previous research, which identified that educational interventions regarding acute oxygen management are effective, but need to be ongoing and not limited to a single educational intervention to change practice.3, 15 Furthermore, educational interventions need to be individualised to suit health professionals working in different environments within hospitals (e.g. to engage surgical colleagues), and health professional ‘oxygen champions’ identified and empowered to drive change and seek senior medical support when guideline discordant care occurs.15 Additionally, a broad cultural shift is needed to dispel common myths and misconceptions that oxygen is a benign ‘cure-all’ among patients, health professionals and the community.22 Importantly in this digital, high tech era, wearable continuous oximetry monitoring and closed-loop automated oxygen delivery systems are more sophisticated, effective options for delivering individualised oxygen therapy to inpatients.23 Furthermore, electronic medical records and electronic prescribing provide opportunities to prompt healthcare professionals to flag patients at risk of oxygen-associated complications, mandate documentation of complete oxygen prescriptions (dose, device, flow and target saturations) for all patients receiving acute oxygen therapy, and prompt healthcare staff to take action if oxygen saturations are outside the prescribed range (including prompting nurses to cease oxygen therapy in patients who are over-oxygenated). Ultimately, a multi-faceted, solution-focussed approach is needed, underpinned by the principles of implementation science, to drive sustainable improvements in the use of oxygen therapy in acute care." @default.
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• W3165154501 title "Over‐oxygenation in the acute hospital setting: an implementation failure in need of an implementation science solution" @default.
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