Audit of Prehospital Oxygen Use in Acute COPD Exacerbation
Audit of Prehospital Oxygen Use in Acute COPD Exacerbation
Background In 2009 the Wellington Free Ambulance implemented an education programme to reduce high concentration oxygen delivery to patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of this audit was to compare pre-hospital oxygen delivery to patients with AECOPD before and after the programme.
Methods An audit of patients who presented to Wellington Regional Hospital by ambulance with an AECOPD in 2005 and then in 2010, after implementation of the education programme. Oxygen therapy was categorised as: HIGH, supplemental high concentration oxygen therapy ≥3 L/min and/or delivery via high concentration mask; NEB, high concentration oxygen only during nebuliser use; or LOW, neither of these.
Results In 2005 those in the HIGH, NEB and LOW categories were 81 (75.0%), 18 (16.7%) and 9 (8.3%) of 108 identified patients. In 2010 those in the HIGH, NEB and LOW categories were 80 (44.0%), 61 (33.5%) and 41 (22.5%) of 182 identified patients. The proportions of patients in the three oxygen groups were significantly different between 2005 and 2010 (p<0.001).
Conclusions The proportion of patients administered supplemental high concentration oxygen therapy markedly decreased between 2005 and 2010 following implementation of the education programme. However, in 2010 more than half of the patients not managed with high concentration oxygen therapy were still exposed to high concentration oxygen through the use of oxygen-driven nebulisers. To reduce exposure to high concentration oxygen in AECOPD the use of air-driven nebulisers or metered dose inhalers with spacers is required.
The routine administration of high concentration oxygen therapy to patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) leads to worse outcomes including increased risk of mortality. However, high concentration oxygen therapy is commonly administered in the prehospital management of AECOPD. This has lead to consideration of the reasons for the divergence of recommended and actual practice, and strategies that might change practice.
Wellington Free Ambulance (WFA) is a charitable trust which provides services to a population of 475 000 people, operating from 11 ambulance stations in the greater Wellington region. All paramedics are trained to administer oxygen and all vehicles are equipped with pulse oximeters, but end-tidal carbon dioxide monitoring is designed mainly for postintubation use. Paramedic guidelines advise that oxygen administration should be restricted in patients with AECOPD and that the target oxygen saturation for this group is 88–92%. To ensure management of patients with COPD according to their guidelines WFA developed an integrated education programme in 2009.
To investigate the effect of the education programme on oxygen administration by paramedics, we audited prehospital oxygen delivery to WFA patients with an AECOPD in 2005 and 2010. Our hypothesis was that the programme would reduce the use of supplemental high concentration oxygen therapy but that the use of oxygen-driven nebulisers to administer bronchodilators would result in exposure to high concentration oxygen in an important proportion of patients not otherwise exposed.
Abstract and Introduction
Abstract
Background In 2009 the Wellington Free Ambulance implemented an education programme to reduce high concentration oxygen delivery to patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of this audit was to compare pre-hospital oxygen delivery to patients with AECOPD before and after the programme.
Methods An audit of patients who presented to Wellington Regional Hospital by ambulance with an AECOPD in 2005 and then in 2010, after implementation of the education programme. Oxygen therapy was categorised as: HIGH, supplemental high concentration oxygen therapy ≥3 L/min and/or delivery via high concentration mask; NEB, high concentration oxygen only during nebuliser use; or LOW, neither of these.
Results In 2005 those in the HIGH, NEB and LOW categories were 81 (75.0%), 18 (16.7%) and 9 (8.3%) of 108 identified patients. In 2010 those in the HIGH, NEB and LOW categories were 80 (44.0%), 61 (33.5%) and 41 (22.5%) of 182 identified patients. The proportions of patients in the three oxygen groups were significantly different between 2005 and 2010 (p<0.001).
Conclusions The proportion of patients administered supplemental high concentration oxygen therapy markedly decreased between 2005 and 2010 following implementation of the education programme. However, in 2010 more than half of the patients not managed with high concentration oxygen therapy were still exposed to high concentration oxygen through the use of oxygen-driven nebulisers. To reduce exposure to high concentration oxygen in AECOPD the use of air-driven nebulisers or metered dose inhalers with spacers is required.
Introduction
The routine administration of high concentration oxygen therapy to patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) leads to worse outcomes including increased risk of mortality. However, high concentration oxygen therapy is commonly administered in the prehospital management of AECOPD. This has lead to consideration of the reasons for the divergence of recommended and actual practice, and strategies that might change practice.
Wellington Free Ambulance (WFA) is a charitable trust which provides services to a population of 475 000 people, operating from 11 ambulance stations in the greater Wellington region. All paramedics are trained to administer oxygen and all vehicles are equipped with pulse oximeters, but end-tidal carbon dioxide monitoring is designed mainly for postintubation use. Paramedic guidelines advise that oxygen administration should be restricted in patients with AECOPD and that the target oxygen saturation for this group is 88–92%. To ensure management of patients with COPD according to their guidelines WFA developed an integrated education programme in 2009.
To investigate the effect of the education programme on oxygen administration by paramedics, we audited prehospital oxygen delivery to WFA patients with an AECOPD in 2005 and 2010. Our hypothesis was that the programme would reduce the use of supplemental high concentration oxygen therapy but that the use of oxygen-driven nebulisers to administer bronchodilators would result in exposure to high concentration oxygen in an important proportion of patients not otherwise exposed.
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