Oxygen use in hospital settings

Master in Quality & Safety in Healthcare Management

Year Two, 2010-2011

Oxygen Use Monitoring in Hospitals: Literature Review

Oxygen Use Monitoring in Hospitals: Literature Review

search strategy methods and methodologies application of findings to the writer's organization

Oxygen is vital element in people life.. It is a fact that, in a normal room, the percentage of oxygen is only 21% and this amount is sufficient for healthy people. However, most patients need higher levels of oxygen to circulate blood and allow body tissues to function normally (Thannickal, 2009). Oxygen is frequently used as a form of medication in community and hospital settings by the nurses and doctors employed. Use of oxygen as a medicine is not chosen for specified situations nor it is normally prescribed by doctors as part of a medical treatment (Wilkinson, Wright and Goble, 2005). Use of high percentage of oxygen in cases of acute illnesses can save patients from experiencing rigorous form of hypoxaemia (Longphire et al., 2007).

According to Dias et al. (2008), oxygen use has certain procedures that need to be followed to make it effective without causing any negative interactions and/or complications. They argue that if oxygen is used excessively or is not monitored regularly, it can cause more harm than benefits. In an earlier study, Ukholkina et al. (2005) revealed that many hospitals have reported that deficiency of proper monitoring of oxygen has led to complications for many patients. However, they argue that the use of oxygen cannot be stopped because of its benefits.

Similarly, Bassand et al. (2007) review the guidelines presented by the British Thoracic Society on how to administer oxygen use for patients and found that sometimes hospitals fail to administer protocols of oxygen consumption. No oxygen prescriptions are usually issued, so patients may receive less or extra oxygen. This increases the cost of oxygen use. Furthermore, depending on the patient's condition, a higher or lower dose of oxygen can be damaging.

The purpose of this review is to analyze how hospitals monitor the use of oxygen. The review carries significant value for clinicians since this analysis will thoroughly cover the concept of oxygen use covered in regional, national, and international literature.

The approach adapted by the writer for reviewing the literature has been by discussing it in three different themes. They are Suitable apparatus, oxygen use monitoring by trained professionals, and the impact of high-level monitoring process.

Search Strategy

In order to collect relevant data for the results, concise and yet comprehensive information related to the topic have been compiled from articles published in Pub- med, emerald, science direct, Ovid, and Medline by individual researchers, as well as, research institutions. The aim of the study is to critically review the strengths and weaknesses of both conception and implementation of research pertinent to our topic. This section also presents new questions raised by the research and their potential for future enquiry. The keywords used to collect data had been, "oxygen use is wards," "oxygen use," "oxygen use is hospitals," "oxygen monitoring."

Evaluation of the data will be based on calculating the intended affect or the outcomes/results of the study. The method used to measure the results of the study will be the same as those found in other research synthesis studies. The writer will also look into the process with which the results are obtained so that limitations in the methods can be determined and improvements can be suggested.

Overview of the Literature

In this section the writer will review three themes emerging from the literature related to oxygen use monitoring. The writer found good number of research articles through which the selected themes had been discussed. However, the writer had to drop some articles due to major bias and poor methodologies.

Theme 1: The most suitable apparatus for monitoring oxygen levels

The writer has reviewed seven articles on monitoring oxygen levels. By analyzing these studies one can infer that the best form of monitoring oxygen levels is either invasively by arterial blood drawing or by the use of the pulse oximeter device as non-invasive method. The primary function of the pulse oximeter is to calculate the levels of oxygen saturation (SpO2) in a patient. It does this through the use of a standardized clip-on sensor, normally clipped on the earlobe or the finger of the patient being monitored. In addition, the device also helps in monitoring and identifying the initial stages of hypoxemia in the monitored patient before it becomes clear to sight (Bassand et al., 2007).

Similarly, the arterial blood gases measurements help, not just in monitoring the overall flow of oxygen and its level, but also provide additional medical data like the acid-base balance experienced by the patient. In a relevant study, the researchers explained that the primary use of the arterial blood gases is to monitor oxygen use and is irregularly used to monitor or gather additional data and the corresponding results are not obtainable immediately (Martin et al., 2005).

Slagboom et al. (2005) have found that the reason why regular monitoring is given so much importance in modern times is because it is used as the foundation for prescribing or using supplemental oxygen treatment. This was done before as well, but most of the use was done through guess work. The use oximeters and the arterial blood gasses have helped to make the decision about the supplemental oxygen therapy a lot more concrete and thorough (McNulty et al., 2005). The writer agrees with the conclusion of both these researchers and believes that the induction and use of these machines have assisted in creating accurate and precise results.

When it comes to the emergency rooms and wards, the use of pulse oximetry is mainly to monitor and examine the alterations or interactions that might occur in patients during and after the oxygen therapy has begun (Stone et al., 2009). Likewise, Bassand et al. (2007) found that researchers have highlighted the benefits of using pulse oximeter. The writer, once again, agrees with their conclusions and thinks that pulse oximeter is more preferable than arterial blood gases. That is because it is non-invasive, quick, and more acceptable by patients.

On the contrary, it is important to note here that the pulse oximeter does not give a full picture of the delivery of oxygen and its impact i.e. It does not have relevant data on the concentration of hemoglobin, on the impact it has had on the tissues and the relevancy of ventilation amongst others (Dotsenko et al., 2007). The writer argues that all machines have their limitations and that manufacturers should focus on enhancing the effectiveness of pulse oximeter so that the current holdups can be averted in the future.

Gainnier and Forel (2006) reviewed clinical studies that focused on the use of helium-oxygen on patients. They, too, used meta-analysis of research studies carried out in the past as their methodology. They found that benefits of helium-oxygen have been well documented throughout the medical literature. They found that care has to be taken though that the ratio of helium and oxygen remains balanced, as an increase in the level of oxygen in the mixture drastically decreases the overall benefits of the breathing the compound. Furthermore, if He/O2 is being used in Intensive Care Units (ICU), expert monitoring must be administered to avoid negating and damaging impacts (Gainnier and Forel, 2006). The writer agrees with the conclusion of these researchers. Maintaining oxygen levels is unique for each patient and efforts should be directed towards providing each patient his/her required dose.

Theme 2: The significance of applying oxygen apparatus by trained professionals

Eight articles have been reviewed by the writer in line with this theme and the results of his analysis reveal that several mistakes have been made whilst managing oxygen apparatus by untrained healthcare professionals. The common theme recurring in these studies is that quite often the job description of these individuals did not include managing and monitoring oxygen use; however, they had been asked to do so by the senior staff.

According to Espiritu et al. (2009) the senior staff quite often delegates oxygen monitoring authority to their juniors even though it is part of their job description. This simply means that those appointed to monitor oxygen saturation levels do not do it themselves. The found that amongst the 208 hospitals, the percentage of the "other" hospital staff dealing with oxygen use in wards had been 39%. Similarly the results also indicated that nearly 28% had delegation policies. They found that where delegation policies did not exist, monitoring of oxygen use was often carried out by untrained individuals. This is where the lucid transference of instructions and training becomes crucially important one implication of this study is that all hospitals should have a clearly written oxygen use policy, which not just explains how oxygen should be monitored but also, if necessary, how its use should be delegated.

Beasley et al. (2007) reveal that while oxygen use can help prevent serious harm it can, on the other hand, inflict significant harm if monitored by untrained professionals. This particular aspect is what most medical trainers miss when dealing with interns or newly appointed nurses. They found that oxygen use, if below the necessary requirement can be damaging, so can its overuse. In another study, it has been found that using oxygen below the prescribed level can instigate damage in the organs, respiratory structures and can be especially damaging for patients who have chronic obstructive pulmonary disease (Danchin et al., 2009). Hence, the training and instructions that are given must follow be thorough enough to let the health caretakers realize that the monitoring is not merely a game of reading and recording, but it can have serious repercussions if handled carelessly.

Some of the common mistakes, which can be avoided through proper and accurate transference of instructions and training, occur in different medical circumstances. Sometimes nurses tend to miss the monitoring deadline. For instance, if a patient is required to have 80% of oxygen flow and saturation level, and overnight observations are not recorded, the patient could end up requiring intubation and ICU admission (O'Driscoll et al., 2008). Similarly, Cabello et al. (2009) found that no action had been taken on irregular saturation levels. They found that sometimes patients were required to have a certain level of oxygen saturation but during the monitoring session, the saturation levels recorded were higher than what was required. They warned that if this particular change is not properly reported to the doctor, the patient could experience a damaging or even fatal cardiac arrest. One implication from all these studies is that untrained and inexperienced professionals should not be handling oxygen use. Any exception to this rule, at any time, can turn out to be damaging for the patients.

Wilkinson et al. (2005) in their study reviewed oxygen toxicity and found that untrained individuals can make the mistake of using compressed air instead of oxygen in cylinders. This mistake, they found, can be made if careful observation is not made. Furthermore, in some cases this can lead to certain death for the patient. One implication for this study is that compressed air should never be used as an alternative for 100% oxygen. It has been noted that, from time to time, oxygen cylinders can be left empty or be kept on very low levels. This has to be monitored carefully so that complications in the respiratory structure can be prevented (Slagboom et al., 2005). One consequence from this study is that only trained professionals should be delegated with the responsibility of managing oxygen use.

Enarson et al. (2008) studied the use of new oxygen concentrator systems in district hospital paediatric wards throughout Malawi. They surveyed district hospitals and found that most of the paediatric wards did not have a proper oxygen use set up. However, a government program, namely, "Child Lung Health Programme," supplied oxygen concentrators and other essential apparatus to twenty two districts and three regional hospitals. After the integration of oxygen concentrators the researchers the trained the hospital staff on how to use and maintain it. This was done after developing a curriculum. The researchers found that monitoring the oxygen supply apparatus is a very delicate process and only trained professionals are suitable to handle and maintain the use of oxygen equipment in hospital wards. The writer agrees with the conclusions of this study and argues that oxygen use protocols ought to be developed in all healthcare institutes in order to minimize the misuse of apparatus.

Theme 3: The impact of high-level monitoring processes

For this section, seven articles have been selected and reviewed. Researchers found that if and when oxygen saturation levels rise above or falls below the prescribed level, it can result in fatal damages for the patients. Every treatment has its benefits and risks, so does oxygen use, hence it needs to be monitored carefully.

Longphire et al. (2007) in their study reveal that oxygen is a drug that can save lives. Unlike oxygen, other life-saving drugs are used with prescriptions, which specify the specific dose required. They argue that oxygen use should always be administered with specific protocols. One implication of this study is the judicious use of oxygen in hospital wards with strict protocols.

Oxygen use protocols should include not just the dose required by individual patients, but also the precise time and date. Furthermore, protocols should also be established with regards to how the oxygen dose should be measured since different measuring devises have different strengths and procedures (Dias et al., 2008). Furthermore, in a similar study, Ukholkina et al. (2005) claim that only properly trained staff are suitable to administer oxygen use. They argue that oxygen apparatus is not simple enough to be used by any nurse. Specific training is required to read the oxygen levels and give appropriate dose to each patient. The writer found that both studied implied that oxygen use is a complicated process with difficulties. Any mistake in its delivery can cause significant damage to the patients.

Bassand et al. (2007) reviewed the British Thoracic Society's fundamental guidelines along with need for the utilization of oxygen as a treatment and the relevant monitoring procedures that follow. He found that the report also signifies how carelessness on following the saturation levels can lead to serious complications for the patients. In some states, oxygen use is a prescription drug and failure to monitor oxygen levels can lead to a criminal offense. Therefore, those assigned with the duty of monitoring oxygen levels have got to be vigilant not only to avoid any harm to the patient but also to avoid any lawsuits.

Other researchers state that the least amount of prescribed oxygen, with regards to the patient's disease, must be given. For instance, Lima and colleagues (2009) focused on the use and benefits of regular examinations of the oxygen saturation (StO2) for clinically ill patients. They found that the direction and use of the prescription of oxygen use has to precise and clear so that those responsible for its application can mirror it without any complications Oxygen application at wards has always been a complicated process. Almost all in-patients receive oxygen at some point in their recovery process. However, quite often delivery of oxygen is carried out without any protocols.

Researchers from other study found that going below the prescribed oxygen use is not as damaging as exceeding it. They also found that the use of oxygen must be for the shortest time period as well so that the extended use does not raise complications either. This particular fact, the researchers further add, is essential for patients who have chronic obstructive pulmonary disease (COPD), or those who have decreased hypoxic metabolism with minimal carbon dioxide maintenance. The researchers further reveal that the acute asthma patients could experience difficulties and complications in carbon dioxide exclusion is they are prescribed 100% oxygen saturation, even if it is over a short period of time (Agarwal et al., 2008). One implication of this study is that the physicians should be cautious when they are adjusting the oxygen flow. Any increase or decrease in the flow can disrupt and harm the patient quite significantly.

Aandstad et al. (2006) focused on the damaging effects of overuse of oxygen on children. The reason that the researchers claim this is because high levels of oxygen can also prove to be damaging for tissues and cells in the respiratory structure and tract. The researchers also write that oxygen use in patients with damaged or diseased can also lead to serious and lethal complications as it can cause problems in breathing and eventually instigate chronic respiratory failure. Hence they claim that minimal use of oxygen and for the shortest time should be the first option for all doctors. There are two different aspects to this study. This study used children as subjects and therefore the results are pertinent to that population only. The second, and more important aspect, is whether these results can be used when adults are being treated. Additional research needs to be carried out to ascertain the findings in this area.

Sometimes artificial supply of oxygen, despite being monitored can be life-threatening for the patients. For instance, Robertson (2005) in his study compared the benefits of natural air versus 100% artificial oxygen for asphyxiated babies. The methodology he had employed had been a meta-analysis of research studies carried out in the past. He analysed both qualitative and quantitative studies published in online medical libraries. He found that exposure to 100% oxygen for new born babies, despite being monitored, is harmful. This study too used children as their subjects. It would be interesting to note whether these results also stand true for adults. Once again, the writer suggests that additional research needs to be carried out to ascertain the findings in this area.

Methods and methodologies

In the aforementioned section, the writer reviewed twenty one research studies carried out in the past five years. Two research studies had used the survey method as their data collection process and quantitative analysis as their data analysis (Espiritu et al., 2009; Lima et al. 2009). Similarly, twelve studies had used field research and direct observation as their data collection method. Seven studies had been syntheses of research studies published in online medical libraries. The writer finds that the research methodologies of the sixteen research studies that used field research and research syntheses as their methodologies are very strong. However, the two studies that used the survey method may need to be analyzed more deeply and broadly.

With regards to the field studies, the researchers collected original information at the physical location, instead of relying on previous materials or surveys. Their data analysis and results are also very profound since they used readings from different oxygen apparatus in their statistical analysis. Trochim (2006) argues that field research studies are extremely strong in both validity and reliability since the researcher gathers data, quite deeply and broadly, about a specific phenomenon, which in this case is oxygen use in wards. Similarly, Saunders et al. (2003) argues that a meta-analysis shows results that are more diverse and general than what is anticipated from the particular sample. The seven studies that used research syntheses as their data collection methodologies also had very strong methods since they abided by the conventional protocols of research syntheses studies. Furthermore,

In view of the studies carried out by Espiritu et al. (2009) and Lima et al. (2009), their research approach had been deductive, which means that they used a theory to form hypotheses; thereafter a research strategy was designed to either confirm or refute the hypotheses. This approach may give very accurate and precise results; however, the current literature of oxygen use in hospital wards does not fully reveal sound theoretical frameworks with regards to the lack of protocols of oxygen use. It would have been beneficial if they had approached this study using a dual method of both induction and deduction. With deduction they could have used existing theories to form hypotheses and then test it. Their chosen method However, with induction, first data would have been collected in the form of interviews and then it is analyzed so that a theory/hypothesis can be formed about the lack of protocols of oxygen use (Saunders et al., 2003).

The use of dual methods of induction and deduction would have helped their studies add a new methodological dimension to the literature. The results could have been compared with existing theories of effective oxygen use available in the current literature. This would have helped them understand why there is lack of protocols related to oxygen use in wards and what newer concepts can be added in the theories of effective oxygen use. The advantage of using both, induction and deduction, as research approaches is that they could have helped them limit the dependency on over generalizations (Saunders et al., 2003).

Furthermore, considering timeline, both studies used a cross-sectional format. It is noteworthy here that cross-sectional research studies focus on a single time frame i.e. researchers only take a single time-segment from the entire spectrum. In other words, they perform their experiments only once and reply on the data they have gathered to form conclusions. The opposite of cross-sectional format is the longitudinal format, which as the name suggests takes multiple time-segments from the entire spectrum. Both research studies (Espiritu et al., 2009; Lima et al. 2009) ignored the significance of a longitudinal design, may be because of limited funding. However, since studies on the use of oxygen in hospital wards are lacking it would have been beneficial if they embarked upon a longitudinal format and included more variables into their study.