1. Always do finger oximetry on breathless patients.
Each GP and health professional involved in assessing breathless patients should have a pulse oximeter. These are cheap – at less than £50 – easy to use and a far more accurate way of estimating oxygenation than looking for cyanosis.
2. Be aware of the new oxygen contract.
A new home oxygen contract has been agreed between the Department of Health and a number of providers and will be fully implemented across England and Wales by 2013. There is great emphasis on the establishment of more cost-effective assessment and a prescribing service, by delegating the prescribing of all oxygen therapy to a dedicated home oxygen service assessment and review team, along with a new pricing mechanism. The new contract provides an ideal opportunity to address prescribing issues, deliver value for money and reduce the risks associated with prescribing oxygen.
3. Ensure all patients on oxygen receive regular review.
Oxygen is a powerful, yet potentially lethal, drug. For example, patients with non-COPD causes for hypoventilation – such as the morbidly obese and patients with neuromuscular disease – can die from abolition of the hypoxic drive when excess oxygen is given, so those who are on oxygen need to be closely monitored. There are established guidelines for the content and frequency of these reviews, which can be done by home review teams.
4. Do a risk assessment before referring a patient for oxygen.
Patients on oxygen commonly continue to smoke. Oxygen lingers around the patient for at least 20 minutes after the oxygen flow stops.
There are several cases each year of significant burns and deaths in patients who continue to smoke while on oxygen.
A patient who requires oxygen should have a thorough risk assessment to estimate the risks to the patient, and their carers and neighbours.
Prescribers will need to account, usually to the coroner in fatal cases, for the risk-assessment procedure they carried out should injury occur as a result of oxygen therapy.
5. Do not prescribe oxygen for dyspnoea in the absence of hypoxaemia.
There is no evidence that oxygen is effective at relieving dyspnoea in palliative care or any other type of patient in the absence of hypoxaemia – defined as an oxygen saturation of 92% or less.
If there is no hypoxaemia, either at rest or on exertion, then oxygen therapy is not indicated.
Seek other remedies to correct the dyspnoea. Once oxygen is prescribed in these circumstances, it is very difficult to stop.
6. Understand new prescribing restrictions.
With the new oxygen contract, there is also a new home oxygen order form.
Non-specialists – any prescriber who is not part of an oxygen assessment and review centre or respiratory team (including paediatric) – will only be allowed to prescribe long-term oxygen therapy and static cylinders as a temporary emergency measure prior to an assessment of the patient's needs by an oxygen assessment and review team.
7. The need for long-term oxygen should prompt end-of-life discussions.
Long-term oxygen for lung disease means the patient's respiratory reserve is severely limited.
It should be a trigger for you to consider end-of-life discussions.
8. Only use short-burst oxygen therapy for cluster headaches.
Short-burst oxygen therapy – for periods of around 10-20 minutes at a time – is only the therapy of choice for cluster headaches. There is no evidence that short-burst oxygen therapy is effective at relieving dyspnoea, and it is an expensive placebo.
Long-term oxygen therapy – more than 15 hours per day – for hypoxaemic patients with COPD prolongs survival, which is a major aim of the NHS Outcomes Strategy for COPD.
The correction of hypoxaemia with supplemental oxygen improves quality of life.
9. Audit your patients on oxygen.
Estimate the current cost of oxygen therapy in your practice. Currently 85,000 patients in England have oxygen at home at a cost to the NHS of around £110m a year.
Between 24-43% of the oxygen that is prescribed to these patients is not used properly or confers no clinical benefit.
10. Understand your legal responsibilities as a prescriber.
Whoever ultimately prescribes oxygen takes clinical and legal responsibility for the patient receiving it and removing it when it is not needed. Prescribers will have to sign a declaration when they order oxygen confirming the accuracy of the form, that they are the registered healthcare professional responsible for the information provided and accepting that providing false information may lead to prosecution or civil proceedings. They also need to confirm that the patient has read and signed the consent form.
Dr John Williams is a respiratory consultant at Warrington and Halton Hospitals NHS Foundation Trust and co-lead of the North West SHA respiratory pathway team
This article was co-authored by Dr Ruth Hunter, assistant commissioner for NHS Merseyside.
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