P65 Why has emergency oxygen administration failed to improve despite 'best practice' interventions?
Introduction and Objectives Despite instigating all operational and educational recommendations in the BTS Emergency Oxygen Guideline (local policy, standardised prescription and bedside documentation and training) our performance in the BTS annual Emergency Oxygen Audit has failed to improve, in line with national findings, with only 56% of oxygen prescribed, none signed for and 66.7% outside the target range at the most recent audit. Our aim was to investigate the reasons underlying this. Methods A link to an online survey was emailed to all junior doctors and nursing staff on hospital mailing lists. The survey was designed to utilise Pathman's four stages of guideline compliance (awareness, agreement, adoption and adherence) (1) Results Results are summarised in Table 1. Free text comments focussed on a desire by both doctors and nurses for the prescription chart to be clearer and to be located in a more prominent area of the drug chart, whilst doctors were concerned their prescriptions were not followed, nurses commented that doctors frequently failed to prescribe oxygen correctly, if at all. Abstract P65 Table 1. Survey results. All percentages are for number of respondents answering that question, all Likert scales are reported as mean scores out of 5 with 1 being the most negative response and 5 being the most positive, with standard deviation in parentheses afterwards. Variable Doctors Nurses Demographics: Responses Complete (partial) 21 (41) 24 (72) Rank/Grade (self professed respiratory interest) F1 *F2 *CT1 *CT2 *ST3+ *HCA *Band 5 *Band 6 *Band 7 *Band 8 9 (1)9 (1)1018N/AN/AN/AN/AN/A N/AN/AN/AN/AN/A124(10)24(16)8(8)1(1) Ward/Work environment: *Respiratory Ward *Acute/Coronary Care Unit (includes NIV) *A&E *ITU *Medical Wards *Surgical Wards *Other N/AN/AN/AN/AN/AN/AN/A 224614444 Awareness of Guidelines: BTS Guideline awareness 64.9% 46.2% Trust Policy awareness 78.4% 88.5% Able to locate Trust Policy on intranet 34.3% 17.1% Read guidelines: *BTS *Trust *Both 34.3%8.6%8.6% 7.3%36.6%19.5% Received training within last 5 years 62.9% 43.9% Usefulness of training (1=Not at all 5=Very) 3.41 (0.67) 3.82 (0.73) How much did the training change your practice(1=Not at all 5=Significantly) 3.09 (1.06) 3.71 (0.92) Awareness of Content: Awareness of concept of target saturations 100% 100% Confidence: Prescribing* Administering to target saturations(1=Not at all confident 5 Very confident) 4.23(0.65)3.97(0.92) N/A3.97(0.68) Prescription Scenarios (mean mark out of 5 by two assessors (five way k=0.274) Doctors expected to diagnose and prescribe, nurses asked to comment what they thought prescription should be for given diagnosis) *Critically Ill Patient *Acute Coronary Syndrome *COPD at risk of Type II Respiratory Failure *Carbon Monoxide Poisoning *Obesity Hypoventilation with home nocturnal NIV 3.652.933.563.353.35 2.892.173.222.782.26 Agreement: Understanding of why the approach to oxygen administration has changed 66.7% 85.2% Belief changes are beneficial to patients (1=Outcomes are a lot worse 5=Outcomes definitely better) 4.44 (0.75) 4.74 (0.59) Change in ease of: *Prescribing *Administering 3.33(1.24)3.26(0.9) N/A4.26(0.86) Since new guideline(1=Much harder 5=Much easier) Desired improvement in drug chart 44.4% 40.7% Desire for merged drug and observation chart 85.2% 59.3% Adoption: Believe they apply guidelines in their daily practice (1=Never 5=Always) 3.93 (0.62) 4.44(0.64) Adherence: Most frequently cited barriers to guideline adherence: *Habit *Too many policies *Used to treat breathlessness *Not my responsibility *Lack of familiarity with guidelines *Guidelines are unclear *Guidelines not enforced *Drug chart confusing *Oxygen is not interesting *Lack of understanding of rationale behind guidelines *Lack of training *Practical/Logistical difficulties 33.3%20.8%16.7%8.3%4.2%4.2%4.2%4.2%4.2%0%0%0% 16%8%4%0%40%0%0%0%0%8%12%12% Suggested measures to improve adherence: *Teaching behind rationale *General teaching *Reminders *Increased monitoring *Individual penalties *Trust penalties *Other 23.4%21.3%17%14.9%10.7%4.3%8.5% 33.8%22.5%16.9%16.9%5.6%2.8%1.4% Discussion Responders reported good levels of awareness, agreement and adoption, yet adherence, as measured by audit, performance in prescribing and administration scenarios and an inability to locate guidelines on the Trust intranet would suggest that further intervention is required. The high level of belief that their own application of the guidelines, by both medical and nursing staff, is good would suggest that either this self selected cohort perform better than their less interested peers or that lack of awareness, so called "unconscious incompetence"(2) is a concern. Generally the desire is for yet more training, however, our concern remains that this has limited effect and systems need to be strengthened to improve oxygen prescribing and administration. References 1. Pathman et al. The awareness to adherence model of the steps to clinical guideline compliance. The case of paediatric vaccine recommendations. Medical Care 1996;34:873 89. 2. Conscious Competency The Mark of a Competent Instructor. The Personnel Journal. 1974;53:538 9.
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