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Are we being an Oxy-moron : The overuse of oxygen in a community hospital setting. Paavani Atluri MD, Abhinav Agrawal MD, Koteswararao Thella MD, Anar Modi MD, Mana Rao MD, Imran Ismail MD, Tisha Tan MD, Madhu Paladugu MD.
Monmouth Medical Center, Long Branch, New Jersey – USA. INTRODUCTION
STATISTICS & COST ANALYSIS
Oxygen is one of the most important and yet the most misused therapy in an in-patient hospital setting. In spite of having clear indications like hypoxemia (arterial hypoxia), chronic disease states complicated by anemia, migraine headaches, coronary artery disease, heart failure, COPD, seizure disorders, sickle-cell crisis, and sleep apnea, physicians often tend to order oxygen on every patient being admitted without an actual indication. This leads to wastage of valuable resources and increases the cost of healthcare. More importantly, oxygen therapy is not benign and can cause hypoventilation in severe COPD, loss of hypoxic stimulation in COPD, pulmonary fibrosis, adverse effects related to free oxygen radicals and retinopathy of prematurity in newborn. Our objective was to study the overuse of oxygen and institute an intervention to prevent the wastage of resources and prevention of such potential adverse events.
METHODS We designed a pilot project and implemented on one of our telemetry units. Our study had 3 parts to it, pre-intervention, intervention and post-intervention. We first assessed the patients on a single inpatient floor at bedside and looked into their electronic health records for indication of oxygen, co morbidities, orders for oxygen therapy, orders for titration, actual implementation of the physician orders by nurses and respiratory therapists and made our best effort to avoid observation bias. Our intervention was to educate the residents, nurses on the targeted floor and respiratory therapist about the potential adverse effects of overuse of oxygen, importance of titration of oxygen to a set goal, indications and expenses involved in the usage and wastage of oxygen therapy. After 4 weeks of intervention, we collected post-intervention data using the same parameters on the same floor.
RESULTS We calculated the following results : PRE-INTERVENTION
POST-INTERVENTION
Total number of patients
40
40
No. of patients on oxygen as documented No. of patients n O2 with indication No. of patients with NC in use No. of patients with NC lying next to bed No. of patients with sats >92% on NC without being titrated Common Indications
28
22
24
22
18
20
10
2
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12
4
COPD, CHF,CAD, Afib.
CODP, CHF/CAD, Anemia, Afib.
Fischer Exact Test.
Pre-Intervention
With indications to use Without indications to O2 use O2 24 4
Post-Intervention
20
2
Pre-Intervention
P value – 0.6825 O2 via nasal cannula being used 18
O2 via nasal cannula being wasted 10
Post-Intervention
20
2
P value – 0.0447 Patients on O2 with titration
Patients on O2 without titration
Pre-Intervention Post-Intervention
16
12
18 P value - 0.0761
Cost of oxygen per 24 hour period1: $0.50 Delivery per day ($0.50 x 28): $14 Delivery per day being wasted ($0.50 X 10) $5 Delivery being wasted after intervention ($0.50 X 2) $1 Delivery per year ($14 x $365): $5110 Delivery per year being wasted ($5 X $365): $1825 Delivery per year wasted after intervention ($1 X $365): $365
4
Delivery device2: $1.68 Annual, device per bed ($1.68 x 73)3: $122.64 Annual delivery 28 patients ($122.64 x 28): $3433.92 Annual wastage of delivery devices ($122.64 X 10): $1226.4 Annual wastage after intervention ($122.64 X 2): $245.28 .
.
Total annual Cost: ($5110 + 3433.92)4: $8543.92 Total annual wastage pre-intervention: ($1825 + $1226.4): $3051.4 Total annual wastage after intervention: ($365 + $245.28): $610.28 Total savings after 1 intervention on a floor with 40 patients: ($3051.4 - $610.28): $2441.12 (1)Assuming 2 liter/minute flow, (2) Per unit, (3) Cost of 73 units per year per patient assuming a stay of 5 days and constant patient load (4) per inpatient unit (on our floor with 40 patients)
Total annual saving after 1 intervention on a floor having 40 patients: $2441.12.
CONCLUSION Based on our results, we concluded that oxygen is often used a placebo because of lack of awareness of its potential hazards as mentioned above and its expenses involved. This involves : (1) Oxygen therapy being initiated without an appropriate indication. (2) Wastage of oxygen and oxygen delivery devices in patients who are off the floor or are doing well without oxygen therapy. (3) Lack of titration of oxygen therapy to meet the standard order to keep saturation > 92% (4) Lack of awareness about adverse effects of oxygen. By the means of education of the physicians, trainee physicians , nurses and ancillary staff, we calculated that we can save a significant amount of expense and also avoid the preventable adverse effects of overuse of oxygen therapy.
REFERENCES [1] Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93:391. [2] Recommendations of the 6th long-term oxygen therapy consensus conference.Doherty DE, Petty TL, Bailey W, Carlin B, Cassaburi R, Christopher K, Kvale P, Make B, Mapel D, Selecky P, Tiger J. Source: Division of Pulmonary Critical Care, Sleep Medicine, University of Kentucky, Lexington, 40536-0284, USA.
