SEPSIS

Sepsis is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This leads to blood clots and leaky blood vessels. They cause poor blood flow, which deprives your body's organs of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, blood pressure drops and the heart weakens, leading to septic shock (multisystem failure - shock).

• Anyone can get sepsis, but the risk is higher in:

-people with weakened immune systems

-infants and children

-the elderly

-people with chronic illnesses, such as diabetes, AIDS, cancer, and kidney or liver disease

-people suffering from a severe burn or physical trauma

This response may be called systemic inflammatory response syndrome (SIRS).

Causes

The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response.

A bacterial infection anywhere in the body may set off the response that leads to sepsis. Common places where an infection might start include the:

-bloodstream

-bones (common in children)

-bowel (usually seen with peritonitis)

-kidneys (upper urinary tract infection or pyelonephritis)

-lining of the brain (meningitis)

-liver or gallbladder

-ungs (bacterial pneumonia)

-skin (cellulitis)

For patients in the hospital, common sites of infection include intravenous lines, surgical wounds, surgical drains, and sites of skin breakdown, known as bedsores or pressure ulcers.

Symptoms

In sepsis, blood pressure drops, resulting in shock. Major organs and body systems, including the 

kidneys, liver, lungs, and central nervous system stop working properly because of poor blood flow.

A change in mental status and very fast breathing may be the earliest signs of sepsis.

In general, symptoms of sepsis can include: chills, confusion or delirium, fever or low body temperature (hypothermia), light-headedness due to low blood pressure, rapid heartbeat, shaking, skin rash and warm skin. Bruising or bleeding may also occur.

Fast action is key to prevent sepsis death:

Full article at: https://medlineplus.gov/news/fullstory_160574.html

Following the recommendations of The UK Sepsis Trust we can assess our patients easily. If our patient looks sick or the New Early Warning Score has triggered we should wonder if there is an infection present even if the source is not clear yet.

If there is an infection, we should look for ANY Red Flag Criteria:

If one of the above is present, the Sepsis 6 pathway should be started immediately. If none of the above is present we should look for any Amber Flag criteria:

If there is an Amber Flag criteria present a set of routine blood samples and an urgent senior review should take place within an hour, if Acute Kidney Injury is present the Sepsis 6 pathway should be started.

Sepsis 6 pathway

When the Sepsis 6 pathway has to be started, a treatment escalation plan should be made and the CPR status of the patient should be clarified. The patient has Red Flag Sepsis and all the following actions have to be completed within one hour:

If after delivering the Sepsis Six, the patient still has:

-systolic BP < 90 mmHg

-reduced level of consiousness despite resuscitation

-respiratory rate over 25 breaths per minute

-lactate not reducing

or the patient is clearly critically ill at any time, Critical Care Outreach team should be called immediately.

Sources:
-http://sepsistrust.org/
-https://medlineplus.gov/ency/article/000666.htm
-https://medlineplus.gov/news/fullstory_160574.html
-https://www.emaze.com/@AOZTZRZO/CAMPA%C3%91A-PARA-SOBREVIVIR-A-LA-SEPSIS.pptx

NAUSEA AND VERTIGO

Nausea and vomiting (also called emesis)

Nausea is an uneasy or unsettled feeling in the stomach together with an urge to vomit. Nausea and vomiting, or throwing up, are not diseases. They can be symptoms of many different conditions. 

Many common problems may cause nausea and vomiting, including:

-food allergies

-infections of the stomach or bowels, such as the "stomach flu" or food poisoning

-leaking of stomach contents (food or liquid) upwards (also called gastro-oesophageal reflux or GORD)

-medicines or medical treatments, such as cancer chemotherapy or radiation treatment

-migraine headaches

-morning sickness during pregnancy

-seasickness or motion sickness

-severe pain, such as with kidney stones

Nausea and vomiting may also be early warning signs of more serious medical problems, such as appendicitis, blockage in the intestines, cancer or a tumor, ingesting a drug or poison (especially by children) or ulcers in the lining of the stomach or small intestine.

Nausea and vomiting are common. Usually, they are not serious. Medical advice should be sought immediately if :

-vomited for longer than 24 hours

-blood in the vomit

-severe abdominal pain

-headache and stiff neck

-signs of dehydration, such as dry mouth, infrequent urination or dark urine.

Vertigo

The most common symptoms of vertigo include a feeling of spinning (you or the room around you), tilting or swaying and feeling off balance. These feelings come and go, and may last seconds, hours, or days. You may feel worse when you move your head, change positions (stand up, roll over), cough, or sneeze. Along with vertigo, you may vomit or feel nauseous, have a headache or be sensitive to light and noise, see double, have trouble speaking or swallowing, feel weak or short of breath or sweaty and have a racing heart beat.

The most common causes of vertigo include:

• Inner ear problems: collections of calcium, inflammation, and certain infections can cause problems in the vestibular system. The vestibular system includes parts of the inner ear and nervous system, which controls balance.
• Benign paroxysmal positional vertigo (BPPV): sometimes called benign positional vertigo, positional vertigo, postural vertigo, or simply vertigo, is a type of vertigo that develops due to collections of calcium in the inner ear. These collections are called canaliths. Moving the canaliths (called canalith repositioning) is a common treatment for BPPV. Vertigo is typically brief in people with BPPV, lasting seconds to minutes. Vertigo can be triggered by moving the head in certain ways.
• Meniere disease:  is a condition that causes repeated spells of vertigo, hearing loss, and ringing in the ears. Spells can last several minutes or hours. It is probably caused by a buildup of fluid in the inner ear. 
• Vestibular neuritis: vestibular neuritis, also known as labyrinthitis, is probably caused by a virus that causes swelling around the balance nerve. People with vestibular neuritis develop sudden, severe vertigo, nausea, vomiting, and difficulty walking or standing up; these problems can last several days. 

• Head injury: head injuries can affect the vestibular system in a variety of ways, and lead to vertigo.
• Medications: rarely, medications can actually damage or affect the function of the inner ear or brain and lead to vertigo.
• Migraines: in a condition called vestibular migraine or migrainous vertigo, vertigo can be caused by a migraine. This type of vertigo usually happens along with a headache.
• Brain problems, such as a stroke or TIA (transient ischemic attack), bleeding in the brain, or multiple sclerosis can also cause vertigo. 

-Drugs used in nausea and vertigo:

• Antihistamines:                                                                         

           -cinnarizine (Stugeron, Arievert)                                                        -cyclizine (Valoid)                                                                    

           -promethazine hydrochloride                                                              -promethiazine teoclate (Avomine).                                                              

• Phenothiazines and related drugs: 

            -chlorpromazine hydrochloride

            -perphenazine

            -prochlorperazine (Stemetil, Buccastem)

            -trifluoperazine.

• Domperidone and metoclopramide:

           -domperidone (Motillium)                                      

           -metoclopramide hydrochloride (Maxolon)

• 5HT3 antagonists:

           -dolasetron mesilate (Anzemet)

           -granisetron (Kytril)

           -ondansetron (Zofran)

           -palonosetron (Aloxi)

• Neurikinin receptor antagonist:

          -aprepitant (Emend)

          -fosaprepitant (Ivemend)

• Cannabinoid: nabilone

• Hyoscine: hyoscine hydrobromide (Joy Rides, Kwells, Scopoderm TTS patches)

• Other drugs for Meniere's disease: betahistine dihydrochloride (Serc).  

Sources:

-https://medlineplus.gov/nauseaandvomiting.html

-http://www.medscape.org/

-https://medlineplus.gov/dizzinessandvertigo.html

-http://www.uptodate.com/contents/dizziness-and-vertigo-beyond-the-basics?view=print

-http://backinmotionfl.com/stop-suffering-vertigo/

-http://www.manxhealthcare.com/products/betahistine.html

-https://www.theindependentpharmacy.co.uk/onlinedoctor/treatment/cyclizine-50mg-tablets100/

CONTROLLED DRUGS

The Misuse of Drugs Regulations 2001 (and subsequent amendments) define the classes of person who are authorised to supply and possess controlled drugs while acting in their professional capacities and lay down the conditions under which these activities may be carried out. In the regulations drugs are divided into five schedules each specifying the requirements governing such activities as import, export, production, supply, possession, prescribing, and record keeping which apply to them.

• Schedule 1: includes drugs such as lysergide which is not used medicinally. Possession and supply are prohibited except in accordance with Home Office authority.

• Schedule 2: includes drugs such as diamorphine (heroin), morphine, nabilone, remifentanil, pethidine, secobarbital, glutethimide, the amfetamines, sodium oxybate, and cocaine and are subject to the full controlled drug requirements relating to prescriptions, safe custody (except for secobarbital), the need to keep registers, etc. (unless exempted in Schedule 5). 

• Schedule 3: includes the barbiturates (except secobarbital, now Schedule 2), buprenorphine, mazindol, meprobamate, midazolam, pentazocine, phentermine, temazepam, and tramadol. They are subject to the special prescription requirements. Safe custody requirements do apply, except for any 5,5 disubstituted barbituric acid (e.g. phenobarbital), mazindol, meprobamate, midazolam, pentazocine, phentermine, tramadol, or any stereoisomeric form or salts of the above. Records in registers do not need to be kept (although there are requirements for the retention of invoices for 2 years).

• Schedule 4: includes in Part I benzodiazepines (except temazepam and midazolam, which are in Schedule 3), zaleplon, zolpidem, and zopiclone which are subject to minimal control. Part II includes androgenic and anabolic steroids, clenbuterol, chorionic gonadotrophin (HCG), non-human chorionic gonadotrophin, somatotropin, somatrem, and somatropin. Controlled drug prescription requirements do not apply and Schedule 4 Controlled Drugs are not subject to safe custody requirements.

• Schedule 5: includes those preparations which, because of their strength, are exempt from virtually all Controlled Drug requirements other than retention of invoices for two years

Standards and safety checks

NMC(standards for medicine management)

-Controlled drugs are kept in a locked cabinet and the keys are carried by the nurse in charge (access to the keys and the CD cabinet is restricted to authorised registrants). CD stationery which is used to order, return or distribute controlled drugs should be kept in the locked cabinet. No other medicines or items to be stored in the controlled drug cupboard.

-There should be a list of the CDs to be held in each ward as stock items, only the CDs listed may be routinely requisitioned or topped-up.

-A copy of the signature of each authorised signatory should be available in the pharmacy department for validation.

-When CDs are delivered to a ward they should be handed to a designated person, under no circumstances should they be left unattended. After the delivery, the registrant in charge and a witness (another registrant) should check the CDs against the requisition, place the CDs in the CD cupboard, enter the CDs into the ward controlled drug record book, update the running balance and check that the balance tallies with the quantity that is physically present.

-All entries in the controlled drug record book must be signed by two registrants.

-Checking the balance in the controlled drugs register against current stock should be done twice a day, recording stock checks along with the date and signature of both health professionals carrying out the check. 

-The registrants should record the amount given and the amount wasted (if there is any) when administering a CD.

-Audits should be carried out to ensure that the record keeping is up to date and correct.

Sources:

-http://www.evidence.nhs.uk/formulary/bnf/current/guidance-on-prescribing/controlled-drugs-and-drug-dependence

-Controlled drugs: safe use and management(2016) NICE guideline NG46

-https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-medicines-management.pdf

Images: kwizoo.com, www.officestationerywarehouse.co.uk, www.davidwolfe.com, www.opiates.com.

OBESITY

Obesity means having too much body fat. It is not the same as being overweight, which means weighing too much. A person may be overweight from extra muscle or water, as well as from having too much fat. Both terms mean that a person's weight is higher than what is thought to be healthy for his or her height.

Causes

Taking in more calories than you burn can lead to obesity. This is because the body stores unused calories as fat. Obesity can be caused by: 

-Eating more food than your body can use 

-Drinking too much alcohol 

-Not getting enough exercise. 

Many obese people who lose large amounts of weight and gain it back think it is their fault. They blame themselves for not having the willpower to keep the weight off. Many people regain more weight than they lost.

Today, we know that biology is a big reason why some people cannot keep the weight off. Some people who live in the same place and eat the same foods become obese, while others do not. Our bodies have a complex system to keep our weight at a healthy level. In some people, this system does not work normally.

The way we eat when we are children can affect the way we eat as adults.

The term eating disorder means a group of medical conditions that have an unhealthy focus on eating, dieting, losing or gaining weight, and body image. A person may be obese, follow an unhealthy diet, and have an eating disorder all at the same time.

See more about imbalanced nutrition: http://enfermeriastgo.blogspot.co.uk/2014/03/imbalanced-nutrition-care-plan-and-must.html

Sometimes, medical problems or treatments cause weight gain, including: 

-Underactive thyroid (hypothyroidism) 

-Medicines such as birth control pills, antidepressants and antipsychotics. 

Other things that can cause weight gain are: 

-Quitting smoking: many people who quit smoking gain 4 to 10 pounds in the first 6 months after quitting 

-Stress, anxiety, feeling sad, or not sleeping well 

-Menopause: women may gain 12 to 15 pounds during menopause 

-Pregnancy: women may not lose the weight they gained during pregnancy.

DRUGS USED IN THE TREATMENT OF OBESITY

Obesity should be managed in an appropriate setting by staff who have been trained in the management of obesity; the individual should receive advice on diet and lifestyle modification and be monitored for changes in weight as well as in blood pressure, blood lipids and other associated conditions.

An anti-obesity drug should be considered only for those with a body mass index of 30kg/m or greater in whom at least 3 months of managed care involving supervised diet, exercise and behaviour modification fails to achieve a realistic reduction in weight.

Drugs should never be used as the sole element of treatment. The individual should be monitored on a regular basis; drug treatment should be discontinued if the individual regains weight at any time whilst receiving drug treatment. 

1. Anti-obesity drugs acting on the gastro-intestinal tract:
-Orlistat (Xenical).

2. Centrally acting appetite suppressants:
-Rimonabant (Acomplia)
-Sibutramine Hydrochloride (Reductil).

In July 2012, the FDA approved two new medicines for chronic (ongoing) weight management. Lorcaserin hydrochloride (Belviq®) and Qsymia™ are approved for adults who have a BMI of 30 or greater. 

SURGERY

Weight-loss surgery might be an option for people who have extreme obesity (BMI of 40 or more) when other treatments have failed. It is also an option for people who have a BMI of 35 or more and life-threatening conditions, such as:

-Severe sleep apnea 

-Obesity-related cardiomyopathy

-Severe type 2 diabetes

Two common weight-loss surgeries include banded gastroplasty and Roux-en-Y gastric bypass. For gastroplasty, a band or staples are used to create a small pouch at the top of your stomach. This surgery limits the amount of food and liquids the stomach can hold. 

For gastric bypass, a small stomach pouch is created with a bypass around part of the small intestine where most of the calories you eat are absorbed. This surgery limits food intake and reduces the calories your body absorbs.

Like any surgery, there are risks associated to this interventions, side effects and lifelong medical followup is needed after both surgeries.

Sources:
-https://medlineplus.gov/obesity.html
-BNF 57 March 2009
-https://www.nhlbi.nih.gov/health/health-topics/topics/obe/treatment
-http://mhadegree.org/obesity-and-your-healthcare-career/
-http://lifescienceevents.com/2016-obesity-summit-12th-14th-april-2016/

BREAKING BAD NEWS

Clinical communication with patients, relatives and care givers can be a challenge to healthcare providers. However, the use of communication skills and a therapeutic relationship may help seriously unwell patients and their families achieve the best way possible to cope with the illness (Finset 2015).

The first thing to be done whenever a clinical interview takes place or very important medical information is going to be disclosed to patients and/or family is planning and preparing the interview. 

Breaking bad news is reported to be one of the most stressful communication tasks (Porensky et al. 2015), this is why preparation is so important, including where and how the information is going to be given and anticipating possible questions. Preparation includes preparing oneself, the patient/family and the environment (Barnett 2013). 

Allowing enough time is key to enable successful communication. As the Regional Guidelines state “that it is strongly recommended that the person (named or specialist nurse) accompanying the professional who delivers the news, remains with the patient or family member if appropriate and help provide continuing support” (Department of Health, Social Services and Public Safety 2003). 

Different strategies for managing difficult situations like the Ten-step approach, SPIKES (Box 1) and Seven-step approach have preparation as its first step (Lewis et al. 2010).

Use a “warning shot;” that is, say something to prepare such as, “I do not have good news.”

Regional Guidelines state “that warning a patient or family member that bad news is coming may help lessen the shock and may help to process the information they receive” (DHSSPS 2003). 

Social psychology research has suggested that this approach may be most effective in reducing shock and distress of news with potentially serious implications (Porensky et al 2015). 

The news should be given in small chunks with pauses in between allowing time for information to be processed and encourage questions (DHSSPS 2003). Although the medical team will always try to make decisions in the best interest of the patient, the involvement of the patient and the family is decisive as the evidence suggests that patients increasingly want additional information regarding diagnosis, prognosis and treatment (DHSSPS 2003). It is important to remember the use of simple words and short sentences to ensure that the information provided is as clear as possible.

Patients and family often express feelings without talking about them (Egan 2013), their reactions and non-verbal communication can give us an idea of what the patient and family think and feel. 

Planning and preparing includes establishing goals and objectives, select method of disclosure, select the content and arrange resources (Hargie 2010).  Patients and family who have a clear plan for the future are less likely to feel anxious and uncertain (DHSSPS 2003). Furthermore, communication has a direct impact on the degree to which patients cope (Hawthorn 2015).

A study has shown that individuals who hear the negatively-framed prognosis are significantly more distressed than individuals who hear the positively-framed prognosis (Porensky et al 2015).

Breaking bad news is often a continuing process, it is important not to offer unrealistic hope but it is equally important that patients and family can discuss, consider options and come to terms with limitations without feeling abandoned by the health professional team (DHSSPS 2003).

Every person is different and the degree of information desired can vary as well as their expectations and their coping mechanism.

Evidence suggests that tailoring the amount of information provided according to the level of information a patient desire is associated with lower anxiety and better problem-focused coping (Porensky et al. 2015).

Breaking bad news can be extremely stressful for the professionals involved, emotions such as anxiety, a burden of responsibility for the news and fear of a negative response can have an adverse effect on those receiving and those delivering the news (DHSSPS 2003). Preparing the interview and following steps is a useful way of gaining confidence. Being clear about care goals may also assist staff who may need formal support in order to deliver high quality of care (Lewis et al. 2010).

Sources:

-Egan, G. (2013) The Skilled Helper. 10th Pacific Grove, California Belmont Brooks Cole/Cengage Learning.

-Hargie, O. (2010) Skilled interpersonal communication: Research, theory and practice. Hove Routledge.

-Porensky, E.K. and Carpenter, B.D. (2015) Breaking bad news: Effects of forecasting diagnosis and framing prognosis. Patient Education and Counseling, 99, 68-76.

-Lewis, D. and Kitchen, C. (2010) The role of communication skills in end-of-life care. Journal of renal nursing, 22(2), 69-74.

-Hawthorn, M. (2015) The importance of communication in sustaining hope at the end of life. British Journal of Nursing, 24(13), 702-705.

-Barnett, M. (2013) Breaking Bad News – Pointers and Pitfalls. Scottish Universities Medical Journal, 2(2), 54-57.

-Leonard, M., Graham, S., and Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care, 13(1), 85-90.

-Department of Health, Social Services and Public Safety. (2003) Breaking bad news  Regional Guidelines. DHSSPS, Belfast.

-Finset, A. (2015) The elephant in the room: How can we improve the quality of clinical communication during the last phases in patients’ lives? .  Patient Education and Counseling, 99, 1.

-http://www.ama-assn.org/ethic/epec/download/module_2.pdf

 http://www.jpalliativecare.com/article.aspissn=09731075;year=2010;volume=16;issue=2;spage=61;epage=65;aulast=Narayanan

SKILLED INTERPERSONAL COMMUNICATION

The importance for health care professionals of having a "good bedside manner" has long been realized. In 400 BC, Hippocrates noted how the patient "may recover his health simply through his contentment with the goodness of the physician". In recent years, this belief in the power of communication to contribute to the healing process has been borne out by research.

Rider and Keefer (2006) and Tallman et al. (2007) have shown that high levels of practitioner interpersonal skill are positively correlated with increases in the quality of care and effective health outcomes, while ineffective skills are associated with decreased patient satisfaction, increased medication errors and malpractice claims. These findings are corroborated in the field of nursing, where effective interpersonal communication has been shown to be related to improved health outcomes, such as greater patient satisfaction and quality of life (Klakovich and dela Cruz, 2006).

The nature of interpersonal skills

Hargie (2006a: 13) defined interpersonal skill as "a process in which the individual implements a set of goal-directed, inter-related, situationally appropriate social behaviours, which are learned and controlled", it emphasises seven separate components of skill:

1. Skilled performance is part of a transactional process which involves: formulating appropriate goals, devising and implementing related action plans, monitoring the effects of behaviour, being aware of and interpreting the responses of others, taking into account the context in which interaction occurs and adjusting, adapting or abandoning goals and responses in the light of outcomes.

2. Skilled behaviours are goal directed: goals both motivate and navigate the interpersonal process (Berger, 2002; Oettingen et al., 2004).

3. Skilled behaviours are interrelated and synchronised.

4. Skills should be appropriate to the situation.

5. Skills are defined in terms of identifiable units of behaviour: verbal and nonverbal.

6. Skilled behaviours are learned.

7. Skills are under the cognitive control of the individual: learning when to employ behaviours is just as crucial as learning what these behaviours are and how to use them.

Zimmerman (2000) identified four key stages in the learning of skills:

-Observation
-Emulation
-Self-control
-Self-regulation: the person learns to use the skill appropriately across different personal and contextual conditions.

Communication and interpersonal communication

Communication is a transactional process, inevitable, purposeful, multidimensional and irreversible.

Conceptual model of skilled interpersonal communication 

This model builds upon skill models developed, inter alia, by Dickson et al. (1997), Bull (2006) and Hargie (2006c), based upon early theorising by Argyle (1983). It identifies six elements of skilled interpersonal interaction:

1. Person-situation context: personal characteristics, knowledge, motives, attitudes, personality, emotion, age, gender, situational factors and culture.

2. Goals: 

-Task and relational goals

-Instrumental and consummatory goals

-Implicit and explicit goals

Goals are hierarchically structured and have a temporal dimension (short or long term). They differ in their level of concreteness and compatibility, goals may be similar, complementary or opposed.

3. Mediating processes: these processes mediate between the goal being pursued, our perceptions of events and what we decide to do about them.

-cognitive processes: Nelson-Jones (1996) recommended a seven-stage framework for rational decision making: confront, generate options and gather information, assess the predicted consequences of options, commit to the decision, plan how to implement the decision, implement the decision and assess consequences of implementation.

-affective processes: skilled communication must always be adaptively and reflexively responsive to the emotional needs of the other.

4. Response: plans and strategies decided upon are implemented at this stage, there is no guarantee that their translation into action will be flawless or successful, When people fail to achieve an interactional goal but persist, they tend to adjust low-level elements of the plan (e.g. volume or speed of speech) rather than more abstract higher order elements (e.g. general strategy)(Knowlton and Berger, 2007).

5. Feedback: enables us to assess the effects or our communications, convergence towards mutual understanding and shared meaning is proportional to the degree which feedback (verbal or nonverbal) is put to effective use.

6. Perception: not all information potentially available via feedback is perceived, and not all information received is perceived accurately. Perception is an active and highly selective process (Eysenck, 1998). Skilled communicators have the ability to make accurate perceptions of self and how one is being perceived by others.

Sources:
-http://www.redtierabbit.com/what-are-interpersonal-skills/
-Hargie O. 2010 Skilled interpersonal communication: Research, theory and practice. Hove Routledge.

EMERGENCY OXYGEN THERAPY IN ADULTS: PROFESSIONAL COMPLIANCE AND EDUCATION

In the last few months, I have been introduced to the passionate and sometimes stressful world of research, specifically in research in health and social care. As part of my learning I developed a research proposal which is partially shown here. 

Although I am still far from expert, I think the literature review  brings up some interesting questions. Also, constructive feedback is always welcome.

EMERGENCY OXYGEN THERAPY IN ADULTS: PROFESSIONAL COMPLIANCE AND EDUCATION.

INTRODUCTION

Oxygen is probably the   most common drug used in medical emergencies and its inappropriate administration can have serious or even fatal consequences (BNF 70). The literature review carried out by Ingrid Nippers and Andrew Sutton in 2014 states that there is evidence that oxygen therapy is not being prescribed, administered and monitored correctly. They suggest the implementation of planned audits and educational programs for staff to ensure adherence to both local and national guidelines.

The aims of this study are to measure the level of professional compliance with local guidelines when administering oxygen therapy and to assess the effectiveness of educational interventions in the acute settings of the Belfast Health and Social Care Trust.

The objectives of this study are to obtain information about the current situation of oxygen administration, to provide high quality training tackling all aspects of oxygen therapy and to evaluate the success of the educational program in practice.

In order to achieve these objectives, a quantitative approach has been chosen, it is an experimental study before and after a training session. It will take place in the Emergency and Medical Admissions departments at the Royal Victoria  Hospital and the Mater Hospital, both under the Belfast Health and Social Care Trust policies and guidelines.

Although the Belfast Trust is in process of developing a new policy, audits (as per Health & Care Audit Activity Report May 2015) and has a mandatory training in Medical Gases, there is no information available about professional compliance regarding oxygen therapy at present or evidence of the actual success of the Medical Gases training. Also, no audits are carried out (at the moment of developing this study) which means that oxygen use is not being evaluated.

BACKGROUND

In 2008, the first formal guidance on emergency oxygen use was produced by the British Thoracic Society. These guidelines have been already criticised by Smith et al. (2012) regarding the target saturation of oxygen for actively treated patients not at risk of hypercapnic respiratory failure. Nippers et al. (2014) states that it has limited evidence, which affects its reliability, and the National Patient Safety Agency recommends further documents for clinical guidance as the BTS (2008) does not cover critical care or children under 16 years. There is a clear need for consensus, clinical guidance should be developed covering all areas of oxygen therapy and kept up to date with recent research. It is beyond this study to develop latest up-to-date guidelines so, the policy from the Belfast Trust regarding oxygen therapy will be the one used to develop the instrument for data collection.

Organizations like the National Institute for Health and Care Excellence do not have any clinical guidelines about oxygen.

Also, the medical use of oxygen needs to be further examined in search of solid evidence of benefit in many of the current clinical settings in which is routinely used as stated by Sjoberg et al. (2013).

A rapid response report from the NPSA was issued in 2009 after receiving 281 reports of serious incidents related to inappropriate administration and management of oxygen, also, Kane et al. (2013) states that oxygen therapy is often used incorrectly and the dangers of over-oxygenation are unappreciated.

The literature review suggests an incorrect administration tendency in oxygen therapy and a lack of awareness in its dangers, this project has developed an approach that will study both issues.

A quantitative approach has been chosen as it allows to measure objectively the level of compliance, the collected evidence can be transformed in numerical data which can be statistically manipulated to obtain the answer for the research question (Gerrish and Lacey, 2010).

In order to assess the administration of oxygen before and after an educational intervention, a pre and post intervention study will be done as it is an experimental design that reports a change in an outcome following a change in an intervention (Gerrish and Lacey, 2010). Being able to manipulate and   compare the pre and post intervention data will give an overview of the professional compliance and the success of the intervention in practice.

References

-Gerrish, K. and Lacey, A. (2010) The Research Process in nursing. 6th Edition. United Kingdom: Wiley-Blackwell.

-Kane, B., Decalmer, S., & Ronan, O., B. (2013). Emergency oxygen therapy: From guideline to implementation. Breathe, 9(4), 246-253.

-Nippers, I., & Sutton, A. (2014). Oxygen therapy: Professional compliance with national guidelines. British Journal of Nursing, 23(7), 382-386.

-O'Driscoll, B.R., Howard, L. S., & Davison, A. G. (2008). BTS guideline for emergency oxygen use in adult patients. Thorax, 63 Suppl. 6, vi1-vi68.

-Kor, A.C., Lim, T.K. (2000) Audit of oxygen therapy in acute general medical wards following an educational programme.  Annals of the Academy of Medicine Singapore, 29, 2, 177-181

-Sjöberg, F., & Singer, M. (2013). The medical use of oxygen: A time for critical reappraisal. Journal of Internal Medicine, 274(6), 505-528.

-Smith, G. B., Prytherch, D. R., Watson, D., Forde, V., Windsor, A., Schmidt, P. E., et al. (2012). S(p)O(2) values in acute medical admissions breathing air--implications for the British thoracic society guideline for emergency oxygen use in adult patients? Resuscitation, 83(10), 1201-1205.

-Formulary Committee Joint Cover: Paperback. (2015). Oxygen. British National Formulary, 70^th Edition, September 2015-March 2016. United Kingdom: Pharmaceutical Press, page 214.

-National Patient Safety Agency. (September 2009). Rapid Response Report: Oxygen safety in hospitals. Available at: www.nrls.npsa.nhs.uk/alerts.

Note: this is just a proposal done for an assignment, it will not be developed any further.