Observations were documented in main chart, observation sheets,
or in written report. In the first data collection ten (25
per cent) journals had daily documentation of administration method
for oxygen therapy in the chart, such as two litres by nose
catheter. In 24 (60 per cent) journals documentation in the
chart was missing. In some patient charts the SpO2 values
were documented, but not that oxygen had been administered.
In the second data collection there was a small improvement, 18
(28.5 per cent) patient records showed daily documentation in the
charts (table 2).
In the first data collection the observations sheets showed
daily documentation in six (15 per cent) records, whereas the
observation sheet was never used in 24 (60 per cent)
records. In the second data collection the observation
sheet was used daily in 29 (46 per cent) records, while it was
never used in 29 (46 per cent) records. There was a
significant difference between the two time periods. In the
case of HHHFNC treatment in particular the observation sheet was
not used, while we saw more frequent use in the case of CPAP
treatment (table 2). We found a significant change in the
number of documented observations from the first to the second time
period. In the first data collection the frequencies of
documentation 1 – 2 times per shift and 3 – 4 times per
shift were 27 (67.5 per cent) and eight (20 per cent)
respectively. In the second data collection this had changed
to 22 (34.9per cent) and 30 (47.6 per cent) respectively (table
During the two time periods in which we registered oxygen
therapy to hospitalised children with bronchiolitis and pneumonia,
40 of 135 children and 63 of 202 children respectively, received
oxygen. The bronchiolitis season varies from year to
year. Studies show that the majority of patients with this
diagnosis are hospitalised during the winter months.
RS-bronchiolitis appears from October to May in the northern
hemisphere (1). At the first data collection we had a peak of
patients in March. The first part of the registration period
was quiet with few patients. At the second data collection
there were many patients in January and fewer during the rest of
the registration period. A long and varied bronchiolitis
season challenges the health services economy, hospital space, and
the employee situation in paediatric wards (1).
In the first data collection 45 per cent of patients receiving
oxygen were in the 0-1 month age group, while in the second
registration the majority of children with a need for oxygen were
in the 2-12 months group. Experience tells us that such
variations arise from year to year. Children under six weeks
and premature children are at high risk for becoming seriously ill
with bronchiolitis (15). Our experience shows that many of
these patients often need CPAP treatment, and will thus remain in
hospital longer; we see this in the first data collection period as
Nurses need to be able to initiate acute oxygen therapy.
To achieve safe administration of oxygen, clear routines are needed
for the prescription of administration method, flow, and desired
saturation value (14). The findings from our project showed
that oxygen to a greater extent is prescribed in writing at the
second registration point (25 per cent and 46 per cent at first and
second registration respectively).
There was only a small degree of change in written prescription
of oxygen therapy by nasal catheter and steam, but the registration
shows a trend where oxygen to a greater extent is prescribed in the
case of HHHFNC and CPAP and for unstable patients. After the
new procedure for HHHFNC treatment was ready, better routines were
initiated for this treatment (16). In one study we see
significant improvement in prescription of oxygen by using
guidelines from clinical interdisciplinary collaboration
(14). An interdisciplinary focus and close collaboration with
the ward’s head physisian was emphasised in our project with
revised guide for updating charts and new instructions to the
physician group describing oxygen as a medication for which
prescription in writing is needed.
In the second data collection, in the case of prescription of
oxygen, a desired SpO2 value for start-up of oxygen therapy was
more often specified. Listing clear criteria and standards for when
and how oxygen therapy shall be administered will enable us to
secure better quality oxygen therapy. At HHHFNC and CPAP
treatment, desired SpO2 value was more often defined. Several
studies have recommended monitoring the patient’s SpO2 value,
respiratory rate, heart rate, and respiratory rate (1).
However, no clear consensus exists with regard to evaluations of
SpO2 value and start-up of oxygen therapy in the case of
bronchiolitis (1). As a result, oxygen therapy is
administered on varying SpO2 values. In Great Britain, a SpO2
value between 92-95 is recommended for initiating oxygen therapy,
while the corresponding SpO2 limit in the US is 90 (1).
As described in the Norwegian Knowledge Centre for the Health
Services’s model for quality improvement, anchoring all
quality improvement work in leadership is essential (10). It
is also vital that time is spent on information and discussion with
all involved. During the work process we wished to focus on
prescription of oxygen therapy in the whole personnel group and to
discuss current practice for written documentation of
administration method and observations related to oxygen
therapy. We had an inkling that we were not implementing this
treatment in line with recommended criteria and standards, and this
has been confirmed by the registrations.
Feedback, written and oral, is a common strategy for quality
improvement. It is most effective when clear goals and action
plans are made, and when the improvement work is carried out by a
supervisor or colleague (17). Data from the patient records
with registration of current practice for written prescription of
oxygen, administration method, and observations and documentation
have been presented and evaluated in seminars and teaching sessions
for the whole personnel group. This gave impetus to
interdisciplinary discussions on the ward. We have increased
the awareness around the use of oxygen and the respect for oxygen
therapy. A new procedure for HHHFNC treatment has been
implemented. Several studies have identified guidelines as an
important tool to support good oxygen management (11). We
will keep working on a general clinical guideline for oxygen
Observations and documentation
A significant change in daily documentation in observation
sheets was registered (15 and 46 per cent respectively) between the
two data collection points. Cardioscope, continuous pulse
oximetry, or occasional checking of pulse oximetry is used to
monitor the oxygen therapy. Studies have shown that the
patient to a varying degree is monitored in connection with oxygen
therapy. This is unfortunate, as inappropriate administration
of oxygen may have serious consequences (11). When going
through the records it was hard to find precise information of
which monitoring method was used, as this was frequently not
documented. With CPAP and HHHFNC treatment we assume
that the patient was monitored by cardioscope, which is common
practice. Prescription of monitoring and method was not a
registration parameter in the project, but we noticed that in some
instances “’scope, checks” were specified by
physician. The value of having the nurse continuously
monitoring the effect of oxygen therapy by using pulse oximetry has
been described earlier (11). Earlier research has recommended
that all oxygen therapy be monitored with pulse oximetry (18).
It has earlier been shown that documenting monitoring on the
observation sheet and interpreting vital signs have a significant
effect on optimal oxygen therapy (11,13). At the time of the
first registration period the observation sheet used did not have
any space for entering important observations or to document
respiratory effort. The observation sheet was also used in
CPAP and HHHFNC treatment, but lacked space for documenting these
administration methods. Documentation has, from the time of
Florence Nightingale, been one of the nurse’s most important
functions (19). The existing sheet’s lack of suitable
space may explain why it was not used much. After
professional feedback and discussions with nurses and physicians on
the ward, we decided to start using a more suitable observation
sheet. The new observation sheet, with ample space for
documenting both the administration method and the effect of the
oxygen therapy, made using the sheet much more practicable.
At the second registration we noticed a clear improvement in
documentation; the observation sheet was more frequently
used. Earlier studies have shown that good monitoring and
interpretation of vital signs give a more certain effect of the
oxygen therapy (11). The frequency of documentation of
observations has varied at the two times of measurement in our
project. According to Australian recommendations all settings
and values should always be documented at the shift change-over or
in case of any changes (13).
We have not seen any significant improvement in the
documentation of administration methods in the main charts despite
having communicated back to personnel on the results of the first
data collection, which showed incomplete chart completion.
The main chart gives a good overview, such as for instance of how
many days the patient has received oxygen therapy.
Strengths and limitations
A strength of the project is that patient records of all
hospitalised patients with bronchiolitis and pneumonia were read in
a limited time period with a one year interval. The
implementation was anchored in leadership and involved both
physicians and nursing groups. A weakness of the project may
have been that we used only data from the patient chart (main
chart, medication charts, charts for prescriptions, observation
sheets) and nursing documentation in DIPS as a basis for reviewing
if oxygen was prescribed in writing. The reason for choosing
to register data solely from the patient record is that this
document is what nurses first and foremost use to initiate further
observations and interventions. We considered including
physician’s memo in the patient record in the study, but as
such data did not supply any new information to the review, this
information was not systematically read and registered.
Another weakness of the project may be that only the
patients’ diagnosis at admission was registered at the two
data collection times. Some of the patients admitted with
diagnosis bronchiolitis received an additional diagnosis of viral
pneumonia. Experience has shown that these patients will need
oxygen for a longer time period. Registering any additional
diagnoses would have been an advantage as such diagnoses may result
in a longer stay.
The project has shown that current practice concerning
prescription of oxygen therapy was unsatisfactory. The study
also shows that documentation practice for administering and
monitoring was significantly different in the second data
collection period. The findings from the first registration
have resulted in the development of new local policy for written
prescription of oxygen, and a systematic effort to work out new
clinical guidelines for oxygen therapy has been initiated.
We want to thank section head physician Asle Hirth, statistician
Jannicke Igland, nurse Jennifer Cairncross, and the personnel group
on ward 4 for good discussions, commitment, and ideas during the
implementation of the project.
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