Implementing an oxygen weaning guideline for babies with chronic neonatal lung disease

• Meet customer expectations of a seamless service between acute and community setting.
• Deliver responsive service which meets the child’s needs.
• Implement new ways of working to increase effectiveness and improve quality of care.
• Development of individual’s clinical expertise through the use of a supportive guideline to deliver high quality care.
• Deliver safe oxygen weaning process alongside consistent practice amongst staff.
• Share knowledge, experience through peer supervision and joint working.
• Reporting of activity/contact levels to inform service planning.
• Gaining customer feedback.
• Learn from feedback and incidents to develop and improve.
• Evidence to support clinical effectiveness and measure patient outcomes.
• Evidence to support service efficiencies and staff time efficiencies.
• Review effective data obtained to support weaning protocol.

These aims relate to the NICE Quality Standard (QS120) for the following reasons;

• Shared decision making. The guideline is shared with parents and paediatrician at the discharge planning stage and agreement to use it is reached, taking into account preferences. This aims to achieve medication adherence and enhanced patient outcomes (Quality Standard 1).
• Patient involvement in reporting medicines‑related patient safety incidents. Attendance at discharge planning meetings, raising awareness amongst patients, parents and paediatricians about the use of the guideline. The guideline indicates home visit within 24 hours of discharge and a home oxygen checklist must be carried out. An element of the checklist is education for parents. This involves them and mitigates room for adverse incidents or error (Quality Statement 2).
• Learning from medicines-related patient safety incidents. There had been one incident where oxygen monitoring in the home had not been effective and an administration error occurred. To implement and support the use of the guideline fully, it was necessary to put in place measures that allowed for risk to be minimised. This was achieved in the form of a home oxygen check list and home information pack. (Quality Statement 3).
• It provides a form of structured medication review which can lead to a reduction or stopping of medication (in this case oxygen) or a reduction or complete eradication of adverse events (Quality Statement 6).

The Children’s Community Nursing (CCN) Service receives referrals from The Royal Devon and Exeter Hospital Neonatal Unit to discharge babies home on long term low flow oxygen. The CCN Service did not have or use a robust guideline for the weaning of long term oxygen therapy in infants with chronic neonatal lung disease (CNLD).

There was no regional pathway or guideline for the weaning of long term oxygen therapy in infants with CNLD. The process was often protracted, unsafe and unstructured. The CCN's lacked autonomy yet had lots of experience. Additionally, the equipment being used was out of date and not fit for purpose, it relied on being docked in the office for downloads which lengthened the process further. Once a download had been undertaken, the CCN be waiting for a response from the consultant to proceed with either a reduction in oxygen or to remain where they are. In very straight forward babies, the nurses are highly experienced and able to interpret the results and make clinical decisions based on them but they were unable to in this current situation.

A pathway has been written and shared with the neonatal consultants at The Royal Devon and Exeter Hospital and updated oxygen saturation monitors have been purchased, to fit in with equipment used in the neonatal unit at Exeter, giving consistency of the data collected, and to allow data to be downloaded in the home, providing the CCN with the information they need to make a clinical decision whilst following a prescriptive guideline.

My stakeholders were service users, consultant paediatricians, managers and the CCN's. I met with all of these groups to gain their support in the project. I was faced with some barriers at this stage, one such barrier was from a colleague who felt upset that she hadn’t been instrumental in this project as it had been something she had considered doing. The way I got around this was to involve her in my work and sought her valuable opinion. Another barrier was with one of the paediatricians who didn’t get involved in decision making and failed to comment at time of consultation. A limited number of paediatricians are reluctant to follow the guideline strictly and prefer to identify their own way of doing things. As a group we are strongly advertising and supporting the use of the guideline in patients that meet the criteria and this information is shared at the discharge planning meeting where paediatricians are present. If the paediatrician is reluctant to use the guideline despite the baby meeting the criteria then we challenge this.

The quality standards I have identified fit very nicely with the work I undertook on this project because they aim to improve the structure, process and outcomes of care in oxygen weaning as it was identified as needing quality improvements. There were no systems to keep our babies on oxygen safe and there was not a robust pathway to support the safe and structured process of weaning them from oxygen. The current way of doing things was lengthy, clunky and inefficient. There was also no other guideline of it’s kind in our region.

My project incurred some cost to the service and a business case proposal was written.

The costs incurred were as follows; Software - £316.00 Saturation monitor - £1,200.00. The source of funding was from our CCN budget directly.

• I undertook a literature review and found there were no guidelines or pathways for the management of this patient group. Through a review of the current evidence and information from The British Thoracic Society.
• I developed a standardised pathway to support a structured and safe weaning programme for babies that met the referral criteria.
• I circulated and discussed the pathway with the paediatric medical team who welcomed the initiative and supported its implementation provided certain monitoring was utilised and data findings communicated appropriately.
• I reviewed the equipment and software requirements to meet the criteria of the pathway which included the ability to review detailed oxygen monitoring information in the patient’s own home. Suitable equipment and software was sourced, a business case developed and finally procured.
• I trained all nursing and medical colleagues on the pathway, the equipment and software before implementing the pathway in practice. We implemented the pathway and subsequently audited the utilisation and effectiveness over a six month period for the first four patients.
• 3 out of 4 babies followed the guideline throughout.
• Average weaning time 8.75 weeks.
• Only one Masimo probe was used in all cases.
• In all cases initial assessment undertaken within 24 hours of discharge.
• In all cases there was evidence that alterations in oxygen flow rate were communicated to the consultant/multi-disciplinary team.
• In all cases parents were involved in decision making following a trace.
• In all cases there was evidence of support from the wider CCN team.
• In all cases spot saturations were undertaken within 24 hours of oxygen flow adjustments.
• The data downloaded from the Masimo was sufficiently accurate to support clinical decision making.
• In all cases the CCN completed the home oxygen pack on every visit.
• In all cases parents reported that the process met expectation.

My findings were that the pathway was well utilised and followed, despite one baby dropping out of the study due to clinical reasons. It was evident that weaning time was significantly reduced from a previous average of 21.75 weeks down to 8.75 weeks.

There were cost savings to our service in the use of one probe throughout the duration of weaning, less travelling for the nurses therefore less mileage costs, and more time efficiencies made allowing for other work to be done and other patients to be visited. At this time, due to technical difficulties we were unable to download data in the home, but clearly efficiencies were still made. We are now on our second episode of utilisation of the pathway and are now able to download in the home so hoping to observe further efficiencies still.

We are currently re-auditing and focusing on time and cost efficiencies only.

I have learnt many new skills undertaking this project:

• I have learnt how to take a critical examination of practice.
• I have learnt how to use evidence to develop guidance, how to implement, monitor and audit processes.
• I sought help and advice from experienced colleagues and I would advise others to do the same if they were going to implement a project like this. It was important to get stakeholders on board and in support of the project.
• I was concerned that if I didn’t have all the evidence, information and facts before I approached my nursing colleagues, that barriers might be put up, or confusion around proposed processes might incur. To address this, I sought evidence and information from The British Thoracic Society and emailed Professor Balfour-Lynn himself to clarify parameters for oxygen saturations. I then wrote the pathway before taking it to a paediatrician colleague. It only required some minor tweaks before it was sent to other stakeholders for consultation.
• The consultation process was smooth and the pathway was agreed quickly. Since then, the paediatrician has asked that my pathway be shared with our regional colleagues which is very exciting.

In future I would take the 'plan, do, study, act’ approach (PDSA). This approach would provide a much more structured framework for the implementation and audit process. Both these processes were a new concept to me which I feel I explored to the best of my ability but quite tentatively. At times I got lost and confused about what it was I was trying to achieve. I now feel in hindsight, a structured approach would have prevented tis from happening and would have benefitted me greatly.