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Early findings from oxygen issues during COVID-19 pandemic investigation

by Communications team

We have been investigating piped oxygen gas supplies in hospitals and have produced an early interim bulletin to help trusts deal with oxygen flow issues in their organisations.

The pandemic has placed massive pressure on the healthcare system, particularly when providing patients with enough oxygen to help treat the symptoms of COVID-19.

Our investigation so far indicates that trusts experiencing issues with oxygen demand have plenty of oxygen reserves [liquid oxygen]. However, the issue lies with a combination of the pipework/system used to deliver the oxygen and where patients needing the most oxygen are cared for along the oxygen supply network.

We are therefore suggesting estates, pharmacy services and clinicians work closely together to map out the capabilities of their piped systems. They should consider spreading out patients with the highest need for oxygen more evenly, to help inform decisions about where patients may be safely cared for.

The current pandemic has forced hospitals to reconfigure wards, and in so doing this has unbalanced the oxygen supply.

Many hospitals work on a radial system, so the gas is pumped along the pipe network in one direction. When the system is balanced, anticipated levels of oxygen can be piped to everyone around the hospital. But, with increased and uneven demand on the pipe network - due to a group of COVID-19 patients, for example - oxygen supply levels may be reduced to other patient areas.

Reference event

In our investigation reference event, the hospital in question declared a major incident over concerns about oxygen demand, which resulted in all incoming patients being diverted to other hospitals and elective surgery being cancelled.

The problem started when two patients on the high dependency unit (HDU) lost the required level of oxygen in their blood. The Trust considered this could be due to a drop in their oxygen supply pressure and moved them to theatres where sufficient oxygen was available.

Scott Hislop, HSIB Principal National Investigator says: “The Trust identified that the lack of oxygen flow available to the HDU, and the associated pressure reduction, was due to the distribution of patients and types of oxygen therapy required in other parts of the hospital. This had created excess demand on the oxygen supply system reaching the HDU.

“The Trust had developed a plan but found it to be ineffective for multiple reasons including a discrepancy in the oxygen supply calculations between anticipated and actual need.”

The Trust revised its plans and tried to understand where patients requiring oxygen therapy could be cared for within the hospital to maintain sufficient pressure across the system. Patients were then redistributed across the hospital to provide a more equal spread of oxygen demand and allowed one of its hospital sites to readmit patients.

Early findings

This investigation is in no way complete, and these are early findings.

Chief Investigator, Keith Conradi says: “It has taken us less than two weeks from launching this investigation to developing considerations which we hope will help trusts deal with a problem that is becoming increasingly widespread across our hospitals.

“Providing the right quantities of oxygen to patients is essential as part of any treatment regime. We hope this bulletin, and the final report, will put an important additional focus not only on existing alerts and guidance, but also the need for hospital teams to have a shared understanding of the limitations in oxygen systems across all clinical areas.

"This has a very real impact this has on patient safety and clinical decision-making.”

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