Nurse / Midwife Initiated Medicine Protocol
Oxygen – emergency use in the management of a deteriorating patient
Title
Oxygen – Nurse / Midwife initiated use during an episode of acute
deterioration
Areas where Protocol/Guideline
applicable
ADULT patients only (over 17 years): All HNE Health inpatient
units, Emergency Departments and Outpatient Clinics where the NSW
Rural Adult Emergency Clinical Guidelines do not apply.
NB: The protocol has been developed for inpatient units but can be
applied in Community Health settings where appropriate.
Areas where Protocol/Guideline not
applicable
Paediatrics ( NSW Kids 0-17)
Authorised Prescribers
Registered Nurses, Registered Midwives, Nurse Practitioners,
Endorsed Enrolled Nurses, Enrolled Nurses
Indication for use and Proposed Place
in Therapy
Contraindications to Nurse Initiated
Use

First-line management of an adult deteriorating patient, for
example, patients with acute onset of breathlessness or
hypoxia, chest pain or tightness, hypotension, confusion,
altered level of consciousness, seizures.

Oxygen saturation (SpO2 ) is less than or equal to 95% or where
there is an alteration to the calling criteria documented - this is
dependant on the patient and should be reviewed for each
individual patient and documented by a Medical Officer on the
Standard Adult General Observation (SAGO) Chart and in the
medical record on admission.
Nil - Oxygen administration should never be withheld in an emergency
situation.
NB: Need to consider possible contraindications for patients with
chronic respiratory conditions and sedative drug overdose if oxygen
therapy is ongoing
Important Drug Interactions &
Other Effects
Caution should be exercised in the administration of oxygen to patients
with Chronic Obstructive Pulmonary Disease (COPD) and toxicology
patients with sedative drug overdose to prevent hypercapnia.
It is imperative that these patients have alterations to calling criteria
documented on the Standard Adult General Observation (SAGO) Chart
by the Medical Officer on admission to direct the nurse in the
appropriate administration of oxygen therapy for each individual patient,
Dosage
The aim of oxygen therapy is to maintain oxygen saturation levels with
the least amount of oxygen aiming for a saturation (SpO2) of > 95%, or
at the level indicated by altered calling criteria on the Standard Adult
General Observation (SAGO) Chart. (Ref: Rural Adult Emergency
Clinical Guidelines 3rd Edition and DETECT Manual 2nd EDITION
2010) using one of the following oxygen delivery systems:
Breathing Patients:
1. Nasal cannulae: flow rate 2 - 4 L/min (lowest concentration
delivered)
2. Simple facemask: flow rate 5 - 10 L/min (medium concentration
delivered)
3. Non-rebreathing facemask: flow rate 15 L/min (highest
concentration delivered)
Non-Breathing or Ineffective Breathing Patients:
Protocol: Nurse / Midwife Initiated Oxygen for Deteriorating Adult Patients_V6_ 5th August 2010_HB Changes
1. Mask-to-mouth with supplemental oxygen
2. Bag-valve-mask (BVM) device using high flow oxygen @15 lpm
NB: Venturi masks deliver 24 – 50% oxygen concentrations and should
be used when accurate oxygen concentration delivery is required in
COPD / respiratory patients on an ongoing basis and should be ordered
by a Medical Officer or Nurse Practitioner on the National Inpatient
Medication Chart / Medical Record.
Duration of therapy
Nurse/Midwife initiated: Initial management of patients meeting "Clinical
Review or Rapid Response" calling criteria (including altered calling
criteria) on the Standard Adult General Observation (SAGO) Chart and
should be continued until the patient has received a Clinical Review or
Rapid Response.
NB: Oxygen is a medication and should be prescribed by the Medical
Officer or Nurse Practitioner on the National Inpatient Medication Chart /
Medical Record if oxygen is used as an ongoing form of treatment.
Safety Precautions
Administration instructions
Monitoring requirements
Fire risk is greatly increased where there is a higher than normal
oxygen concentration in the environment. Precautions include:

No smoking, naked or lighted flames

No grease /oil /fat based soaps or lubricants on or near oxygen
equipment

No use of electrical equipment eg. shaver, hair dryer

No use of metal and clockwork toys

Ensure correct flow meter is used

Oxygen cylinder should be turned off at the valve when not in
use

Recorded and signed by nurse/midwife on nurse initiated
section of the National Inpatient Medication Chart / Medical
Record

Record date, time, type of device, dosage and evaluation of
intervention on Standard Adult General Observation Chart
(SAGO)

If therapy is to continue the Medical Officer or Nurse
Practitioner must order the dose, device and titration
instructions in the National Inpatient Medication Chart / Medical
Record
Frequent clinical re-evaluation as indicated by the patient’s condition
including blood pressure, pulse rate, respiratory rate, oxygen saturation,
and where necessary / available Arterial Blood Gas analysis.
Review by Medical Officer as soon as possible in accordance with
calling criteria for Clinical Review or Rapid Response.
Management of complications
References
Call for immediate Medical Officer review according to the Clinical
Review and Rapid Response Calling Criteria and local Clinical
Emergency Response Protocols. Document in progress notes.
1. Between the Flags DETECT Manual 2nd EDITION 2010, Clinical
Excellence Commission
2. NSW Health. 2010. Rural Adult Emergency Clinical Guidelines
3rd Edition
http://www.health.nsw.gov.au/policies/gl/2010/GL2010_003.html
3. Guideline for Emergency Oxygen Use in Adult Patients,
Protocol: Nurse / Midwife Initiated Oxygen for Deteriorating Adult Patients_V6_ 5th August 2010_HB Changes
October 2008, British Thoracic Society www.brit-thoracic.org.au
JBI_HNEH Acute Care Manual 2009. Oxygen Therapy, pp. 597601
Protocol: Nurse / Midwife Initiated Oxygen for Deteriorating Adult Patients_V6_ 5th August 2010_HB Changes