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Covid-19 HSE Clinical Guidance and Evidence

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Residential Services - Interim Guidance on the use of oxygen in long term residential care settings for older people during the Covid-19 pandemic

Interim Guidance on the use of oxygen in long term residential care settings for older people during the Covid-19 pandemic (CD19-076 /10.04.20)


  • This document was written by National Clinical Programme for Respiratory (NCPR) and approved by the Clinical lead Dr Des Murphy and the Irish College of General Practitioners (ICGP) leads; Dr Mark O’ Kelly and Dr Dermot Nolan.  It has been approved and endorsed by Dr Siobhán Kennelly, National Clinical & Advisory Group Lead, Older Persons, HSE and by Dr David Hanlon, National Clinical and Advisory Group Lead, Primary Care, HSE.
  • Target audience: GPs and nursing home prescribers and staff.
     
Introduction
  • The primary pathology causing death in patients with Covid-19is respiratory failure as a result of a viral pneumonia. Viral myocarditis has also been reported as a cause of up to one third of deaths. Secondary bacterial infections are rarely reported. Death is more common in those with significant frailty or co-morbidities with lower physiological reserve.
  • In the absence of effective anti-viral therapy, management in any setting is primarily symptomatic and supportive. As the disease can progress rapidly or unexpectedly, advance care plans including decisions on ceilings of care should be documented in advance of decisions regarding oxygen treatment.
     
The role of supplemental oxygen
  • Recent evidence suggests that supplemental oxygen has only a limited role in the management of Covid-19 n care settings outside acute hospitals. Oxygen may have some value in supporting patients with respiratory and cardiac morbidity, where it should be titrated against oxygen saturation levels and knowledge of background co-morbid disease, in particular COPD where Type 2 respiratory failure is more common.
  • There is consensus amongst palliative care physicians that oxygen does not typically improve symptoms of breathlessness at end of life where the approach should instead be the provision of appropriate supportive palliative medications (see CG Management of severe breathlessness). This often needs to be explained to carers and relatives.
     
Prescribing oxygen
  • Oxygen is a treatment for hypoxia and should be prescribed in the medication kardex by the registered medical practitioner or nurse prescriber. All changes to prescription / flow rate must be discussed with the prescriber.
  • Maximum titration flow in care settings outside hospital is 4 l/min. When supporting a patient with Covid-19 for recovery with oxygen, supplementary oxygen can be commenced when saturations are less than 94%. The oxygen should then be titrated to achieve a target of 94%-96% in those patients who do not also have COPD.
  • In patients being treated for Covid-19 with a co-morbidity of COPD, oxygen saturations should be targeted at 90 - 94% due to the risk of Type 2 respiratory failure.
     
Related policies and staff competencies
  • Key policies and procedures to support the safe use and storage of oxygen should be in place and all staff should be trained in same.
  • Staff should be trained and aware of IPC procedures in relation to oxygen use.
  • Staff should be trained in appropriate palliative measures to ease severe breathlessness in setting of Covid-19.

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