Sam Craik

A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient's abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.

Drs. Hutchinson and Craik are co-presenting and are joint first authors. <b>Background:</b> British Thoracic Society guidelines state that oxygen should be used to treat hypoxaemia and prescribed to a target saturation range. ^[1] Patients at risk of type 2 respiratory failure should target 88-92%, with the rest 94-98%.This audit aims to identify current practice in Telford9s Princess Royal Hospital compared to the BTS National Audit in 2013. ^[2] <b>Methods:</b> Target standards: 90% of patients receiving oxygen have oxygen prescribed 100% of patients prescribed oxygen have a documented target range 100% of patients have oxygen delivered appropriately to target Data collected on the Respiratory ward from two separate audits in Autumn/Winter 2015. Drug charts and VitalPaC were used as data sources. <b>Results:</b> 70 patients were on oxygen, of which: 61% (n=43 /70) had it prescribed. 95% of those with a prescription (n=41 /43) had a documented target saturation range. 63% of those with a documented range (n=26 /41) were correctly oxygenated to target. <b>Key Messages:</b> We are below the targets for all 3 standards. However, if prescribed, majority would follow good practice of prescription and delivery of oxygen. <b>Recommendations:</b> 1. Use bedside alert cards 2. Educate all staff about oxygen prescription 3. Nominate an Oxygen Champion Nurse 4. Use the #PrescribeTargetDeliver hash-tag to promote awareness 5. Re-audit after above measures. <b>References:</b> [1] O9Driscoll BR, Howard LS, Davison AG; BTS guideline for emergency oxygen use in adult patients; <i>Thorax</i>; June 2008; 63(Suppl VI):vi1–vi68. doi:10.1136/thx.2008.102947 [2] BTS Oxygen Audit 2013; last accessed 21/01/2016: https://www.brit-thoracic.org.uk/document-library/audit-and-quality-improvement/audit-reports/bts-emergency-oxygen-audit-report-2013/

<h3>Background</h3> British Thoracic Society (BTS) guidelines state that oxygen should be used to treat hypoxaemia and prescribed to a target saturation range.¹ Patients at risk of type 2 respiratory failure should target 88–92%, with the rest 94–98%. In the BTS national audit in 2013, out of 6214 patients, 55% had oxygen prescribed and 52% were prescribed and delivered to within a target saturation range.² <h3>Methods</h3> We ran a Quality Improvement Project (QIP) involving three PDSA cycles to improve the delivery of oxygen to patients on the Respiratory Ward at the Princess Royal Hospital, Telford. We set our standards as: 90% of patients receiving oxygen have it prescribed on a drug chart 100% of patients prescribed oxygen have a documented target saturation range 100% of patients have oxygen delivered appropriately to target The QIP process commenced in Autumn 2015. After the first cycle we used bedside prompt cards and delivered teaching sessions with doctors, nurses and healthcare assistants (HCAs). After the second cycle we appointed a nurse, HCA and two FY1 doctors as <b><i>‘O2 Ninjas’</i></b>. Data were collected at three points after each cycle from drug charts and VitalPaC. <h3>Results</h3> See Table <h3>Conclusions</h3> Our QIP shows that education and empowerment of ‘grass root’ healthcare workers can improve oxygen prescription on a Respiratory ward. We suggest this QIP is replicated in other trusts and specialties to improve safe oxygen delivery. <h3>References</h3> O’Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. <i>Thorax</i> 2008;<b>63</b>(Suppl VI):vi1–vi68. BTS Oxygen Audit 2013. https://www.brit-thoracic.org.uk/document-library/audit-and-quality-improvement/audit-reports/bts-emergency-oxygen-audit-report-2013/(accessed 21 January 2016).

<h3>Introduction</h3> DomNIV in patients with chronic Type 2 respiratory failure results in improved survival. HOT-HMV study produced encouraging results in patients with COPD treated with home oxygen and DomNIV. [Murphy <i>et al</i>, JAMA, 317(21), 2177–2186] DomNIV usage with or without oxygen has been prevalent in our hospital setting over for 10 years. <h3>Objective</h3> Our primary aim was to look at the indications for prescription of DomNIV in our local hospital. Our secondary aim was to look at overall unadjusted mortality in this cohort and in particular any relationship with different types of oxygen provision. <h3>Methods</h3> We collected data on all patients who have received DomNIV from 2008–2018 with or without oxygen prescription from our local database. Data on mortality was obtained from our Clinical Portal. We used MS Excel and Vassar stats (http://vassarstats.net/) for statistical analysis. <h3>Results</h3> 105 patients commenced DomNIV; 60% were female with a mean (SD) age of 61 (13) years. Indications were Obesity hypoventilation (OH), Overlap syndrome, COPD, Neuromuscular disease, Bronchiectasis and others. 40% of patients did not receive oxygen with DomNIV (wO2), 36% received long term oxygen therapy (LTOT), 15% received overnight oxygen (OO2) and the rest received PRN oxygen. 43% of patients (N=45) died during the study period, of these 40% (N=18) died within the first 12 months. 29% died with LTOT versus 17% wO2 and 0% with OO2 in the first 12 months. This was statistically significant between LTOT and OO2 groups: RR 0.71 (95% CI 0.58–0.87), and also between wO2 and OO2 groups: RR 0.83 (95% CI 0.72–0.95). <h3>Conclusion</h3> Majority of patients received DomNIV treatment for OH; 36% (N=38) had received long term oxygen therapy (LTOT) along with DomNIV; Patients receiving overnight oxygen with DomNIV survived longer compared to those who had it as LTOT or who didn’t have any oxygen at all.

<b>Background/Objectives:</b> UK Emergency and Acute Departments are increasingly adopting triage and urgent call systems for a wide range of acute respiratory presentations with an over-reliance on the Early Warning Scoring (EWS) systems. The primary objective presently was to re-assess individual components and EWS scores in acute pulmonary thrombo-embolic disease (PTE). <b>Methods:</b> Data from 1700 acute presentations investigated by Computed Tomography Pulmonary Angiography (CTPA) over a 12 month period were analysed retrospectively. Data were also collected on vital signs at presentation. Comparative data were analysed using the MedCALC Statistics program. Results are reported comparing, respectively, outcomes from negative versus positive findings for PTE on CTPA. <b>Results:</b> 365 (21%) CTPA scans were abnormal for PTE; mean (SD, range) age of comparative groups did not differ significantly at 66.5 (17.4, 15-99) versus 68.8 (15.2, 23-102) years. D-Dimer scores were higher in the acute PTE group (mean 550 versus 796, p&lt;0.0001) but otherwise Heart Rate (87.5 versus 87.9/min), Respiratory Rate (18.2 versus 18.4/min), Systolic blood pressure (131.8 versus 132.2 mmHg) and EWS (2.36 versus 2.41) did not differ statistically. Oxygen saturation was also similar between groups (95.8 versus 95.5%) but where information was available (n=1065), 35.9% of those with negative CTPA and 25.7% positive scans were assessed on oxygen at admission. <b>Conclusions:</b> The presentation of acute PTE remains difficult with a large number of negative tests on CTPA. The vital signs at presentation and EWS do not help discriminate and at present can only have a limited role in triage.