A week in the life of a Home Oxygen Nurse
by Sara Mason - Senior Oxygen Nurse and Team Lead, North Cumbria Home Oxygen Service
Monday
Today I am running one of our adhoc clinics. It’s where we can get patients to come to us instead of doing a home visit. I have six patients coming in today, 3 are relatively straight forward, looking at alternative equipment in particular the portable Oxygen concentrator, another needs some documents completing for an upcoming holiday. Two are coming for CBGs and another for a general respiratory review. We are an unusual service in that patients have their initial ABG done in the hospital and subsequent CBGs in the community. When the ABG is completed they are referred back to us to initiate treatment. We have a business case ongoing to try to amalgamate this so patients come to us for everything. My first lady into clinic has been previously for a CBG, she was prescribed LTOT on discharge and has been keen to come off this. Unfortunately the gas today reveals she needs to continue with her LTOT. She then became quite upset and we had a long talk about how the disease and its progression is affecting her and also her family and marriage. We did some work around anxiety management and some modified CBT and I referred her to our health and wellbeing service for some additional support. My second lady is a long standing ambulatory Oxygen patient who has been really struggling and has been using her POC at rest. On arrival I noted her resting Sp02 were 73% on room air, I did a blood gas and commenced her on some LTOT. The last man also needed a blood gas for a review. His results were not particularly reliable as he had sp02 of 96% on his current prescription, yet his P02 was only 5.55. This is always a tough call but he has been very well and on balance we made no changes to his prescription. I love doing these adhoc clinics, it’s always a mixed bag, and unfortunately I also always get off late!
Tuesday
I have some home visits booked in the morning and then it’s my afternoon for messages and discharges. We have had to allocate someone to be office based every afternoon as the demand can be so high. I start with two nice and easy home safety checks, patients where we have assessed them in ambulatory Oxygen clinic and they just need their risk assessments verifying and a support visit to see how they are getting on. My next visit is to one of our younger patients who is waiting for a transplant. I see her monthly, we always check her Oxygen requirements as if she deteriorates she will be moved to the very top priority. She is really struggling and becoming increasingly disabled, she has also had two false alarms since my last visit. The first she was called back before she left the house as she had the same antibodies as the donor, but the second she had got to the hospital but then was told the lungs were not suitable for transplant. She is living on a rollercoaster of emotions and I do my best to support her through this process. Today it her rapid deterioration is clear, a blood gas reveals she is eligible to me moved to the upmost priority list. We have some very difficult conversation about the possibility of a transplant not being available in time. We formulate an advanced care decision and an emergency care plan.
I get back to the office and there are three discharges waiting and countless messages from GPs, patients and families with clinical queries and requests. I start on the discharges, first checking they have had blood gasses which is not always the case. One has not had them and one actually does not meet the criteria to be discharged with Oxygen. I spend an age trying to get through to the wards to discuss them with the ward doctors. I then contact the patient’s families and complete the risk assessments, education and safety advice over the telephone before arranging for the equipment to be installed. The other messages are the usual, a GP trying to expedite a referral as our waiting time for clinic is five months, a district nurse asking advice about a palliative patient in a care home, patient experiencing nasal symptoms, a husband concerned his wife is generally deteriorating and asking for a review, and a patient wanting a mask instead of nasal cannulas. Another late finish but I get everything completed.
Wednesday
Another day of home visits. I am covering for one of my nurses who is on maternity leave. Her territory is an hour and a half from me, so I’m very limited in the visits I can do in the time I have. I have four booked in. Three are patients with pulmonary fibrosis. We follow the ILD guideline that myself and colleagues from the North East have worked on. If we cannot assess these patients within four weeks of referral we assess them initially at home. The last visit is a spot check on a patient who has been smoking around his Oxygen equipment. This patient’s behaviour had been reported to us a few months before and we had followed our processes. We always do a visit to establish if we can re-educate the patient and they sign an additional safety agreement stating Oxygen will be removed if there are any further instances and agreeing to unannounced spot checks. Sometimes we do an immediate removal but this patient previously was given a second chance. On arrival unfortunately it was clear we needed to remove the Oxygen urgently. The patient was asleep on the settee with his Oxygen on via a concentrator, he had a full flask of liquid Oxygen at his feet and on a coffee table beside him was his smoking materials, a full ashtray and inhalers. His mother in law who suffers with dementia was in the house and two dogs were leaping around. The front door was locked so the mother in law could not get out easily. I knew from his risk assessment a disabled neighbour lived in the house attached. We hate doing safety removals, they are upsetting and stressful for everyone. The patient was not stable without Oxygen and therefore I arranged for him to be admitted to hospital where he could have Oxygen delivered safely. Then back to the office for the mountain of paperwork that safety removals warrant.
Thursday
Firstly we have a clinical supervision session alternate Thursdays. The team can discuss any complicated patients, or issues they have had. Invariably there is a lot of reflection about actions and decisions taken. We then head off into ambulatory Oxygen clinic. We usually see a combination of new patients, 8 week reviews and urgent reviews. Currently due to inadequate resource and the Covid backlog we do not have any capacity to carry out routine clinic reviews. Today’s clinic is fairly mundane, but there are the usual issues. One of our 8 week review patients has been using her AOT as SBOT and using it overnight as she felt breathless following an exacerbation. We reiterated the safe use of Oxygen therapy and the importance of complying with the prescription. She claims she was never told how to use her Oxygen, a claim that is all too familiar and all too false! Another patient does not meet the criteria for AOT as he maintains his sp02 above 90%. He is a bit disappointed as he is clearly breathless and thought Oxygen would be the panacea. We spent some time going through his inhaler use and some breathing control techniques. We also were successful promoting pulmonary rehabilitation and referred him to our local team.
Friday
I’ve allocated today as a management day, attending various meetings regarding setting up the virtual respiratory ward this winter. I complete one of my team’s appraisal and her revalidation. We have some really good discussions around reflection and how this has helped her recently. The next job is monitoring our monthly concordance reports and KPIs. As I am leaving I get a message from my patient waiting for transplant, she has got her third call, is in Newcastle and all is good to go. A thrilling end to a busy week.