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Referral
Home Oxygen
Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral letter
As of the 1st October there will be a new contract and new arrangements for the ordering and provision of home oxygen therapy. Anyone who already has oxygen in place on the 1st of October 2016 will continue with their current oxygen supplier.
Oxygen does not help breathlessness in non-hypoxic patients.
Any health care professional can access Part A of the new portal and order static oxygen for the home through this portal. - link
Wherever possible static oxygen should only be via concentrator.
Cylindered oxygen costs substantially (potentially £1000s) more than a concentrator.
To prevent over-usage of oxygen via a concentrator it is essential that patients are advised that they should not use oxygen for longer periods than it is prescribed.
Long term oxygen therapy has an evidence base which shows improved prognosis in patients with COPD. There is no significant evidence demonstrating increased length of life in other pathologies, but it is assumed that it is of benefit in respiratory conditions with chronic hypoxia.
Short burst oxygen therapy has no evidence base and should not be prescribed without consideration of other methods to palliate/manage breathlessness.
Ambulatory oxygen therapy, of which there are now many options, can only be ordered by specialist users and only following specialist assessment, via Part B. The Specialist Oxygen Teams have received Part B training and will be happy to organise assessments for ambulatory or specialist oxygen equipment.
Nocturnal oxygen therapy has little evidence base and should not be prescribed without appropriate assessment in a sleep clinic.
Palliative oxygen therapy has little evidence base but can be used to treat intractable breathlessness in end stage malignant disease, where other methods of palliation have been tried. It should only be prescribed if the patient is hypoxic. When home oxygen is provided on a palliative basis a formal assessment by the Home Oxygen Service may not be necessary unless ambulatory oxygen is required.
Removing Oxygen
Most patients on long term oxygen therapy will always use it as part of their therapy. Those on short burst or ambulatory will have oxygen to trial initially. If this is started by the HOS or hospital inpatient team the HOS will undertake the review, if started by the GP then they will be responsible for the review. A referral to the HOS team is essential for all patients started on oxygen at home apart from those using oxygen for palliation of symptoms. If patients stop using oxygen, the CCG will continue to be charged rental fees. If a patient no longer requires or does not want to use their oxygen please notify the oxygen provider customer services via:
The HOS team should be notified of the removal either via email or letter.
PRE REFERRAL CRITERIA
Patient must have a definite diagnosis of chronic respiratory disease or heart failure.
If there is no clear diagnosis and the patient is chronically breathless and needs assessment for oxygen therapy they should first be referred to the Respiratory Medicine Clinical Service.
Patient should be chronically hypoxic – this means -
-A minimum of 2 sets of 02 sats over a period of at least 5 weeks
- 02 sats <94% should be used if polycythaemia felt to be due to hypoxia or in the presence of pulmonary hypertension or right heart failure
- If the SpO2 reading is borderline, circa 90-92% patient should be asked to return for repeat oximetry in 8 weeks.
Acute and/or reversible causes for hypoxaemia must have been excluded and/or treated. If possible a list of examples here:
Ensure optimum therapy for COPD and/or Heart Failure has been trialled.
For patients with COPD, inhalers do not always improve breathlessness and may have been stopped.
This is acceptable for referral but should be stated in the letter.
Recent (within 6 weeks) FBC results
FBC measured in last 6 weeks, to check for polycythaemia
Minimum of 2 sets of 02 sats over a period of at least 5 weeks
02 sats <94% should be used if polycythaemia felt to be due to hypoxia or in the presence of pulmonary hypertension or right heart failure
If the SpO2 reading is borderline, circa 90-92% patient should be asked to return for repeat oximetry in 8 weeks.
Patient must have a definite diagnosis of chronic respiratory disease or heart failure.
If there is no clear diagnosis and the patient is breathless and needs assessment for oxygen therapy they should be referred to the Respiratory Medicine Clinical Service.
Acute and or reversible causes for hypoxaemia must been excluded and/or treated.
Ensure optimum therapy for COPD and/or Heart Failure has been trialled. For patients with COPD, inhalers do not always improve breathlessness and may have been stopped.
This is acceptable for referral but should be stated in the letter.
Diagnosis of chronic hypoxia requires > 2 measurements of 02 sats <92% within a min 5 week period
02 sats <94% should be used if polycythaemia felt to be due to hypoxia or in the presence of pulmonary hypertension or right heart failure.
If the SpO2 reading is borderline, circa 90-92% patient should be asked to return for repeat oximetry in 8 weeks.
Ideally, patients must be 8 weeks clear of an exacerbation before an oxygen assessment is undertaken.
Exacerbation can cause a temporary fall in arterial oxygenation.
For those that are never 8 weeks clear of exacerbation a referral can be made at any stage that an oxygen assessment is thought necessary (based on the criteria within this document)
It is important to establish whether the patient is in a stable condition: in other words whether the results are consistent over an eight-week period.
NB If a patient with COPD is exacerbating spO2 between 88 and 92% is acceptable.
WHEN TO REFER TO HOS
If the patient remains hypoxic after a period of 8 weeks stability and is on or tried maximum therapy refer to Home Oxygen Service
In individuals who have adequate oxygenation at rest (above 94%) who have demonstrated desaturation on exertion (SaO2 drops below 90% and more than 4% of baseline on walking) consider referral to the HOS service in regards to ambulatory oxygen therapy..
The potential benefits of oxygen therapy i.e. life prolonging effects; improvement in exercise tolerance must be discussed before referral as the patient may not wish to start therapy.
Information, preferably written and verbal should be given to patients referred to home oxygen assessment services at the time of referral.
Identify any risks particularly the risk associated with smoking. Where patients/carers are smokers, good links are needed with local smoking cessation services. Patients who are at high risk of trips and falls need special consideration when considering oxygen therapy.
Please note referrals that do not provide evidence that the patient is hypoxaemic or hasn't been trialled on maximum treatment may be returned causing delays in patient assessment.
Referral criteria
Referral criteria are detailed in the pre referral criteria and assessment and investigations/ management sections above.
Home oxygen referral instructions
Ideally all home oxygen should be prescribed by the specialist oxygen team however GP's and other professionals can order oxygen for palliative patients via the Part A portal which can be accessed here: Healthcare professional portal
There is no requirement for a password for Part A portal and prescribers need to follow the steps on the screen. There is also a guide to Part A and a short video to part A training which can be accessed via a link at the top of the page.
Home Oxygen Consent Form (HOCF) is available on the portal.
All patients must have a HOCF completed.
Home Oxygen Risk Assessment Form will be available on the portal
All patients must have a Home Oxygen Risk Assessment Form completed.
Wherever possible please order an oxygen concentrator rather than cylinders, this will save over £1000 per annum. To prevent over-usage of oxygen via a concentrator it is essential that patients are advised that they should not use oxygen for longer periods than it is prescribed.
Please refer any patients started on oxygen apart from those for whom use is palliative to the specialist home oxygen service. Please inform all patients that the supply might be temporary.
Ambulatory Oxygen, of which there are now many options, can only be ordered by specialist users and only following specialist assessment, via Part B. The Specialist Oxygen Team has received Part B training and will be happy to organise assessments for ambulatory or specialist oxygen equipment.
Refer using the e-Referral Service:
- Specialty: Respiratory Medicine
- Clinic type: Not otherwise Specified
- Service: DRSS-South Devon & Torbay-Respiratory Medicine- Devon ICB - 15N
Patient Information
Air liquid – Home Oxygen Services
Evidence
British Thoracic Society, Home Oxygen Guidance 2015 for use in adults
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: August 2017
