Oxygen requirements & level of care

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Part of our floor is COVID med-surg. When we first opened we were told patients had to be stable on 6L or less per nasal cannula for at least 2 hours before they could come. Last week it changed to 10L or less NC or simple mask. Today they sent us a patient on an oxymizer, technically it was less then 10L, but even if it is less than 10 don't they produce higher FIO2? House Sup. said to take patient we're guessing pt was the most stable in the ICU. 

Do you have guidelines as to who is med-surg vs imc/ICU? Are they continually changing? Do your physicians write specific O2 orders? Our doctors usually write an order at the beginning of stay, but some patients quickly exceed it. 

Any resources on knowing how/when to go between different oxygen devices- nasal cannula, simple mask, non-rebreather, oxymizer? Need a refresher on this "middle ground".

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I think you can expect things to change as conditions get worse.  

Don't know where you are, but presumably a bunch of folks there had big thanksgiving gatherings.

You can expect the ICU to get hit hard, your unit to increase acuity, and their Christmas gatherings to be a bit smaller. 

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8 hours ago, hherrn said:

Don't know where you are, but presumably a bunch of folks there had big thanksgiving gatherings.

Or maybe crowding into stores on Black Friday?

Here in the Buckeye State the Der Fuehrer (the governor) has lectured and lectured about "not more than 10 at Thanksgiving gatherings" (Christ would have been in trouble at the Last Supper).

But NOT a peep about avoiding stores and crowds on Black Friday -go figure! 

And we have a 10 pm to 5 am curfew in place for the next three weeks. 

Much of this makes no rational or scientific sense. 

I am also sick to death of the stupid slogans & virtue signaling like: "Just be a good person wear a mask"

 

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Specializes in Emergency.
5 hours ago, DaveMHA-RN said:

Here in the Buckeye State the Der Fuehrer (the governor) has lectured and lectured about "not more than 10 at Thanksgiving gatherings" (Christ would have been in trouble at the Last Supper).

Not for nothing but comparing dewine to hitler simply shows a complete lack of historical knowledge as well the inability to make a valid analogy. 

And are you implying that jesus would have ignored a public health recommendation? I believe you were being tongue-in-cheek but seriously. 

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58 minutes ago, emtb2rn said:

Not for nothing but comparing dewine to hitler simply shows a complete lack of historical knowledge as well the inability to make a valid analogy. 

And are you implying that jesus would have ignored a public health recommendation? I believe you were being tongue-in-cheek but seriously. 

I think it is a perfect analogy -and I know history. DeSwine goes around barking "orders" and then send his good squad to enforce compliance. People have lost their livelihoods, and people have committed suicide. DeSwine has blood on his hands.

Yes Jesus would have ignored public health orders to keep His Passover which is what the last supper was. Just as he chased money changers from the temple.

In Mark 12:17 He tells us to render to Caesar the things that are Caesar’s, and to God the things that are God’s. But honoring God comes before obeying Caesar because no man can serve two masters: for either he will hate the one, and love the other; or else he will hold to the one, and despise the other. Ye cannot serve God and mammon (Mathew 6:24, KJV).

Jesus Christ conquered death -I doubt He would have feared the rona. In fact in Mathew 6 he tells us "not to worry" 3 times -so I ain't scared of no rona either.

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How did this become religious & political? I was simply wanting resources on switching between oxygen devices.

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Specializes in Critical Care.

There isn't much purpose to a Covid unit that doesn't do high-flow supplemental oxygen, that's mainly what these patients require since these patients are primarily hypoxic respiratory failure patients, rarely are they hypercapnic or mixed respiratory failure.

Unless they require a ventilator or other advanced therapies, they don't need to be ICU level patients.  They should be on continuous oximetry, but other than that should be manageable as lower level of care than ICU.

Ideally you have access to a respiratory therapist that can guide you on the appropriate oxygen delivery device, but basically delivering oxygen to the lungs depends on: how much oxygen is in the air going to the lungs, how much air is going to the lungs, and how much of the total air going to the lungs is being managed (nasal delivery alone ie cannula vs nasal + oral delivery ie mask).  

A nasal cannula offers the amount of flow while inhaling, and only based on the amount of inhaled air that goes through the nose.  An oximizer is a cannula with an oxygen reservoir so that when they inhale the amount of oxygen inhaled through the nose is greater than the flow rate.  A high flow nasal cannula uses both an adjustable amount of supplemental oxygen along with forced airflow, which can actually provide some level of PEEP.  

A simple mask provides supplemental oxygen through both the mouth and nose but only the amount flowing into the mask during inhalation.  A non-breather has an oxygen reservoir so that they are getting close to 100% oxygen with each inhalation.  

I've personally never seen a Physician order a specific amount of oxygen, it's always based on the oxygen saturation goal with options to achieve that goal without having to check with the MD, if the goal isn't achieved with the available options then you would readdress the situation with the MD.

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Specializes in Critical Care.

It would be nice to have these patients on a step down/progressive care unit but unfortunately due to lack of resources because there are too many covid patients and because covid patients are so sick and decompensate quickly, many nurses find that they’re caring for higher acuity patients than they’re used to. This is a pandemic where most nurses have had to step out of their comfort zones.

If they have increased oxygen requirements and are getting close to the max oxygen that you can do, you need to have critical care evaluate the patient. Keep in mind you can always throw a 100% non rebreather mask on top of the maxed out HFNC. Covid patients have little /no reserve and usually need higher oxygen with any exertion. 

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On 11/30/2020 at 11:40 PM, MunoRN said:

There isn't much purpose to a Covid unit that doesn't do high-flow supplemental oxygen, that's mainly what these patients require since these patients are primarily hypoxic respiratory failure patients, rarely are they hypercapnic or mixed respiratory failure.

Unless they require a ventilator or other advanced therapies, they don't need to be ICU level patients.  They should be on continuous oximetry, but other than that should be manageable as lower level of care than ICU.

Ideally you have access to a respiratory therapist that can guide you on the appropriate oxygen delivery device, but basically delivering oxygen to the lungs depends on: how much oxygen is in the air going to the lungs, how much air is going to the lungs, and how much of the total air going to the lungs is being managed (nasal delivery alone ie cannula vs nasal + oral delivery ie mask). 

I've personally never seen a Physician order a specific amount of oxygen, it's always based on the oxygen saturation goal with options to achieve that goal without having to check with the MD, if the goal isn't achieved with the available options then you would readdress the situation with the MD.

Thanks for the info. Our unit originally started out as COVID overflow.... Typically patients who were being admitted for other issues, but tested positive. It's been the past 2-3 weeks we've been getting more COVID positive with respiratory issues. We only have 2-3 cont pulse/ox devices for our floor & biomed insist we're out in the hospital. Our floor definitely doesn't have high flow cannulas, this week were allowed to put them on oximizers, but they have to come from distribution. Our flow meter go to 15L & today we got permission from the manager to titrate to 15 L on a simple masks. 

I think the physician order might just be in their "med-surg order set.  Today I saw a couple "nursing communication" O2 titration orders. 

8 hours ago, RealNurseMom said:

It would be nice to have these patients on a step down/progressive care unit but unfortunately due to lack of resources because there are too many covid patients and because covid patients are so sick and decompensate quickly, many nurses find that they’re caring for higher acuity patients than they’re used to. This is a pandemic where most nurses have had to step out of their comfort zones.

If they have increased oxygen requirements and are getting close to the max oxygen that you can do, you need to have critical care evaluate the patient. Keep in mind you can always throw a 100% non rebreather mask on top of the maxed out HFNC. Covid patients have little /no reserve and usually need higher oxygen with any exertion. 

I honestly wouldn't mind taking care of them if we had more resources. We are still staffed like med-surg 1:5-6 but have patients on 15L non-rebreather and a wait for step down/ICU beds several hours. No cont pulse/ox or high flow/ vapo-therm. We share RT with a couple other floors; housekeeping, wound care, admit/discharge nurses and a few other ancillary services & disciplines/specialties won't/can't come on a COVID unit. I didn't mind that set-up at first, but today they changed the staffing matrix. Sorry I'm on a rant- I feel it's about so much more. P.s. I used to work high-obs so I'm not intimidated, but we had a RT in unit 90% of the time to guide us & we could bounce ideas off each other.

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Specializes in Med-Surg/Telemetry.

I work med surg  tele with ratio of 1:4 and more often than not have covid patients on heated high flow or oxymizer. It really is unnerving to have one on both high flow and the non rebreather though.

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Specializes in Cardiology.

Everywhere I've worked O2 requirements have always been a gray area. At my old job on a step-down we technically couldn't have hi-flo but we did because they were "stable". It was more likely because there were no beds on the floors that usually took them. Also at my old job they had I believe 1 hour to wean off a non-rebreather and if they couldn't they went to the unit. My current job its more like 2 hrs. We can have ventimasks but we usually are able to wean them off. 

For covid it used to be if their requirement needed more then 3 liters they went to the unit. Not sure if that's still the case, I haven't worked down there in months. 

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In the Spring, we were basically sending everyone who wasn't a DNI to be intubated once they passed 6L.  They also didn't want to have high-flow humidified because of the aerosolization, so people's mucosa were getting ridiculously dried out. Now we know the early intubation was a mistake, as was the reluctance to humidify.  

With cases ramping up, we are seeing a lot of higher level O2 on the regular med-surg COVID units. Some patients are there for weeks on heated high flow. Basically, as long as they are meeting their saturation goals, they stay there on whatever non-invasive O2 they need.  When they're no longer stable, they transfer.

On 12/4/2020 at 3:27 PM, RealNurseMom said:

If they have increased oxygen requirements and are getting close to the max oxygen that you can do, you need to have critical care evaluate the patient. Keep in mind you can always throw a 100% non rebreather mask on top of the maxed out HFNC. Covid patients have little /no reserve and usually need higher oxygen with any exertion. 

Yes, this was exactly what happened yesterday! I admitted a patient from the ED at start of shift on 15L.  Went back and forth between NRB and NC at that level.  Patient was finally put on HHF 60L at 100% late morning.  Patient's work of breathing improved greatly, was able to eat, converse, etc.  Then she started getting worse in the afternoon. Desaturated into the low 80s with turning (needed a complete bed linen change), and was slow coming back up. I called respiratory who told me to put on the NRB over the HHF.  The patient was still tachypneic and using accessory muscles at rest.  I could get the saturation up to about 88-89% if I stayed right there and coached her in deep breathing, but she was exhausted, and would start breathing more shallowly, and would dip back to the mid-low 80s.  Called a rapid response, and got her transferred to ICU.

Not everyone is that sick, of course.  We have a mix of patients who are there for COVID and those who are there with COVID.  Some never need any supplemental oxygen at all.

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