S06 HomeO2-ClinicalIndications-08-28-2020 (002).pdf

August 28, 2020 VHA DIRECTIVE 1173.13

CLINICAL INDICATIONS

1. As part of the determination of risks and benefits for home oxygen use, the prescribing provider must use the following clinical indications (references g-j):

(a) The patient must have a documented severe hypoxemia or severe desaturation (see below) at rest from primary or secondary chronic lung disease. Patients with cluster headache or sleep disordered breathing with hypoxemia may be candidates for a home oxygen prescription with modifications (see below).

(b) Steady state arterial blood gas at rest must document an arterial partial pressure of oxygen (PaO2) of 55 millimeters of Mercury or less. A pressure of 59 millimeters of Mercury or less is acceptable if signs of Cor Pulmonale and other signs of hypoxemia, such as erythrocytosis, are present. Alternatively, an oxygen saturation (SaO2 or SpO2) at rest must document a SaO2 or SpO2 of 88 percent or less while breathing room air.

For in-patients with acute respiratory decompensation, room air arterial blood gas or saturation measurement must be taken prior to home oxygen request when the patient's respiratory condition is in a clinically stable state for discharge home. Any oxygen flow rate over 4 LPM requires a prescription from a pulmonologist.

(c) Desaturation with exercise is no longer a routine indication for new prescriptions for home oxygen (See (d) below.) These patients should be given assurance that they will not benefit from home oxygen. However, documentation of desaturation with exercise is recommended in most patients to exclude the possibility of further evaluation for home oxygen (The patient may not meet any criteria) or oxygen with air travel (see below). While routine prescriptions are no longer indicated, prescriptions can be given in selected patients when prescribed by a pulmonary physician either on individual basis or as part of local policy. Active smoking is considered a relative contraindication for home oxygen; however, it is an absolute contraindication for home oxygen for desaturation with exercise, and a thorough consideration must be made of the risks and benefits of home oxygen therapy prior to and during treatment. NOTE: Smoking includes marijuana, tobacco, e-cigarettes, or similar item.

(d) Patients may be candidates for home oxygen based on indications other than intrinsic pulmonary disease. These include, but are not limited to:

(1) Cluster headaches under the care and evaluation of a neurologist (no requirement for saturation documentation). NOTE: Requests for oxygen therapy may be initiated by the neurologist for this indication.

(2) Hypoxemia associated with sleep-disordered breathing can be prescribed at the discretion of the Sleep physician after evaluation in Sleep Clinic. This can only be prescribed in conjunction with CPAP therapy.

(3) Documented oxygen prescriptions from outside physicians can be referred to the VA prescribing provider for evaluation and consideration of home oxygen therapy.

However, documentation of hypoxemia/desaturation at rest from an outside healthcare

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August 28, 2020 VHA DIRECTIVE 1173.13 facility must meet the same criteria described above and may require evaluation at the discretion of the prescribing provider.

(4) Oxygen for air travel. Some patients may not meet above criteria for home oxygen but may be at risk of significant desaturation during air flights. See references for a common algorithm for determining oxygen needs during air travel.

b. In the event of an adverse event:

(1) Re-evaluation of home oxygen therapy and documenting in the patient’s electronic health record the reasons for continuing oxygen therapy despite the adverse event.

(2) Reasons for withdrawal or declining oxygen therapy should be documented in the electronic health record by the prescribing provider. NOTE: If the patient wishes to dispute the decision, the prescribing provider may refer the patient to VHA Directive 1041, Appeal of VHA Clinical Decisions, dated October 24, 2016, or an Ethics consult.

(3) Documenting in the electronic health record, all reported adverse events while oxygen is in use. NOTE: Any health care worker who has knowledge of the dangers of smoking while using oxygen is accountable within the scope of their responsibilities.

For example, a physician who knowingly continues to prescribe oxygen therapy for a patient who continues to smoke while using the oxygen is accountable for that prescription. TJC Q&A 2014.

a. Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005 Oct 19;(4).

b. Long-Term Oxygen Treatment Trial Research Group, Albert RK, et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. The long-term oxygen treatment trial research group. NEJM 375(17):1617-27. 201.

c. The Joint Commission, Oxygen Safety Webinar.

https://www.jointcommission.org/assets/1/6/092514_Oxygen_Safety_Webinar_QA- Final.pdf. NOTE: This linked document is outside of VA control and may not be conformant with Section 508 of the Rehabilitation Act of 1973.

d. The Joint Commission National Patient Safety Goals.

e. Anne Edvardsen et al. Air travel and chronic obstructive pulmonary disease: a new algorithm for pre-flight evaluation. Thorax 2012;67:964-969.

f. A. Johnson. Chronic obstructive pulmonary disease: Fitness to fly with COPD. Thorax 2003;58:729-732 doi:10.1136/thorax.58.8.729.

https://www.jointcommission.org/assets/1/6/092514_Oxygen_Safety_Webinar_QA-Final.pdf https://www.jointcommission.org/assets/1/6/092514_Oxygen_Safety_Webinar_QA-Final.pdf

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CLINICAL INDICATIONS