Hrev_master [page 74] [Emergency Care Journal 2020; 16:8867] Emergency Care Journal 2020; volume 16:8867 Abstract Oxygen is the most commonly used drug in emergency medi- cine. The aim of this study was to identify healthcare profession- als’ preferences regarding oxygen therapy in common medical emergencies. An online 9-part-questionnaire was distributed through Facebook to doctors and nurses working in Greek hospi- tals. The questionnaire included background information of the respondents and addressed individual preferences regarding best oxygenation parameter and oxygen targets in specific acute set- tings. We received 678 responses and we included 663 in our analysis. We found significant differences between doctors’ and nurses’ attitudes towards oxygenation targets in ARDS, sepsis, acute coronary syndrome, and post cardiac-arrest patients. Nurses preferred a more conservative oxygen strategy compared to doc- tors. Furthermore, nurses favor SaO2 as the best oxygenation parameter, while doctors prefer PaO2. In our survey, the type of hospital and department of the respondents did not affect the pre- ferred oxygen strategy. Social media-based survey research is fea- sible and effective. In this single country study, doctors showed a tendency to liberally administer oxygen in acutely ill medical patients. On the other hand, Greek nurses preferred a more conser- vative approach. Introduction Oxygen therapy represents a central focus of emergency care. Nevertheless, the debate among healthcare professionals about the optimal targets of oxygenation is constant. Supplemental oxygen is universally administered to acutely ill patients to treat life-threat- ening hypoxia, but it is now well documented that it may impose potential harmful effects. These include direct cellular damage by reactive oxygen species, pulmonary absorption atelectasis, lung inflammation/injury, and hyperoxemic vasoconstriction.1,2 Sometimes the benefits of attempting to fully reverse arterial hypoxemia may be outweighed by the risks associated with high oxygen concentrations.3 However, it is not known whether the pri- mary culprit is the fraction of inspired oxygen (FiO2) itself or the systemic effects of hyperoxemia. Although recommendations for oxygen therapy in the adult acutely ill patients do exist, the optimal disease specific targets have not been established. Arterial blood gases (ABGs) and partial pressure of oxygen (PaO2) have been historically considered the gold standard for assessment of oxygenation. Measurement of PaO2 though, requires an arterial puncture, can be challenging in some patients and it is not ideal for monitoring. In the new era, oxyhemoglobin saturation measured by pulse oximetry (SpO2 or SaO2) has become a useful adjunct for assessment of oxygen status and it is uniformly used for non-invasive monitoring at the bed- side.4 Currently, the liberal versus conservative approach in oxygen therapy has been a matter of controversy. Data from randomized controlled trials (RCTs) have been inconclusive. A recent meta- analysis of 25 RCTs concluded that liberal oxygen therapy increased mortality in acutely ill adults.5 However, these results were disputed on the basis of poor fragility index of the included studies.6 In this setting, clinicians’ preferences and actual clinical practice regarding oxygen therapy are of significant interest. We conducted a national survey seeking to explore the atti- tudes and practices of doctors and nurses working in Greek hospi- tals. The goal of the study was to quantify current practice by clar- Correspondence: George Karlis, Attavyrou 24, 85100, Rodos, Greece E-mail: georgekarlis@yahoo.com Tel: +306937582535 Key words: Oxygen therapy; Emergency medicine; Survey Contributions: GK, idea conception and manuscript writing; DB, data collection and reference search; GG, statistical analysis and manuscript writing; PM, reference search and data collection; ZM, manuscript reviewing; TX, manuscript reviewing. Conflict of interest: The authors declare no potential conflict of interests. Ethics approval and consent to participate: The manuscript does not contain any individual person's data in any form. Dedication: The article is dedicated to Mike Karlis Jr. Received for publication: 2 February 2020. Accepted for publication: 18 May 2020. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2020 Licensee PAGEPress, Italy Emergency Care Journal 2020; 16:8867 doi:10.4081/ecj.2020.8867 Oxygen therapy practices in the acutely ill medical patients: A social media-based nationwide study of clinicians’ preferences and summary of current recommendations George Karlis,1 Dimitrios Barouxis,2 Georgios Georgiopoulos,3 Panagiota Mitropoulou,4 Zafeiria Mastora,5 Theodoros Xanthos6 1Intensive Care Unit, General Hospital of Rhodes “Andreas Papandreou”; 2Cardiology Department, Laiko General Hospital, Athens; 3Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece; 4Queen Alexandra Hospital, Portsmouth, United Kingdom; 51st Department of Intensive Care Medicine, National and Kapodistrian University of Athens, Greece; 6European University Cyprus, School of Medicine, Nicosia, Cyprus Non -co mmerc ial us e o nly ifying opinions on PaO2 versus SaO2 as a preferred oxygenation parameter and preferences of oxygen therapy targets in specific acute clinical scenarios. We also reviewed the current international guidelines about oxygen treatment in these scenarios. Material and Methods We produced a 9-part-questionnaire in Greek regarding oxy- gen administration in acutely ill adults. The questionnaire consist- ed of two sections. The first section (Q1 to Q3) included back- ground information of the respondents, namely role (specialized doctor, resident doctor, nurse), department (internal medicine sec- tion, surgical section/operating room, intensive care unit/coronary care unit, emergency department), and type of hospital (university, public, private). The second section (Q4 to Q9) addressed individ- ual preferences regarding best oxygenation parameter (PaO2 or SaO2) and oxygen targets in terms of SaO2 range in specific acute settings, namely COPD exacerbation, ARDS, sepsis, acute coro- nary syndrome, and post-cardiac arrest. The questionnaire was pilot-tested in ten healthcare profes- sionals (five doctors and five nurses) to ensure understanding and correct interpretation (face validity). Two questions needed revi- sion and were then approved by all the pilot participants. From 29 June to 20 July 2019 the web-based questionnaire (SurveyMonkey®, Dublin, Ireland) was distributed through Facebook social media platform. The link to the survey was posted to the two largest Facebook groups for doctors and nurses working in Greece. The title of the questionnaire was “Oxygen therapy tar- gets in the emergency department, the intensive care unit and the ward”. A brief description was posted along with the link: “The tar- get population of the survey is doctors and nurses working in Greek hospitals and it is intended to assess individual preferences and practices regarding oxygen therapy and not knowledge of guidelines. This is an anonymous questionnaire and average com- pletion time is 1 minute”. A reminder post was uploaded to each group 10 days after the original post. The survey was closed on 20 July 2019. No specific ethical permissions were required for this survey. Participation was voluntary and completion was regarded as informed consent. All collected data were anonymous. The IP address of the respondents was processed by the website (SurveyMonkey®) to exclude duplicate answers. We did not have any access to the IP addresses of the respondents. Results were analyzed using descriptive statistics. Nominal/ordinal variables are expressed in absolute and percent- age value (%). Differences in oxygenation target (i.e. 88-92 vs 92- 96 vs 96-100%) overall and in terms of specific clinical situations among subgroups of interest, including role, department, and type of hospital, were assessed by the non-parametric chi-squared test. Results are provided as percentages per row and column and illus- trated with bar charts. Post hoc analysis indicated that our sample size had adequate power (more than 80%) to detect differences equal or more than 10% in percentage scale, corresponding to a small to moderate effect size equal to 0.2 according to Cohen’s conventions,7 in target oxygenation preference among different groups. Power considerations were performed with GPower 3.1.9.4.8 Statistical analysis was conducted with STATA package, version 11.1 (StataCorp, College Station, Texas USA). The level of statistical significance was set at p<0.05. Results We received 678 responses. Fifteen of them were not full (respondents skipped one or more questions) and were excluded from the study. We analyzed the responses of 663 healthcare pro- fessionals. Of them, 392 were nurses (59.13%) and 271 doctors (40.87%). Doctors were further divided in specialized doctors (149, 22.47%) and residents or doctors in training (122, 18.40%). The majority of the respondents (38.01%) work in internal medi- cine departments and in public hospitals (58.82%). The summary of all survey data is depicted in Figure 1. The preferred oxygenation parameter is PaO2 for 55.05% of the respondents and SaO2 for 44.95%. However, in the subgroup of nurses 42.86% prefer PaO2 whereas 57.14% prefer SaO2. This dif- ference was statistically significant (p<0.001). Between group comparisons of the respondents’ background with respect to the preferred SaO2 target in specific acute settings (COPD exacerba- tion, ARDS, sepsis, acute coronary syndrome, and post-cardiac arrest) were made. There were no differences in the answers between type of hospital subgroups (university, public, private). The department (internal medicine section, surgical section/operat- ing room, intensive care unit/coronary care unit, emergency department) did not affect significantly the preferred oxygenation targets, with the exception of ARDS. Indeed, respondents working in the intensive care unit/coronary care unit and the emergency Article Figure 1. Summary of all survey data. [Emergency Care Journal 2020; 16:8867] [page 75] Non -co mmerc ial us e o nly department preferred a more conservative approach (p=0.041) in the ARDS patient. Interestingly, when the analysis took into con- sideration the role of the respondents (specialized doctor, resident doctor, nurse) the preferred oxygenation targets differed signifi- cantly in all clinical scenarios. Nurses’ responses showed a prefer- ence for lower SaO2 targets overall compared to doctors. In Figure 2 we present the comparisons by role. Current recommendations regarding oxygen therapy Oxygen is the most commonly used drug in acute medicine. Yet prior to 2008, there was no formal guidance available for the safe use of oxygen. Ambulance staff and emergency department physicians often failed to optimize oxygen therapy, rather by using a “one size fits all” approach.9 According to British Thoracic Society (BTS) guidelines for emergency oxygen use in adult patients, a target saturation of 94- 98% is recommended for most acutely ill patients and 88-92% for those at risk of hypercapnic respiratory failure.10 In Table 1 we summarize the latest international recommendations for oxygen therapy targets in common medical emergencies such as COPD exacerbation, ARDS, acute coronary syndromes, stroke, sepsis/septic shock, post-cardiac arrest.11-15 Discussion This nationwide survey showed that nurses prefer SaO2 as the target oxygenation parameter, while doctors prefer PaO2. In addi- tion, our survey demonstrated that nurses target lower oxygen sat- urations in acute illness, thus showing a preference for a more con- servative oxygen therapy approach compared to doctors. For instance, in ARDS and sepsis, only 9.44% and 23.98% of nurses respectively, would target an SaO2 ≥96%. In the majority of hospital settings worldwide, nurses frequent- ly manage oxygen therapy but they report lack of initiative to rou- tinely escalate it without a doctor’s request or in the absence of specific medical orders.16 It seems that nurses in some settings are less likely to independently titrate oxygen to their own SaO2 target, but more likely to independently treat a falling SaO2.17 Furthermore there are practical issues and difficulties with chang- ing long established behaviors in a given healthcare system. For instance, in the Greek interprofessional culture the role of the physician is more dominant in the decision-making process of patient’s care.18 These might be some possible explanations for our findings in the group of nurses. However, in a corresponding study, the majority of nurses (76%) at a district UK hospital “always” felt comfortable administering oxygen therapy while only 33% of them were aware of the consequences for patients if target SaO2 was above the prescribed limit.19 It is therefore reasonable to sug- gest that the setting, local/cultural aspects and the level of training Article Table 1. Emergency oxygen use guidelines in adults. Recommendation Comments Society Level of evidence COPD exacerbation 88-92% Pending blood gas results BTS Strong ARDS ≥88% Evidence of harm for targets 97-100% ATS/ESICM/SCCM Conditional Acute coronary syndromes ≥90% Hyperoxia might increase myocardial injury ESC/AHA Low Stroke ≥95% Hypoxia should be avoided because it may amplify ischemic brain damage ESO/EAN Low Sepsis/septic shock 94-98% Oxygen consumption is impaired in the face of adequate oxygen delivery BTS Low Post-cardiac arrest 94-98% Hypoxia is associated with worse outcomes ILCOR Very low COPD: Chronic Obstructive Pulmonary Disease; ARDS: Acute Respiratory Distress Syndrome; BTS: British Thoracic Society; ATS: American Thoracic Society; ESICM: European Society of Intensive Care Medicine; SCCM: Society of Critical Care Medicine; ESC: European Society of Cardiology; AHA: American Heart Association; ESO: European Stroke Organization; EAN: European Academy of Neurology; ILCOR: International Liaison Committee on Resuscitation. [page 76] [Emergency Care Journal 2020; 16:8867] Figure 2. Comparison by role. Non -co mmerc ial us e o nly [Emergency Care Journal 2020; 16:8867] [page 77] of healthcare professionals can affect their oxygen preferences and practices. Interestingly, the vast majority of doctors (74.9%) value PaO2 as the most important parameter of oxygenation and therefore, from the physicians’ point of view, the validity of SaO2 in the emergency setting is being challenged. As previously reported, arterial blood gas confirmation of SaO2 is considered the standard of care by ICU doctors.20 Physicians tend to be more aware of the several limitations of pulse oximetry, e.g. in low perfusion states. Junior doctors consider frequent reassessment of arterial blood gases an essential part of oxygen therapy monitoring in acute patients.21,22 Moreover, in our study the group of resident doctors demonstrated the highest preference for PaO2. We compared PaO2 versus SaO2 as the preferred parameter in the evaluation of oxy- genation among healthcare professionals from different depart- ments. We did not assess the ratio of arterial oxygen partial pres- sure to the fraction of inspired oxygen (PF ratio) as a parameter of oxygenation. The PF ratio represents a reliable clinical indicator of hypoxaemia in the ICU setting, mainly used in the evaluation of ARDS severity as part of the Berlin definition.23 Our survey was designed to involve healthcare professionals of different back- grounds and level of training (e.g. junior doctors). Eventually, the majority of respondents (77.22%) reported to work outside the ICU, and therefore PF ratio might not be relevant to their everyday practice. In our study, it was apparent that healthcare professionals in Greece are now well aware of the potential harm from targeting inappropriately high oxygen saturations in patients with an acute exacerbation of COPD.24 Indeed, 60.94% of the respondents favored an SaO2 of 88-92% and only 3.17% preferred a target ≥96%. On the other hand, we found that acute coronary syndromes trigger a response for high oxygen saturations. The 44.80% of respondents preferred an SaO2 target of 96-100%. This was even more prominent in the group of doctors, despite the fact that recent guidelines raise concerns about association of hyperoxia and increased myocardial injury.13 Classic medical teaching used to prefer the mnemonic MONA (morphine, oxygen, nitrates, aspirin) as the mainstay of acute coronary syndrome management in the emergency setting. Nowadays, there are concerns that this approach might be obsolete and inappropriate.25 A similar approach, warranting high SaO2 targets, was also evident in the current survey for patients in the early period post-cardiac arrest. Looking at the guidelines regarding oxygen therapy in the acutely ill, the quality of evidence is low and recommendations are mainly based on observational data and consensus of experts, with the exception of patients at risk of hypercapnic respiratory failure (e.g. COPD).26 A recent meta-analysis of 25 RCTs concluded that liberal oxygen therapy in sepsis, critical illness, stroke, trauma, myocardial infarction and cardiac arrest, defined as SaO2 range 94- 99%, increased in-hospital mortality without improving other patient-important outcomes.5 Moreover, conservative oxygenation strategy may also be appropriate and feasible in the group of mechanically ventilated ICU patients.27 Despite the emerging evi- dence favoring conservative oxygen therapy, there is a longstand- ing cultural norm among healthcare professionals to promptly pro- vide supplemental oxygen to acutely ill patients, regardless of oxy- gen saturation values at presentation. Our study reflects this kind of liberal oxygen mentality especially among Greek physicians and calls for a change in current practice. The widespread use and popularity of social media platforms such as Facebook, Twitter, LinkedIn among healthcare profession- als offers a great opportunity for online survey research. As previ- ously reported, these free and widely accessible websites can be used to target and recruit specific patient or healthcare professional populations.28,29 In the present online survey we managed to rapid- ly engage our target participants and efficiently collect data with minimal resources. Interestingly, nurses were more eager to partic- ipate in our survey compared to doctors, 59.13% versus 40.87% of respondents respectively. The main limitation of this study is its local character, as it involved a large sample of doctors and nurses from a single European country. Furthermore, the population of the study was somewhat heterogeneous. The respondents came from different type of hospitals and different departments. In addition, the years of clinical practice of each participant were not taken into account. In summary, we detected significant differences in oxygen therapy practices between doctors and nurses working in the Greek healthcare system. In the acutely ill medical patient, nurses showed preference for a more conservative oxygen strategy compared to doctors. Moreover, nurses considered SaO2 the most important parameter of oxygenation in contrast to doctors who preferred PaO2. To the best of our knowledge this is the first study to com- pare doctors’ and nurses’ attitudes towards oxygen therapy in com- mon medical emergencies. Conclusions We report a national survey on healthcare professionals’ self- reported preferences for targeting oxygenation in acute illness. Doctors overall favored higher SaO2 targets, thus a more liberal approach, despite the accumulating evidence of harm in the litera- ture. This might have implications in clinical training and future practice. On the other hand, nurses have chosen a more conserva- tive approach towards oxygen titration. Whether this is the effect of education and good clinical practice or a mere reflection of inde- cision in the absence of a specific medical order, remains unclear and warrants further evaluation. The current study confirmed again the feasibility and reliability of online survey research through social media platforms. Given the local distribution of the survey, our results need to be investigated in other healthcare systems. References 1. Chow CW, Herrera Abreu MT, Suzuki T, et al. Oxidative stress and acute lung injury. Am J Respir Cell Mol Biol 2003;29:427- 31. 2. Asfar P, Singer M, Radermacher P. Understanding the benefits and harms of oxygen therapy. Intensive Care Med 2015;41:1118-21. 3. Martin DS, Grocott MP. Oxygen therapy in critical illness: pre- cise control of arterial oxygenation and permissive hypoxemia. 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