#O2TheFix: Swimming Between The Flags

#O2TheFix: Swim Between the Flags

Oxygen (O2) therapy is a medicine which has profound physiological effects which can both help our patients or cause harm. It requires a prescription, appropriate administration and suitable monitoring. Oxygen must be given with caution and only for patients who need it. Too little or too much oxygen is a risk for patients.

In 2015, the Thoracic Society of Australia and New Zealand (TSANZ) released guidelines for the acute use of oxygen in adults in 2015. These guidelines promote the prescription of oxygen therapy to target a level between a prescribed range of oxygen saturations. For example between 92%-96% which is close to normal biological values.

Historically it has been common practice to administer oxygen regardless of need, and without sufficient monitoring and adjustment. Scientific studies have for a long time suggested that too much oxygen is both unnecessary and harmful. Over the past decade clinical studies have revealed to what extent. For example we know that controlling oxygen in this manner for patients coming to hospital can reduce hospital mortality (deaths) by 58% in all hospital admissions and by 78% in patients with chronic obstructive pulmonary disease (COPD)[1]. Despite this, changing current practice of oxygen administration in the clinical setting is challenging and requires novel and extensive initiatives.

Audits undertaken both within Waitemata DHB and in other hospitals in New Zealand and Australia indicated that oxygen is poorly prescribed and does not meet the recommended guidelines from TSANZ.

What are we trying to achieve?

A group of clinicians at Waitemata DHB wanted to improve patient outcomes and safety by ensuring that patients consistently received:

  • the appropriate oxygen prescription
  • the correct form of delivery device
  • the correct target range for each patient  

They saw a way to do this by adding oxygen prescribing and delivery devices to the organisations current electronic prescribing system (MedChart) as a way of improving oxygen prescribing practices. This included building in safety features and standardised prescriptions. They also used social media to help raise awareness and spread their safety message.

"Swimming between the flags" is a concept which guides health professionals to prescribe oxygen only if required, within an appropriate target oxygen saturation range. It recognises there are potential risks in under and over-oxygenating patients.

What have we done?

Clinicians involved in the initiative included a medical respiratory specialist, respiratory nurse specialists, clinical pharmacists, e-prescribing specialist pharmacists, and nurse educators as well as medical and nursing staff from the intensive care unit. This initiative was supported by the Waitemata DHB Medication Safety Group.

A baseline audit of current practice related to oxygen therapy was completed to understand current compliance.  The Waitemata DHB guidelines for the use of oxygen were updated to align with both national and international guidelines.

Standardised oxygen delivery devices with appropriate saturation ranges were entered into the electronic prescribing system MedChart.

Standardised oxygen rates entered into MedChart

We then launched a campaign in October 2016 called “#O2TheFix”. This campaign focussed on the importance of "swimming between the flags" with the catch phrase "O2 the fix, aim 92-96. If highCO2, aim 88-92" – this refers to the patient’s oxygen saturation levels in their blood.

#O2TheFix Campaign

Did we make a difference?


At baseline results showed:

  • 88% of patients were receiving oxygen without a prescription
  • 12% that did have a prescription many did not have this prescribed in a clinically appropriate manner
  • At baseline, oxygen was prescribed on a paper medication chart

A re-audit six months after the campaign showed:

  • an increase of oxygen prescribing from 12% to 49%  

Audit results of oxygen use at baseline and post-campaign


The group have successfully campaigned and rasied awareness of oxygen and device prescribing, including specified target saturation ranges, thereby improving patient safety throughout the DHB.

#O2TheFix – Swimming Between The Flags was the overall winner at the Waitemata DHB Health Excellence Awards 2017 along category winner for 'Excellence in Clinical Care Award'.  

Where to from here?

The group will continue to monitor compliance to oxygen and device prescribing and spreading their important safety message.

This initiative has been presented to the Thoracic Society of Australia and New Zealand (TSANZ) meeting in Queenstown; it will be presented at the annual conference for the New Zealand Hospital Pharmacists Association.


  1. Chronic obstructive pulmonary disease (COPD) is a lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis. Patients’ with this disease retain carbon dioxide (CO2) so require lower levels of oxygen.
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