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PACU - Oxygen Titration - Adult [4]

PACU - Oxygen Titration - Adult [4] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number:   4 
Delegation Protocol Title: 
PACU Oxygen Titration ‐ Adult 
Delegation Protocol Applies To: 
University Hospital Inpatient PACU, Outpatient Surgery Center PACU, Ambulatory Procedure Center/GI 
Target Patient Population: 
Post‐Procedure/Surgical – Adult 
Delegation Protocol Champion: 
Kenneth Van Dyke, MD – Anesthesia 
Delegation Protocol Reviewers: 
Kris Ostrander, RT – Respiratory Therapy 
Lisa Koeppel, RN – PACU Supervisor 
Responsible Department: 
Department of Surgery ‐ Surgical Services 
Purpose Statement: 
This delegation protocol delegates authority from the ordering provider to Registered Nurses (RNs) or 
Respiratory Therapists (RTs) to titrate a patient’s oxygen and/or change the oxygen delivery device 
without additional orders from the ordering provider. 
Who May Carry Out This Delegation Protocol: 
Registered Nurses (RNs) and Respiratory Therapists (RTs) trained in the use of this delegation protocol. 
Advanced Practice Nurse Prescribers, Physician Assistants and Nurse Midwives may not delegate medical 
authority. Orders may be pended and routed for signature to these individuals but may not be implemented 
until signed by the provider. 
Guidelines for Implementation: 
1. Ordering provider selects order to “Initiate Adult PACU Oxygen Titration Protocol”, which will have
the following required questions:
1.1. Starting oxygen delivery device
1.2. SpO2 goal
Provider will also indicate minimum Liter flow, when applicable (i.e. Patient on home oxygen; Specific
end date is indicated)
2. RN and/or RT will follow algorithm beginning with ordered delivery device.
3. The Adult PACU Oxygen Titration Protocol will be discontinued on transfer from PACU to an inpatient floor.
Order Mode: Protocol/Policy, Without Cosign 
References: 
1. AARC Clinical Practice Guideline. Oxygen Therapy for Adults in the Acute Care Facility. 2002 Revision and
Update. http://www.rcjournal.com/cpgs/otachcpg‐update.html
Collateral Documents: 
UW Health PACU Oxygen Titration – Adult ‐ Algorithm 
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org



Approved By: 
UWHC Respiratory Care Committee: December 2014; *January 2017 
UWHC Anesthesia Clinical Practice Committee: December 2014; *January 2017 
UWHC Pharmacy and Therapeutics Committee: March 2015; *January 2017 
UWHC Medical Board: March 2015; *January 2017 
UW Health Chief Medical Officer: March 2015; January 2017 
 
Effective Date: January 2017 
Scheduled for Review: January 2020 
 
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Oxygen
Deliver y Device
pe r physician
order ?
Pl ace on
Nasal Cannu la
at 2-6 L/m
Sp O2
maintained pe r
physician
order ?
Sp O2
maintained pe r
physician
order ?
R eturn to previous
O2 setting /device
th at achie ved
orde red go al SpO2
No
We an NC by 1-2 L/m
with each set of vitals to
ro om air maintaining
SpO2 per physicia n
order or to order ed L/m
per physician orde r
Yes
Sp O2
maintained pe r
physician
order ?
Le ave on oxyg en per
physician order or
attempt to wean to
roo m air and monit or
for 15 minu tes
Yes
S p O2 mainta ine d per
physician order after
monitoring for 15
minutes?
OxyMASK
Nasal
Cannu la
Monitor SpO2 with
vital signs
UW Health PACU Oxygen Titration - Adult
Algorithm
No
No
SpO2
mainta ine d per
physician
orde r?
Adjust OxyMASK wit h each
set of vitals maint aining
Sp O2 per ph ysician or der
aft er monitor ing for 15
minutes
No
S p O2 mainta ine d per
physician order after
monitoring for 15 minutes?
Monitor SpO2 with
vital signs
Ye s
NOTE: Anytime a patient is
exhibiting decreasing
oxygenation,
deeper than expected level of
consciousness, and/or obstructive
sleep apnea, the patient should
be assessed by Anesthesia for
hypoventilation as a cause of
their hypoxemia.
NOTE: Anytime a patient is exhibiting decreasing oxygenation,
deeper than expected level of consciousness, and/or obstructive
sleep apnea, the patient should be assessed by Anesthesia for
hypoventilation as a cause of their hypoxemia.
Ye s
Assessment by
Anesthesia for
hypoventilation.
1 LPM 24-27%
2 LPM 27-32%
3 LPM 30- 60%
4 LPM 33-65%
5 LPM 36- 69%
7 LPM 48- 80%
10 LPM 53-85%
12 LPM 57- 89%
> 12 LPM 60- 90%
Plac e on Ox y MA SK:
1 LPM 24-27%
2 LPM 27-32%
3 LPM 30- 60%
4 LPM 33-65%
5 LPM 36- 69%
7 LPM 48- 80%
10 LPM 53-85%
12 LPM 57- 89%
> 12 LPM 60- 90%
Plac e on Ox y MA SK:
NO
Decre ase d mental
sta tus, decreased
oxyge nation, deep er
th an expected level of
con sciousness, an d/or
obstructive sleep
apnea?
No
Yes
No
D ecr eased men tal statu s,
de cr eased oxyg enation, dee per
than expected level of
consciousness, and/ or obstructive
slee p apnea ?
Assess ment by
Anesthesia for
hypoventila tion.
Yes
No
No
Yes
Begin wean ing or
follow sur geon/
anesthesia
orders
Yes
Begin
weaning or
fo llow
sur geon/
an esth esia
orde rs
Last reviewed/revised: 01/2017
Contact CCKM for revisions.
COPD – Adult – Inpatient/
Ambulatory Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org