National Patient Safety Alert: Interruption of high flow nasal oxygen during transfer (1 April 2020)

Summary

A National Patient Safety Alert has been issued on the risk of harm from interruption of high flow nasal oxygen (HFNO) during transfer.

Content

This alert relates to the risk of harm caused by the interruption of HFNO to babies, children and adults in acute respiratory failure without hypercapnia during patient transfer. Some HFNO delivery devices have a transport mode, but most require mains power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply (UPS) device.

The alert asks providers to add clear labels to HFNO delivery devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest; and that HFNO in any emergency department or short stay unit must not be started without a plan for how to transfer the patient onwards.

Where a UPS is used, action must be taken on the storage and maintenance of UPS devices to ensure they are ready for use and staff know where to locate them.