NCEPOD and BTS Acute NIV

Transcription

1 NCEPOD and BTS Acute NIV Key points by Dr Lisa Vincent-Smith and Iain Wheatley Nurse Consultant BTS NIV Quality Standards (draft consultations Sept 17)

2 Case study 1 An elderly patient was admitted with an exacerbation of COPD. A blood gas sample in the emergency dept showed a ph of 7.28 and CO2 of 8.7kPa. The patient was referred for admission and reviewed by the medical registrar three hours later. The need for NIV was identified but the patient waited a further 4 hours for a bed on the respiratory ward. NIV was eventually started 8 hours after the blood gas revealed acute hypercapnic respiratory failure. The patient improved with NIV treatment and was discharged five days later. The reviewers thought that delay was caused by both the clinical assessment and the local arrangements for NIV provision. Either NIV should have been started in the emergency dept, or a rapid transfer to the NIV unit should have been facilitated. Referrals take time Medical reviews can be delayed by other pressures. Patient flow, beds, delays. Treatment delays as a consequence of everything else. Length of stay may be increased. Further complications due to Hospital stay? 2

3 Swiss cheese model of causation Some holes due to active failures Patients with Type 2 Resp failure Referral delay Review delayed Consequences Treatment delay Bed availability delay Successive layers of organisational and service delivery problem System defences

4 NIV location 4

5 Case study 2 A patient with an exacerbation of COPD, was admitted to the acute respiratory unit with a respiratory rate of 28 and a CO2 9.4kPa, ph They were started promptly on NIV and slowly improved. Ventilation was continued for four days and the patient was discharged home after a week. The reviewers commented that the records contained a welldesigned NIV observations chart. Despite the good outcome, it was difficult to comment on the quality of NIV treatment as the chart for monitoring vital signs and ventilator settings was poorly completed. Good documentation is paramount. The study found. 31.3% Without an NIV prescription form. 16.6% without an NIV specific obs chart % did not have ventilator settings adequately documented.. 5

6 Ventilator management In 20% of cases the ventilator did not have appropriate settings!!!!!! In 14.2% of cases reviewers considered the grade of clinician as inappropriate in adjusting the ventilator settings.

7 Case study 3 An elderly patient with COPD presented to hospital with breathing difficulty and drowsiness. Blood gas analysis confirmed severe respiratory acidosis. Acute NIV was commenced promptly at an inspiratory pressure of 12cmH2O. NIV was delivered for three days with a maximum inspiratory pressure of 14cmH2O. The patient was reviewed several times daily by junior medical staff. The patient remained tachypnoeic, drowsy and acidotic. The reviewers thought that a higher inspiratory pressure should have been used and more senior review would have resulted in better NIV management. Reviewers considered that there was room for improvement in decision making in ventilator management in 60.4% of cases. 7

8 Clinical response to NIV 8

9 Mortality: summary 9

10 Summary Effective NIV care is more complex than it appears In 4 out 5 cases reviewed, care was rated as less than good Wide organisational variation (staffing and monitoring) Case selection often inappropriate Treatment frequently delayed (service organisation, poor recognition) Ventilator and non-ventilator management often poor 10

11 NCEPOD have 21 Recommendations Right Care, Right place, Right time

12 What you need to know quality standards Quality Statement 1 Acute non-invasive ventilation (NIV) should only be carried out in specified clinical areas designated for the delivery of NIV. Quality Statement 2 All staff who prescribe, initiate, or make changes to acute NIV treatment should have evidence of training and maintenance of competencies appropriate for their role. For some services, practical application of NIV and adjustment of ventilator settings are not within the remit of the on-call medical staff. Nevertheless, clinical responsibility requires a clear understanding of physiological principles, the evidence supporting the use of NIV, and decision- making in non-responders. Doctors at ST3+ grade usually represent the first line in clinical decision- making for patients treated with NIV; when required, training should be provided within induction for all doctors involved (including FY grades). Quality Statement 3 Acute NIV should be offered to all patients who meet evidence-based criteria on presentation. Quality statement 4 - Patients who meet evidence-based criteria for acute NIV on admission should start NIV within 120 minutes of hospital arrival. In patients who develop acute hypercapnic respiratory failure (AHRF) after admission, NIV should be commenced within 120 minutes of the first blood gas showing AHRF. Quality Statement 5 All patients treated with acute NIV should have blood gas analysis performed at one and four hours after initiation; failure of these blood gas measurements to improve should trigger specialist review within 30 minutes. Quality statement 6 All patients treated with acute NIV should have a timely and ongoing medical review and a documented escalation plan.

13 References 1. British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group (2016) The British Thoracic Society and Intensive Care Society Guideline for the ventilatory management of acute hypercapnic respiratory failure. (accessed 21 August 2017) 2.Juniper MC, Ellis G, Smith NCE, Protopapa KL, Mason M (2017) Inspiring change: A review of the quality of care provided to patients receiving acute non-invasive ventilation. National Confidential Enquiry into Patient Outcome and Death, London 3. Davies M (2013) British Thoracic Society NIV Audit 2013 (national audit period 1 February 31 March 2013). (accessed 21 August 2017)