Dr Mark Juniper, Consultant in Respiratory and Intensive Care Medicine at The Great Western Hospital NHS Foundation Trust, recently spoke at an event hosted by ResMed to share his thoughts on the current status of acute NIV services across the UK and how they could be significantly improved.
Mark, who is also Clinical Co-ordinator at the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), was involved in compiling the 2017 report, ‘Inspiring Change’, published by NCEPOD. This provides a review of the quality of care given to those receiving acute non-invasive ventilation (NIV).
The report shows that while most hospitals run ward NIV, there is a wide variation in hospital processes, with many instances of unqualified staff involvement in the delivery of treatment and resulting failures to apply NIV correctly.
Currently one in three patients put on NIV for a COPD exacerbation die. This is clearly not acceptable. ... Change will take time but by adopting the new standards, hospitals can take an important step towards the provision of an efficient and effective NIV service across the UK.
NIV is well-documented as an effective treatment for patients presenting with acute exacerbations of COPD, assisting pulmonary rehabilitation, providing benefits in managing chronic hypercapnic COPD patients, and it can reduce mortality.
The potential of reducing mortality by using NIV is demonstrated by the 2000 study by Plant, Owen and Elliott. This study looked at the role of early use of NIV for acute exacerbations of COPD on general and respiratory wards, and its findings demonstrated the effectiveness of NIV, halving mortality in eligible COPD patients from 20% to 10%. However, in BTS audits of NIV since 2010 (2011, 2012), mortality rates have steadily risen and the 2013 audit showed a mortality rate of 34%.
Furthermore, the BTS audit showed that quality of care was rated good in only 28% of cases, with 49% rated as merely adequate and 24% poor or unacceptable.
The question is where did things go wrong?
A core concern is that complexity of the process has reduced system reliability.
Following the publication of “Inspiring Change’, three tools were developed which address the recommendations highlighted in the report. These tools, published in 2018, provide essential reading for those running acute NIV services.
- Mark Elliott, Essential requirements and clinical skills for successful practice.
- BTS Quality Standards for acute NIV in adults.
- BTS Quality Improvement Tool - Non-Invasive Ventilation.
The Quality Standards include six statements which clearly state both the rationale and quality measures for each, and further define the impact of each of the requirements on service providers, healthcare professionals, commissioners and patients.
- Acute non-invasive ventilation (NIV) should be offered to all patients who meet evidence-based criteria. Hospitals must ensure there is adequate capacity to provide NIV to all eligible patients.
- 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.
- Acute NIV should only be carried out in specified clinical areas designated for the delivery of acute NIV.
- Patients who meet evidence-based criteria for acute NIV should start NIV within 60 min of the blood gas result associated with the clinical decision to provide NIV, and within 120 min of hospital arrival for patients who present acutely.
- All patients should have a documented escalation plan before starting treatment with acute NIV. Clinical progress should be reviewed by a healthcare professional with appropriate training and competence within 4 hours and by a consultant with training and competence in acute NIV within 14 hours of starting acute NIV.
- All patients treated with acute NIV should have blood gas analysis performed within 2 hours of starting acute NIV; failure of these blood gas measurements to improve should trigger specialist healthcare professional review within 30 min.
These six standards go some way to address the over complication of the process where the more steps involved in a process, the greater the opportunity for failure. They focus on having a specialist NIV team with an on-call consultant and a protocol for early referral and fast response.
However, if there is to be a change in direction, it will be important that respiratory professionals work together.
There are examples of units that have adopted the principles of the new approach.
Newcastle operates an 24/7 physiotherapy-led service operated by a dedicated specialist NIV team. An audit of the service between October 2016 and October 2017 demonstrated a mortality rate of 20% (compared with the BTS audit of 34%).
Cambridge University Hospitals operate a dedicated specialist NIV team at Addenbrooke Hospital which uses an early rapid response system, with bedside monitoring and daily review by the specialist team. This has been shown to be effective in the recording of lower mortality rates.
These six standards ... focus on having a specialist NIV team with an on-call consultant and a protocol for early referral and fast response.
The talk concluded with a quote from Henry Ford, “If you always do what you've always done, you'll always get what you've always got.”
The successful services, demonstrate what can be achieved when you make changes based on quality improvement (QI). The examples they provide suggest that there is a need for universal re-evaluation by those involved in delivery of acute NIV in order to improve the service provided, patient outcome and experience, and ultimately to reduce mortality rates.
Currently one in three patients put on NIV for a COPD exacerbation die. This is clearly not acceptable. It is hoped that as the president of BTS in 2019, Mark Elliott will bang the NIV drum. Change will take time but by adopting the new standards, hospitals can take an important step towards the provision of an efficient and effective NIV service across the UK.