The trials and tribulations of establishing a domiciliary NIV service

The Specialist Respiratory team at University Hospitals Coventry and Warwickshire

Tuesday, February 12, 2019

Establishing a domiciliary non-invasive ventilation (NIV) service comes with challenges but also significant rewards. Joanna Shakespeare and Asad Ali from the Specialist Respiratory team at University Hospitals Coventry and Warwickshire (UHCW) shared their own experience of the process with the audience at a ResMed-hosted event in London on 6th December.


The NIV team is made up of:


pictured, left to right:

  • Joanna Shakespeare, Clinical Service Manager
  • Edward Parkes, Clinical Scientist
  • Dr Abigail Bishopp, Consultant
  • Dr Asad Ali, Consultant


not pictured:

  • Holly Van Ristell, Respiratory Physiotherapist
  • Catherine Gilsenan, Ventilation Nurse
  • Elizabeth Dobson, Clinical Scientist
  • Enya Greer, Associate Physiologist

The specialist unit at UHCW services the whole of Warwickshire through two major hospitals in Coventry and Rugby, a population of over a million people.  In 2006 an inpatient NIV service was set up but putting in place a domiciliary service would take the team on a journey via a NHSE submission before the Coventry and Rugby CCG finally commissioned UHCW to deliver the service in July 2016, with North and South Warwickshire commissioned shortly afterwards.


“We believe that the future for the service is very positive. We plan to integrate the acute and home ventilation teams and to introduce a service pathway. ... We’ve worked very hard to get the service up and running, and we intend to ensure that we continue to enhance what we offer to patients.”
Joanna Shakespeare

There are full service NIV centres in Oxfordshire, Staffordshire and Leicestershire but before the team established their own service there was a very complicated system in place to service neighbouring counties, including Warwickshire.


An example provided was the case of a 36 year-old man from Worcestershire with a six month life expectancy admitted to hospital in Coventry by his Warwickshire GP. On assessment, the patient was found to need urgent NIV. However, because there was no domiciliary unit in place in Warwickshire at this point, he was sent to Leicester for in-patient transfer and received his follow up treatment in Staffordshire. Clearly this system was ineffective and caused considerable upheaval for an end of life patient and his family.


As well as the obvious poor patient experience, inconvenience and discomfort for a critically ill patient which is demonstrated by this case study, the impact of the lack of service in Warwickshire also led to:

  • Bed blocking
  • A breach of NICE guidelines
  • Increased readmission rates
  • Financial implications of reimbursing travel etc



 As part of their submission process the team developed a business case, and this indicated clear benefits of having the domiciliary NIV service in place:


Clinical benefits:

  • Improved patient survival rates
  • Improved quality of life
  • Reduced acute and emergency admissions


Non-clinical benefits:

  • Reduced overall length of stay
  • Reduced admissions costs
  • Reduced transport costs


The service today

 The domiciliary service was finally commissioned in 2016 and the service was made available to patients who met a specific criteria i.e.:


  • Motor neurone disease
  • Slow progressing neuromuscular disease
  • Chest wall disorders
  • Complex OSA/Obesity Hypoventilation
  • COPD (>1 previous admission requiring NIV)


patients treated

in the second full year


The result of the team’s perseverance is that UHCW now offers a one-stop clinic staffed by a respiratory physician, clinical scientist and physiology staff. They provide respiratory investigations same day, same visit, prior to medical review. In addition, they provide machine and equipment review and new set ups during the same visit and a bi-weekly physiology led NIV assessment and initiation clinic.


The team also has a ‘home’ visit service, which may take place in a patient’s home, a care home or hospice, to conduct reviews, treatment initiation and physiology tests, and provide consultations either in the home or by telephone according to the patient’s needs.


The new service embraces technology and Resmed have provided wireless monitoring through their cloud-based wireless patient monitoring AirView device. This allows the team to monitor the patient’s usage and treatment effectiveness when at home. In addition, the team have developed an email alert system so that when any NIV patient is admitted to the hospital, the whole team is alerted.


There is also close collaborative working with the wider patient care team including palliative care and paediatricians when relevant, and there is a hub collaboration with other hospitals and CCGs in the area such as University Hospital North Midlands in Stoke and Glenfield Hospital in Leicester.



In its first six months of offering domiciliary NIV, the service treated 35 patients, which by the second full year had increased to 73 and the current year is on track to exceed this once again.


bed days saved

across six patients


As a result of having the service in place, the team is able to treat patients, like the one described earlier, from the point of determining that NIV is required to the decision that the service is best provided at home for patients who find it difficult to travel, for example end of life patients, through to provision of the equipment and follow up appointments; all in one place.


The evidence of the success of the unit is shown by the reduction in readmission rates and saved bed days. The team has saved 87 bed days across just six patients, saving £22,000 in costs.


An individual success was the weaning of a spinal cord injury patient. The 45 year-old patient fell from a ladder and spent 3.5 months in ITU. He was introduced to NIV following which he was transferred to long term care facility and it is hoped he will be able to move back to his family and live independently at home. The saving for this patient alone is £250K, while the obvious benefit for patient is that he will enjoy a better quality of life living at home.


Next steps

 There are still challenges to overcome including the repatriation of patients and resources, and managing an expanding need, as well as providing education to both patients and staff. However, the team is very optimistic about the what lies ahead.


Jo comments, “We believe that the future for the service is very positive. We plan to integrate the acute and home ventilation teams and to introduce a service pathway. We also intend to collaborate with Intensivists more closely and to get ITU engagement for weaning services, as well as introducing patient forums and advocates, and to participate in research to demonstrate the effectiveness of the service. We’ve worked very hard to get the service up and running, and we intend to ensure that we continue to enhance what we offer to patients.”


Nick Hart, Clinical Director at the Lane Fox Respiratory Unit, who was chairing the event, concluded the presentation by saying, “It is inspiring to see an initiative of this kind. From our own research we know that home NIV can deliver very real benefits to the right patients, preventing hypercapnic-respiratory failure and reducing readmissions. I commend the team at UHCW for their persistence in securing the service.”