Editorial: Raising Standards in the Delivery of Acute NIV

 

Non-invasive ventilation (NIV) is now widely used in the hospital setting for not only exacerbations of chronic obstructive pulmonary disease (COPD) but also other causes of acute respiratory failure (ARF). As NIV has become more readily available and the scope of use widened, ongoing assessment of the safety and quality of care provided to patients is vital. On Aug 31, 2017, the European Respiratory Society and American Thoracic Society published recommendations for the clinical application of NIV. The guidelines strongly recommend the use of NIV in acute hypercapnic respiratory failure due to COPD exacerbations and in ARF due to cardiogenic pulmonary oedema, while more muted conditional recommendations were given for other indications including ARF in the context of immunosuppression, post-operative patients, palliative care, and trauma and to facilitate weaning from mechanical ventilation in patients with hypercapnic respiratory failure. Clear guidance on how to select patients in whom to initiate NIV is the first step in improving outcomes for patients, but successful NIV management also relies on appropriate timing, delivery, and monitoring of treatment.

In July, 2017, a report was released by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) that reviewed the quality of care provided to patients receiving acute NIV in the UK. The report was requested after three successive BTS audits (2011–13) showed increases in mortality and substandard outcomes in patients treated with acute NIV when compared with international audit data. The NCEPOD report makes for uncomfortable reading and highlights several areas where quality of care fell short of expectations. Less than half of hospitals had the recommended ratio of nurses to NIV patients (1:2), 45% of hospitals had NIV patients being supervised by staff without the required level of competency, only 29% of patients had an oxygen saturation level within the recommended target range and 42% of patients had some aspect of ventilator management that was found to be inappropriate. The report went on to make 21 formal recommendations needed to make the “major improvements” required. Such improvements included early identification of patients in need of NIV, early initiation of treatment, a robust operational policy for each hospital outlining staffing requirements and protocols for clinical reviews, monitoring, senior supervision, and escalation of care where required, and a process where hospitals should audit NIV services and patient mortality annually.

The NCEPOD report highlights that delivering NIV and assessing a patient’s response is a complex process requiring intensive monitoring and an expert knowledge of ventilator settings and the personalised goals of treatment for each patient. Breakdowns in any one of these steps mean that the efficacy of NIV as a treatment can be compromised. It is frustrating to have an efficacious treatment that cannot meet its true potential due to failures in the delivery of care. To try and address the shortcomings of the NCEPOD report, the BTS published an initial draft of quality standards for NIV for public consultation in August, 2017, with the aim of providing health-care professionals and commissioners with a framework to help to plan future NIV service provision and give benchmarks for quality care. These standards echoed the recommendations from NCEPOD and emphasised the need for careful monitoring and documented escalation planning as well as providing suggested targets to meet—including starting NIV within 2 h of a patient meeting evidence-based criteria for acute NIV and specialist review within 30 min if blood gases show no improvement after initiation of NIV.

These quality standards are a great step towards improving outcomes for patients receiving acute NIV but they also highlight that a high quality acute NIV service requires enough funding to ensure adequate equipment, staffing levels and training, and sufficient intensive-care unit bed availability for escalation of care. At a time when the NHS is already under great strain and the capped expenditure process is asking for savings of £500 millon by April, 2018, meeting these goals pose even more of a challenge. However, insufficient funding should not be used as justification for not striving to improve the provision of acute NIV. Many of the shortfalls in quality of care could be addressed through improved training and well-designed services and patient protocols. These reports also underscore the importance of making changes when areas of concern are discovered. We are doing patients a disservice if delivery of patient care is not regularly reviewed and compared with other hospitals and countries, with the aim of raising standards and improving outcomes.

Courtesy of The Lancet Respiratory Medicine

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