Acute non-invasive ventilation
New guidance from the National Confidential Enquiry into Patient Outcome and Death on supporting patients following the use of non-invasive ventilation to treat conditions.
Non-invasive ventilation (NIV) is support for a patient’s breathing using a mask or similar device, without the need for intubation or a tracheostomy. The most common condition that NIV is used to treat in hospital is chronic obstructive pulmonary disease, the fifth biggest killer in the UK and the second most common reason for hospital admission. A study published in 2000 demonstrated the effectiveness of NIV delivered by nursing staff on UK respiratory wards, reducing mortality from 20% to 10%, when compared to standard care.
In July the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published new recommendations on acute NIV, following a review of the quality of patient care. With the study showing that care was rated as less than good in four out of five cases, major improvements are needed, says NCEPOD. Despite guidelines on recommended staff levels and monitoring of patients, there was wide variance in how services were organised, with supervision of care and patient monitoring commonly inadequate. Organisations regularly reported clinical incidents related to NIV, the report says.
The report lists 21 recommendations designed to improve quality of care. NCEPOD says that in all areas providing acute NIV, there should be a minimum staffing ratio of one nurse to two acute NIV patients, as recommended in the British Thoracic Society guideline. Treatment should be started within a maximum one hour of the blood gas measurement that identified the need for NIV, regardless of the patient’s location.
Every hospital should have a clinical lead for their acute NIV service. There should be a treatment escalation plan in place, before NIV starts. Vital signs should be recorded at least hourly until respiratory acidosis has resolved.
How you can help your patient
It is important to remember that from the patient’s perspective, NIV can be very frightening, especially the first time. It is also crucial to ensure that a person’s initial experience of NIV is good, so they are much less anxious about any subsequent episodes or about using equipment at home. Nurses can play a major role in reassuring patients, helping them to get over their fears. Allow plenty of time to explain what is happening, sitting with your patient until they are feeling more relaxed and confident.
Liz Walker is a respiratory nurse specialist and a member of the Association of Respiratory Nurse Specialists (ARNS)
‘The report highlights some very good points, especially about staffing ratios, education and competences. We need nationally agreed competences and this is an opportunity for major stakeholders, such as ARNS and the British Thoracic Society, to get together and write them. Nurses are integral to getting this right, as they are the ones looking after patients throughout, so they need to know what they’re doing.
‘In the large number of cases where care has been rated as less than good, I think a number of factors are involved. These include staffing levels; where patients are looked after – whether a specialist high care unit or general ward; and how quickly they see a specialist respiratory doctor.
‘Evidence shows that mortality rates are much higher when patients are not looked after by the appropriate number of staff, who have the right experience and competence. Speed is also very important, with treatment sometimes delayed by hours. A "flying squad", where someone goes to the patient and starts them on NIV, staying with them until they are moved, would enable treatment to start much more quickly.’
- Association of Respiratory Nurse Specialists (ARNS)
- British Thoracic Society
- NCEPOD (2017) Inspiring change – a review of the quality of care provided to patients receiving acute non-invasive ventilation
- NICE (2016) Chronic obstructive pulmonary disease in adults