Clinical update

New recommendations on acute non-invasive ventilation

National Confidential Enquiry into Patient Outcome and Death calls for major improvements and lists 21 ways to achieve better care, including a minimum staffing ratio, an escalation plan and a clinical lead in every hospital

National Confidential Enquiry into Patient Outcome and Death calls for major improvements and lists 21 ways to achieve better care, including a minimum staffing ratio, an escalation plan and a clinical lead in every hospital


Picture: iStock

Essential facts

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 hospitals 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 in reducing mortality by 10% to 20% compared with standard care.

What’s new

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published new recommendations on acute NIV in July 2017, following a review of the quality of care. The study showed that care was rated as less than good in four out of five cases, and 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.

Key recommendations

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 British Thoracic Society guidelines. Treatment should be started within 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 its acute NIV service. A treatment escalation plan should be in place before NIV starts. Vital signs should be recorded at least hourly until respiratory acidosis has resolved.

How you can help your patient

NIV can be very frightening for patients, especially the first time. It is crucial to ensure that the initial experience of NIV is good so that the patient is less anxious about any subsequent episodes or about using equipment at home. Nurses can play a major role in reassuring patients and helping them to get over their fears. Allow plenty of time to explain what is happening and sit with the patient until they feel more relaxed and confident.

Expert comment

Liz_WalkerLiz 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.

Flying squad

‘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” that could send someone to the patient and start them on NIV, then stay with them until they are moved, would enable treatment to start much more quickly.’ 


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