FICM Comments on the NCEPOD Acute Non-Invasive Ventilation: Inspiring Change report

13 July 2017

FICM welcome the release of the NCEPOD report on Acute Non-Invasive Ventilation and Dr John Butler, FICM representative, has prepared the following summary of the report. 

Inspiring Change: A review of the quality of care provided to patients receiving acute non-invasive ventilation.

NCEPOD Report 2017

The Faculty of Intensive Care Medicine welcomes this report from NCEPOD examining the use of Non-Invasive ventilation (NIV) in acute hospital settings. The NCEPOD investigators found a number of important lessons that should be learned from a high proportion of the clinical cases reviewed. The report makes a series of important recommendations regarding the provision of NIV within hospitals which have important implications for Intensive Care medicine. 

The report focuses on the use of NIV in acute clinical areas with the aim of improving care for patients needing this intervention. It was proposed by the British Thoracic Society (BTS) in response to a series of recent national NIV audits demonstrating an increase in hospital mortality rates.

In conclusion, the study found wide variation in both the clinical care and the organisation of acute NIV services provided. Reviewers found that NIV treatment was often delayed due to a failure of clinicians to recognise which patients would benefit from NIV. Furthermore, even when used appropriately, the NIV treatment delivered was often felt to be sub-standard or ineffective. Monitoring was frequently inadequate and on many occasions, there was no escalation plan documented in the medical notes. When considering the organisation of care the reviewers highlighted concerns in the inadequate levels of nursing staffing to deliver NIV treatment, the location of NIV delivery was often inappropriate and the application and subsequent alteration of the ventilator settings was often poorly documented.

Overall the care of patients was rated as less than good in 80% of cases reviewed with clinical care being one of the biggest areas of concern. Fewer than half of the hospitals reported that they audited their own practice, with 40% reporting that in the previous 12 months there had been times when they had more patients requiring NIV than their capacity to deliver it.

In response to the findings of the study NCEPOD makes a number of principal recommendations. These include having a clinical lead for NIV in all hospitals, adopting a standard for starting NIV when indicated within a time period of one hour regardless of the patient’s location, having a detailed operational policy for the use of NIV in all hospitals and mandating the use of a treatment escalation plan for all patients having NIV which must be place prior to starting treatment. Further recommendations relate to the ongoing care of the patient where all patients must be discussed with a clinician competent in NIV at the time of starting the treatment and must have their vital signs recorded at least hourly until the respiratory acidosis has resolved.  Finally, the report also states that acute NIV mortality rates and quality should be monitored by all hospitals and reported at Board level on a regular basis.

The NCEPOD findings are based on this comprehensive study into the current practice of acute NIV services. The recommendations are far reaching and have implications for the speciality of Intensive Care medicine as well as many other areas of the acute hospital. By adopting and implementing these recommendations we will undoubtedly see significant improvements in the quality of care provided to these patients in the future. 

The full NCEPOD report and its summary can be found here www.ncepod.org.uk/2017niv.html