Less than a third of hospitals are meeting recommended nurse to patient ratios for treating those on non-invasive ventilation (NIV), according to the most in depth investigation into the area to date, which highlighted a range of organisational and clinical failings.
A ratio of one nurse to two NIV patients is recommended by the British Thoracic Society, but the new review suggested that complying with this was the exception rather than the rule in the NHS.
“There was wide variation in both the organisation of acute NIV services and the clinical care provided”
It highlighted concerns about “inadequate” levels of nursing staffing to deliver NIV, “inappropriate” locations in which it was delivered and poor recording on ventilator settings and changes to them.
Acute NIV is being used in an increasingly large number of patients since it is most often employed in treating chronic obstructive pulmonary disease, the second most common reason for admission.
As a result, ensuring that “appropriate treatment is available in our hospitals is of major importance”, said analysts from the National Confidential Enquiry into Patient Outcome and Death.
“Sadly, our study found that this was not always the case. There was wide variation in both the organisation of acute NIV services and the clinical care provided,” said their report – titled Inspiring Change (see PDF attached below).
Their NCEPOD study, which was proposed by the British Thoracic Society, was based on feedback from 162 hospitals, 430 questionnaires from clinicians and 350 sets of case notes.
They found that 48.8% of hospitals – 79 out of the 162 that answered the question on staffing – reported that they had a defined ratio of nurses to NIV patients.
“Organisation of care highlighted concerns in the inadequate levels of nursing staffing to deliver the NIV treatment”
When asked what it was, just 53 hospitals said they had a defined ratio of one nurse to two patients or better, in line with the BTS recommendations.
In 17 of the hospitals, the ratio was one nurse to three or more patients. A further six of the 79 did not provide the data on the ratio they used.
The NCEPOD report highlighted that the BTS recommended that NIV services have trained and experienced staff available to support the service on a 24/7 basis.
“Patients who are treated with acute NIV are seriously ill with complex problems and require enhanced nursing care,” stated the NCEPOD reviewers in their report.
“A staffing ratio of one nurse to two NIV patients for at least the first 24 hours of treatment is recommended,” added the report, which was co-authored by Gemma Ellis, a consultant nurse in adult critical care at the University Hospital of Wales.
“The duration for which this should continue will be determined by each individual patient’s response to ventilation,” the report said.
As well as their concerns around “inadequate levels of nursing staffing” to deliver NIV, the reviewers also criticised other areas of care organisation and provision.
For example, they found that NIV treatment was often delayed due to poor recognition of which patients would benefit from it or the ultimate goal of the treatment.
As a result, they said they found cases where NIV was commenced but where palliative care would have been a more appropriate option.
Even when used appropriately, the NIV treatment delivered was “often felt to be sub-standard or ineffective”, they warned.
“This was demonstrated clinically with inadequate monitoring of vital signs and blood gases and lack of an escalation plan being in place at the start of treatment,” they said.
In their report, they cited the location in which NIV was delivered “being inappropriate” and the application of ventilator settings, and changes, as “often poorly documented or non-existent”.
A key part of the problems with NIV organisation cited in the report surrounded the “wide variation” in where hospitals provided the treatment.
It was delivered in intensive care or specialist respiratory high dependency units in some, but in others it was given on the medical wards, raising concerns with the NCEPOD reviewers.
“Acute non-invasive ventilation is a specialist procedure. Introduction on general wards means that it can be initiated by non-specialists and often junior staff working out of hours,” stated the report.
On a similar theme, the review found staff from a variety of professional groups and at different grades made changes to ventilator settings and took arterial blood gas samples.
“For clinicians, we would like to emphasise the importance of case selection”
More than a half of hospitals had a model of care where ward nurses changed the settings, as well as respiratory specialist nurses and critical care outreach nurses.
In contrast, only around a quarter had a model where ward nurses took arterial blood gas samples, while critical care outreach nurses did so in over half and respiratory nurse specialists in around 40%.
The report warned that, overall, the care of patients in the study was rated as less than good in 80% of the cases that were reviewed by the NCEPOD team.
Clinical care was one of the biggest areas of concern at 34% and a combination of clinical and organisation of care in 27%, it said.
NIV care alone was rated as good in only 27% of patients, but as adequate in 35% and as poor or unacceptable in 23%, said the report.
One important issue is that many hospitals “fail to grasp the size of the problem” regarding NIV, the NCEPOD review concluded.
“Acute NIV usage is all too easily hidden from view due to poor coding,” said the report. “The inaccuracy of clinical coding for NIV is one area that could be so easily fixed at a national level and would support our clinicians and hospital managers in improving patient care.”
Hospitals failing on nurse ratios for non-invasive ventilation
Another one of the main reasons cited for the clinical incidents was “lack of available equipment”, said the reviewers.
Nearly 40% of hospitals reported that, in the previous 12 months, there had been times when they had more patients requiring NIV than their capacity to deliver it.
NCEPOD chair Professor Lesley Regan said: “In order to improve the outcomes for patients receiving acute NIV, NCEPOD is calling for hospitals to appoint local champions to examine and challenge the provision of acute NIV services in their hospital and ensure well designed services with sufficient staff who are competent in both prescribing and treating patients who need NIV.
“For clinicians, we would like to emphasise the importance of case selection, regular patient assessment, specialist involvement and a clear understanding of the clinical factors that influence treatment outcome,” she added.
Dr Mike Davies, from the British Thoracic Society, said the report could “act as a stimulus to improve care for patients requiring NIV”.
“What is most worrying is the high mortality rate of over a third of patients treated with NIV,” he said. “We need a concerted national and local effort across the NHS to raise the profile of this issue and help reduce avoidable deaths.
“We wholeheartedly support the report’s main recommendations which include the need for every hospital to provide NIV in a dedicated clinical area. NIV is a specialist treatment and should be provided by a team that includes a named clinical lead to drive quality improvement and sufficient, trained staff to deliver safe and effective NIV care,” he said.
He added that the British Thoracic Society Society would shortly issue quality standards for NIV for consultation, which would provide commissioners, healthcare professionals and patients with “measurable markers” of good practice in the provision of acute NIV.
“We hope this will provide a practical tool to really lever-up standards of care,” noted Dr Davies.