The British Thoracic Society (BTS) has published 6 new quality standards for acute non-invasive ventilation (NIV) in adults. The standards follow the recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD) which highlighted a mortality rate of over a third for patients receiving NIV.
The BTS recommends that acute NIV should be offered to all patients who meet evidence-based criteria. Poor performance status alone is not an exclusion criterion and “therapeutic nihilism” should be avoided, it says. The society says failure to provide acute NIV when indicated is an omission of care and should be investigated as a serious incident if such decisions are believed to have caused unexpected or avoidable death.
Staff who prescribe, initiate or make changes to acute NIV should have evidence of training and competencies. The NCEPOD found that 45% of hospitals permitted staff without competency to directly supervise the care of patients receiving NIV.
The society also advises that acute NIV should only be carried out in specified clinical areas and senior healthcare professionals should work with operational managers to ensure that their NIV service meets BTS criteria.
Patients should start NIV within 60 minutes of blood gas results and within 120 minutes of hospital arrival for patients who present acutely. All patients should have a documented escalation plan before starting acute NIV and progress should be reviewed by an appropriately-trained healthcare professional within 4 hours and by an appropriately-trained consultant within 14 hours of initiation. Failure to demonstrate at least partial physiological improvement after 2 hours of therapy should prompt consideration of invasive ventilation, the BTS advises.
The NCEPOD found that blood gas sampling was too infrequent for 32% of patients receiving NIV. The new standards recommend blood gas analysis within 2 hours of treatment initiation, with additional sampling at 4 hours and in the event of clinical deterioration.