BTS publishes latest Adult Non-Invasive Ventilation Audit

The audit analysed data provided from over 150 hospitals, for a total of over 3500 patient records, and looked for adherence to our quality standards in the provision of the service.

Some key findings from the audit are below:

• Inpatient mortality was 26%. It has reduced from 34% in 2013 and represents the first time that mortality has improved since the first BTS audit in 2010.
• Compared to the last audit, an increased proportion of patients treated with acute non-invasive ventilation (NIV) had COPD, the indication with the strongest evidence. We saw a decreased proportion of patients who were treated with NIV despite no clearly documented indication. This suggests improved patient selection in line with the evidence base for NIV.
• 50% of patients treated with NIV started NIV treatment within 60 minutes of the blood gas that defined the need for NIV. Clinician responses indicate a reduced perception of treatment delay in comparison to prior audits.
• Acute NIV was successful in resolving respiratory acidaemia for 76% of patients treated, in comparison to 69% in the last audit (2013).
• Only 74% of organisations reported that they have sufficient capacity to deliver the routine acute NIV service.
• Only 52% of organisations had a nursing lead and 34% had a physiotherapy lead for their acute NIV service.

A lot of the findings of the audit point towards improvement in the treatment provided to patients, most notably, of course the decrease in mortality. Looking at the people treated with NIV, we saw a clear improvement in patient selection, with a greater proportion of patients treated for conditions that have a firm evidence-base for NIV.

Another area of improvement is the timeliness of the intervention, with around 50% of patients given NIV within 60 minutes from when their blood gases analysis indicates a clinical need. In response to the results of our 2013 audit and of the NCEPOD report of 2017, we have developed a set of quality standards for acute NIV, a set of measures that aim to improve the delivery of NIV treatment.

Our audit findings also show that these Quality Standards alongside the earlier national NIV study by NCEPOD have had a positive impact.

However, we have also found areas that need improvement. NIV is largely a multi-disciplinary intervention, requiring expertise from different professionals. An effective service should have clinical NIV leads but also in nursing and physiotherapy, and only a low percentage of hospitals audited had all in place.

Most had a clinical lead (89%) but less than half of them had time allocated to provide service leadership. The Intensive Care Society recommends a nurse to NIV patients ratio of 1:2 within the first 24 hours of treatment, but we found only 64% of hospitals could provide it, with several resorting to 1:4 or even 1:8. Again, most hospitals had a designated area for the provision of NIV, but 39% received NIV elsewhere. We found that for these patients, mortality was significantly worse.

Training for staff in charge of initiating or continuing NIV was provided by almost all hospitals, but with variability in levels of completion, training updates and in keeping a register of trained staff.

To maintain momentum towards a better provision of NIV, we set three national objectives for hospitals to match by the next audit cycle in 2022/23. While we do not make official recommendations beside these improvement targets, we encourage trusts to use the results of this audit plan further improvements to their NIV services, and particularly towards greater compliance with the BTS national quality standards for NIV.

Dr Michael Davies, BTS NIV Audit Lead, said:

“The 2019 NIV audit is hugely encouraging, we have seen many areas of clear improvement in the last few years. However, there is still much to be done and it remains the case that there are substantial institutional variations in outcome. NIV is a multidisciplinary effort and this is not yet reflected in trust leadership roles, also, some organisations lack the infrastructure to provide effective NIV services.

“Instead of individual recommendations on each area audited, we decided to set three broader national improvement targets, to serve as a framework to guide the improvement needed. Matching them will require improvements in most of the areas found underperforming, and I am confident that if organisations will strive to match these targets, we’ll see further improvement in patient outcomes”

The three national objectives are:

• Improve patient selection for NIV, evidenced by reducing the proportion of patients who start NIV in the absence of a clearly documented evidence-based indication (current audit = 13%: target <10%).
• Increase the proportion of patients who start NIV within 60 minutes of the blood gas that defines its need (current 50%: target >60%).
• Increase the proportion of NIV services that have a named nursing lead and/or physiotherapy lead with time allocated to provide service leadership (current 69%: target >90%).