• Quality of medical care provided to patients who need help to breathe is “often poor”, research finds
  • Less than half of hospitals had defined ratio of nurses to patients as recommended by the British Thoracic Society
  • Report says NHS must make “major improvements” in care for non-invasive ventilation patients

Four out of five patients who need help to breathe in NHS hospitals receive less than good care, a major study published today has found.

The research into non-invasive ventilation care by the National Confidential Enquiry into Patient Outcome and Death has revealed a range of concerns across the health service after reviewing the care for hundreds of patients.

NIV is often used to treat patients with chronic obstructive pulmonary disease, pneumonia and other conditions where they need help breathing.

NCEPOD looked at the care of more than 330 patients across the NHS.

It concluded: “The care of these patients was rated as less than good in four out of five cases. The mortality rate was high; more than one in three patients died. Despite guidelines that recommend staffing levels and arrangements for monitoring patients treated with NIV, there was wide variation in how services were organised. Supervision of care and patient monitoring were commonly inadequate. Case selection for NIV was often inappropriate, and treatment was frequently delayed due to a combination of service organisation and a failure to recognise that NIV was needed.”

It added: “The quality of medical care provided was often poor. This poor care included both non-ventilator treatments and ventilator management which were frequently inappropriate.”

NCEPOD has made 21 recommendations for improving care for NIV patients focusing on improving governance, training and overall quality.

The study found detailed vital signs monitoring of patients on NIV and blood gas analysis as well as the effect of changing ventilator settings were “frequently poorly done or omitted entirely”.

It also raised questions about the governance of NIV use in hospitals, saying: “Organisations regularly reported clinical incidents related to patients receiving NIV. Despite this they frequently did not audit their own practice. In order to improve the outcome from NIV, organisations must act to ensure services are well designed, local leadership is in place and competent staff are available to deliver care. For clinicians, the importance of case selection, regular patient assessment, specialist involvement and the clinical factors that influence outcome needs to be emphasised.”

Findings from the study included:

  • Only 19 per cent of patients received good care.
  • Out of 150 patients who died, only 30 had their care discussed at a morbidity and mortality meeting
  • Forty per cent of hospitals reported instances of having more patients requiring NIV than they had machines available in the past 12 months.
  • Forty-five per cent of hospitals had staff without a defined competency in NIV supervising NIV patients.
  • Just under half of hospitals had a defined ratio of nurses to NIV patients as recommended by the British Thoracic Society.
  • Early warning scores were not used in 47 per cent of cases.
  • In nearly a fifth of cases treatment with NIV was not an appropriate intervention. In this group, 42 out of the 66 patients died.

Non-invasive ventilation

NIV involves a mask fitted to the patient’s face and connected to a ventilator. It can help patients with COPD and other conditions to breathe and improve levels of oxygen in their blood.

A study in 2000 demonstrated the effectiveness of NIV delivered by nursing staff on respiratory wards in the UK. It reduced mortality from 20 per cent to 10 per cent when compared to standard care.

It is recommended that all patients admitted to hospital with COPD with acidotic ventilatory failure should receive NIV delivered by appropriately trained staff in a dedicated setting.