An audit of Non-invasive ventilation (NIV) in practice and introduction of an integrated care pathway for the management of acute ventilatory failure in an Irish Hospital.

Background: NIV is frequently prescribed, and management undertaken by non-specialist medical non-consultant hospital doctors (NCHDs) on general medical wards. This is a practice that is mirrored throughout many Irish hospitals accepting acute admissions. In this context, we sought to review the quality and safety of NIV management at our institution, and develop a pathway to improve early management of patients requiring NIV. Methods: During November 2016, we performed a retrospective audit of 26 patients started on NIV that month. Results: 15/26 (58%) had inappropriate adjustments made to NIV settings. 15/26 (58%) had no respiratory input during the first 24 hours following commencement of NIV. Intervention A three-pronged NIV initiative was undertaken prior to repeat audit: 1. A Beaumont NIV pathway: a four-page card document incorporating instructions for initiating and managing NIV, a prescription, observation chart and safety checklist. 2. Interactive education sessions: for medical and nursing staff delivered by a specialist NIV team. 3. All patients commenced on NIV were reviewed by a specialist NIV team. Results of re-audit Following pathway introduction, we observed improved appropriate decision making (72% vs 42%), 35% reduction in the total number of arterial blood gases and reduction in LOS by 7.7days (35%). 92% had respiratory input within 24 hours of commencement of NIV. Conclusion: National audits have repeatedly raised concerns that expected patient benefit from NIV is not being received. The Beaumont NIV care pathway is a sustainable initiative that improves quality and safety of NIV management.