The utility and futility of non-invasive ventilation in non-designated areas: can critical care outreach nurses influence practice?

OBJECTIVE

To explore the practice of delivering non-invasive ventilation (NIV) in non-designated areas within a large university teaching hospital by critical care outreach nurses.

METHODS

Local audit was prospectively conducted over a five-month period of all patients commenced on NIV in non-designated areas. The audit was repeated a year later and again four years later.

MAIN OUTCOME MEASURES: Documentation of patient diagnosis and management plan including whether they were suitable for attempted cardiopulmonary resuscitation and endotracheal intubation as per British Thoracic Society guidelines (2002). Patient outcome (to hospital discharge) and arterial blood gas results pre and post commencement of NIV.

RESULTS

115 patients received NIV for the treatment of acute respiratory failure. The mortality rate for the first 2 years data combined (n75) was 57% and attributed to the fact that patients were elderly, acidotic and had diagnoses associated with a poor response to NIV. 86% of patients had a documented resuscitation status and management plan. Resuscitation status (p=0.01) and arterial blood gas improvement within two hours of therapy had a significant effect on patient outcome (p=0.001). Four years later the mortality rate had reduced to 35% possibly due to appropriate patient selection. More patients were deemed suitable for resuscitation, were transferred to designated areas and electively ventilated.

CONCLUSION

Inappropriate use of NIV in non-designated areas is associated with a high mortality. Critical care outreach nurses can play a pivotal role in influencing appropriate patient selection for NIV.