Introduction COPD is a leading cause of mortality and morbidity and timely use of NIV improves outcomes. National guidelines recommend early intervention in persisting acidosis however, audit data suggests that many patients receive NIV late and have high mortality compared to the results of RCTs. We aimed to improve the process of care for these patients through the introduction of a prospective proforma, prompting clinicians to follow guideline recommendations about timely intervention.
Methods The proforma included items that prompted: care in medications being given, ABGs being taken and decisions regarding escalation of care and resuscitation status being made. All emergency COPD exacerbations managed with NIV were included in the study. Data were collected prospectively for 7.5 months in seven Acute Trusts in London and Essex. Each site was given real time feedback on their performance on a monthly basis.
Results The proforma was used in 138 acidotic COPD patients managed with NIV. Combined data from all the involved sites demonstrated no significant improvement in door-to-mask times during the study period. Overall only 47% of patients received NIV within 3 h of admission and there was significant variation between individual sites in door-to-mask times (p=0.0007, Abstract P268 table 1). Sites were grouped according to their respiratory on call system. Sites with a 9-5 respiratory on call had the shortest door-to-mask time, both during 9:00–17:00 and out of hours, mean time=203.5 min (SD 259), vs 291.9 min (SD 231.9) for 24 h respiratory on call and 327 min (SD 314.7) for those without a respiratory on call. Patients who were started on NIV in locations outside A&E had longer mean door to-mask-times (135.62 vs 377.44 min).
Conclusion The introduction of a proforma with monthly feedback reports did not improve door-to-mask times. Less than half the patients managed with NIV received this within 3 h. There remains an unacceptable variation in the standard of patient care that may result from different operational practices across hospitals. There is a need to define optimal service delivery to ensure that all patients receive best care regardless of their place of admission.