Background Treatment Escalation Plans (TEPs) were introduced at the Royal United Hospitals Bath (RUH) in 2013 to help physicians document decisions regarding ceilings of treatment. In implementing a TEP, a patient may be deemed unsuitable for resuscitation and/or Intensive Care Unit (ICU) but remain a potential candidate for ward-based non-invasive ventilation (NIV). However as ward-based NIV is indicated in relatively few respiratory conditions this option should only be available to a small cohort of patients. This study examines how appropriately patients have NIV cited as a ceiling of treatment, using 2002 BTS acute NIV guidelines as a benchmark.
Method We collected data from medical, surgical and geriatric wards at the RUH on three separate days between November 2014 and June 2015. In patients with a TEP who were deemed unsuitable for CPR, we recorded a) the ceiling of treatment decision b) reason for admission and c) co-morbidities. We reviewed how many patients with NIV as a ceiling of treatment had an indication in accordance with BTS guidelines.
Results 658 patient notes were reviewed. 109/658 patients were deemed not suitable for ICU but had NIV as a ceiling of treatment. 64/109 patients (59%) had an indication in accordance with BTS guidelines, while 45/109 patients (41%) were non-compliant. There was variation in compliance between specialties (General Medicine 60% compliant, Elderly Care 54% compliant and Surgery 33% compliant). The Respiratory ward was the most compliant (100%).
Conclusions Whilst NIV can offer significant survival benefits to patients with certain conditions (eg COPD exacerbations, obesity hypoventilation syndrome and chest wall disease) national BTS audits have repeatedly shown that ward-based NIV is often used unsuccessfully outside of these indications. The current study demonstrates that over 40% of patients admitted to our hospital inappropriately have NIV set as their ceiling of treatment, albeit with some variability between wards and specialties. This suggests that further education is required about the potential limitations of NIV, particularly for non-respiratory specialists who often make TEP decisions.
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