CLINICAL GOVERNANCE

The report by the Royal College of Physicians (RCP) Working Party looked at the interface between acute medicine and critical care and highlighted the fact that the standard of care received by acutely ill inpatients in the UK has been shown to be suboptimal in a number of recent surveys and publications.¹ In a confidential inquiry into quality of care before admission to the ICU,⁴ two external reviewers assessed the quality of care—especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing and circulation, oxygen therapy and monitoring—in 100 consecutive admissions to two UK ICUs. Twenty patients were deemed by both to have been well managed and 54 to have received suboptimal management, with disagreement about the remainder. Case mix and severity were similar between the groups, but ICU mortality was worse in those who both reviewers agreed received suboptimal care. Admission to the ICU was considered late in 37 patients in the suboptimal group. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.

In another UK study⁵ of patients either dying unexpectedly on a general ward or requiring admission to the ICU during a 6 month period, 317 of the 477 hospital deaths occurred on the general wards of which 20 (6%) followed failed attempts at resuscitation. Thirteen of these unexpected deaths were considered potentially avoidable: gradual deterioration was observed in physiological and/or biochemical variables, but appropriate action was not taken. During the same period 86 hospital inpatients were admitted on 98 occasions to the ICU, 31 of whom received suboptimal care before the ICU admission either because of non-recognition of (the severity of) the problem or inappropriate treatment. Mortality rates were significantly higher in these patients than in well managed patients in both the ICU (52% v 35%) and hospital (65% v 42%), p<0.0001. The authors concluded that patients with obvious clinical indicators of acute deterioration can be overlooked or poorly managed on the ward.

In a study from the USA⁶ the records of consecutive inpatients who had a cardiac arrest over a 20 month period were reviewed. There were 150 cardiac arrests on the medical wards with a hospital mortality rate of 91%. In 99 cases a nurse or physician had documented deterioration in the patient’s condition within 6 hours of the cardiac arrest. Common findings included failure of the nurse to notify a physician of a deterioration in the patient’s mental status or failure of the physician to obtain or interpret an arterial blood gas measurement in the setting of respiratory distress. Cardiac arrests were more common in patients discharged from the ICU. Schein et al⁷ reported a similar picture with 84% of inpatient cardiac arrests having documented deterioration within 8 hours of the event. There is therefore a clear need to improve the quality of care afforded to patients with acute non-cardiac medical conditions.

There are a number of solutions,⁸ including better education of medical and nursing staff and more senior input into the assessment of patients at an early stage in the admission. ICU outreach teams are strongly recommended to avert admissions by identifying patients who are deteriorating and either helping to prevent admission or ensuring that admission to a critical care bed happens in a timely manner to ensure best outcome.⁹ This presupposes that such patients are brought to the attention of the team and this can be helped by the use of early warning scores.¹⁰ The team needs to be available 24 hours per day. The RCP Working Party recommended that appropriate facilities for provision of level 2 care (see box 1) to medical patients be available. Ideally this should be in close proximity to the level 3 facility and suggests the need for a unit for medical patients, of whom a significant proportion will be those with respiratory disease.

NON-INVASIVE VENTILATION

There is now a robust evidence base^11,12 for the use of non-invasive ventilation (NIV) in patients with mild (pH 7.31–7.35),¹³ moderate (pH 7.25–7.30),^14–17 and severe (pH <7.25)¹⁸ acidotic exacerbations of chronic obstructive pulmonary disease (COPD).¹¹ It is best instituted “early” before ventilatory support is definitely needed but, even when the patient appears to warrant intubation and mechanical ventilation, there is much to be gained and little to be lost by a trial of NIV.¹⁸ NIV has also been used in patients with hypoxaemic respiratory failure resulting from a variety of different conditions.^19–22 It has been shown to be both more effective and cheaper than intubation and ventilation on the ICU²³ and conventional treatment on general wards.²⁴ It is certainly feasible outside the ICU.¹³

A review of adult critical care services in the UK published by the Department of Health⁹ recognised that NIV was one of a number of clinical areas impacting upon the level of critical care provision that required additional evaluation. In response the NHS Modernisation Agency Critical Care Team assembled a multiprofessional working group to discuss the issues relating to current practice and the resources needed to deliver a service. Their report and an Executive Summary were published in April 2002² and are available at www.criticalcare.nhs.uk. A key recommendation was that “an NIV service be established in each acute trust for the management of patients with acute respiratory failure . . ..”. A number of further recommendations were made including that NIV should be available continuously, appropriately supported by nursing and allied health professional staff, equipped to standards specified by the British Thoracic Society²⁵ with data collection and audit facilities and a training facility for all junior medical, nursing, and allied health professional staff.

Acute NIV has grown out of home ventilation and the technology necessary to deliver it is easily portable. It could therefore be argued that it is easy to take the equipment to the patient and there is no need to have a specialist unit with NIV being possible for all patients in any clinical area. However, the evidence does not support this approach for the generality of patients needing NIV. In a study by Plant et al,¹³ while it was clear that NIV was feasible on a standard general ward with the usual staffing complement, subgroup analysis suggested that the outcome for those with a pH of <7.30 using a simple ventilator according to protocol was not as good as the results seen in patients with similar illness severity managed in a higher dependency setting. There is much more to NIV than the provision of the necessary hardware and there are many advantages to concentrating the NIV service in one location. Foremost among these is the development of the appropriate expertise, particularly among the nursing staff. Whether nurses are the primary deliverers of NIV or whether another professional group such as physiotherapists or technicians takes the main role, the nurses must be familiar with it because they are the only healthcare professionals who are with the patient 24 hours per day. They must be both confident about the technique and recognise when there are problems, particularly of a technical nature. Continued use of skills once learnt is important in maintaining them, and this will be facilitated by concentrating all the NIV in one area. Plant et al²⁶ showed that if all patients needing NIV shortly after admission to an average district hospital with an acute exacerbation of COPD were managed in two areas, the staff would treat ≤1 patients per month 20% of the time, whereas if it was all delivered in one mixed sex location this reduced to 2%. NIV is used for many other conditions, but patients with an acute exacerbation of COPD are likely to remain the largest group. A single location also facilitates the purchase and use of appropriate monitoring equipment and storage of both ventilators and consumables.

One further approach to consider is that of an NIV team, perhaps led by a nurse consultant, which does indeed take the technology to the patient. This is in keeping with the philosophy behind comprehensive critical care—namely, of a service rather than a place—but it is difficult and expensive to provide such a service 24 hours per day throughout the year. Because the nurse primarily responsible for the bedside care of the patient is unlikely to be familiar with NIV or to gain much experience of it over time, a lot of “hands on” support will be required on a “one to one” basis. It may be difficult for the team if there are a number of patients receiving NIV dispersed around the hospital. In practice most of the time is needed at initiation of NIV^13,15,27 and, once patients are established, they will just need a watching brief and regular review, but help should be readily available if there are problems.

The exact model will vary from hospital to hospital, but there is now a clear requirement to provide an acute NIV service² in all hospitals admitting emergency medical patients and to improve the standard of care for patients with acute severe medical conditions generally.¹ These requirements may be best met by a general medical or multispecialty high dependency unit (HDU). However, in a recent survey only 26% of 190 general hospitals with an ICU had an HDU²⁸; the proportion of beds allocated for medical patients was not stated. Anecdotal evidence suggests that there has been a considerable expansion in HDU facilities in the last 2–3 years, but there are no firm data on this. Most of the extra provision has been for surgical patients, driven by cancelled operations because of the lack of ICU bed and waiting list targets. Physicians as a group should certainly be pressing for more level 2 facilities for their patients. However, if these are not forthcoming, the need to improve the standard of care for patients with acute respiratory disease and to provide an NIV service could be achieved in respiratory medicine at a relatively small extra cost compared with many other critical care initiatives.

The experience of NIV in Continental European and North American ICUs suggests that a nurse to patient ratio of 1:3 or 4 is satisfactory, which compares favourably in economic terms with a classical UK HDU in which one nurse is recommended for two patients. Designating part—say, one bay—of a larger specialist ward as a mixed sex “acute respiratory care unit” would provide a focus for NIV, as well as the care of level 1 and 2 patients with acute severe respiratory disease. In such a unit staff can be used flexibly and there is no need for major and expensive building works. It is largely an administrative change, with some extra staffing resource and improved monitoring. The patients are already being cared for within the medical (usually) bed base; instead of being dispersed they are now in one location. The beds must be considered in the same light as coronary care and other higher dependency beds in terms of bed management to ensure that the patients who need acute respiratory care are managed in the right environment. It should no longer be acceptable—even at times of great pressure when medicine extends outside its bed base—for acute admissions with physiological compromise due to respiratory or any other organ failure to be managed at the end of a non-acute surgical ward.

A further advantage of such units is that they can allow earlier discharge of some patients with respiratory disease from level 3 beds. Training and education are vital,^1,25 and junior medical staff should spend some time in critical care areas as part of their general professional training.^1,2,25 Respiratory physicians must ensure that all junior medical and nursing staff are adequately trained in the management of acute severe respiratory disease. Some consultants who were appointed before NIV became available may need training in this specific area. In the future the training of more physicians with dual accreditation in respiratory medicine and critical care is desirable.^29,30 The requirement to provide an acute 24 hour per day NIV service is a major driver to improve the standard of care for all patients with acute severe respiratory disease. The development of acute respiratory care units, either integrated into a more general HDU or as part of an existing respiratory ward, is a logical way forward. Such units should not function in isolation and clear protocols and coordination with intensive care units are vital.