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P133 Acute hypercapnic respiratory failure; application of a novel human factors approach to improve recognition and management
  1. HJ Pick1,
  2. P Cull1,
  3. E Mullaney1,
  4. S Smith1,
  5. N Taylor2,
  6. G Lowrey1
  1. 1Royal Derby Hospital, Derby, UK
  2. 2Hu-Tech Human Factors Ergonomics, London, UK


Aim Acute hypercapnic respiratory failure (AHRF) is a medical emergency.1,2 Data from National COPD Audit Programme identified that median time from admission to Non-Invasive Ventilation (NIV) is 4.1 hours and only 42.7% of patients requiring ventilatory support receive it in under 3 hours. We utilised a novel human factors approach, reviewing AHRF case examples and undertaking multi-disciplinary discussion, to review current systems and develop interventions to improve the recognition and management of AHRF.

Methods Multi-disciplinary workshops were undertaken across emergency medicine, acute medicine, and specialist medicine to discuss case examples of AHRF. Attendees discussed the identification and management of AHRF based on the presented cases and their clinical experience. Output from the workshops and case reviews were analysed and informed the development of a Bow-Tie model that reviewed current systems in AHRF. The model identified barriers which usually facilitate effective management of these patients and threats to barriers which compromise patient care (figure 1) Interventions to address threats were developed and implemented.

Abstract P133 Figure 1

Bow-tie model identifying barriers and threats in the recognition and management of acute hypercapnic respiratory failure.

Outcome/Results Interventions resulting from the multidisciplinary workshops and novel application of Bow-Tie analysis (figure 1) included: automated flag of Results showing AHRF on electronic Results software; AHRF management and referral checklists; multifaceted training of teams in management of AHRF (simulation training, capillary blood gases training, ward based training).

Conclusions The novel application of this human factors approach in a healthcare setting allowed the identification of specific threats and development of interventions to strengthen barriers targeted at improving patient care and reducing harm.


  1. Ahmad N, et al. Acute hypercapnic respiratory failure (AHRF): Looking at long-term mortality, prescription of long-term oxygen therapy and chronic non-invasive ventilation (NIV). Clin Med (Lond)2012;12(2):188.

  2. Kaul S, et al. Non-invasive ventilation (NIV) in the clinical management of acute COPD in 233 UK hospitals: Results from the RCP/BTS 2003 national COPD audit. COPD2009;6(3):171–6.

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