Non-Invasive Ventilation (NIV) and Continuous Positive Airways Pressure (CPAP) in Adults
Type:
Clinical Guidelines
Register No: Status:
10061 Public
Developed in response to: Contributes to CQC Outcome
Requirement for an NIV and CPAP service Outcome 4
Consulted With Dr Kevin Kiff Hilary Bowring Anne Powell Professionally Approved By Dr Keith Hattotuwa Version Number Issuing Directorate Ratified by: Ratified on: Executive Board Date Implementation Date Next Review Date Author/Contact for Information Policy to be followed by (target staff) Distribution Method Related Trust Policies (to be read in conjunction with) Document Review History Version No 1.0 2.0 3.0 3.1 3.2
Post/Committee/Group Consultant Anaesthesia and Intensive Care Lead Nurse, Critical Care. Lead nurse, Interim Head of Nursing,Emergency medicine. Consultant Respiratory Physician,
Date July 2013 July 2013 July 2013 July 2013
3.2 Medicine & Emergency Care Document Ratification Group 28th November 2014 February 2013 2nd December 2013 November 2016 Author Mandy Lewis updated by Lisa savage NIV Nurse Facilitator Nursing, therapy services & medical staff using & supporting NIV Infection Prevention Policies
Reviewed by Mandy Lewis, NIV Nurse Facilitator Lisa Savage Mandy Lewis Lisa Savage paras 5.7-5.11 6.5 Lisa Savage paras 5.1-11 5.15 5.20
Active Date July 2011 July 2013 November 2013 September 2014 November 2015
Contents 1.
Purpose
2.
Definition
3.
Scope of the policy
4.
Staff Training
5.
Policy
6.
Equipment
7.
Medical Records
8.
Equality and Diversity
9.
Infection Prevention
10.
Audit
11.
Communication & Implementation
12.
References
Appendix 1
NIV Referral Guidelines (BTS)
Appendix 2
Initiating NIV/BiPAP Therapy tool (BTS)
Appendix 3
Initiating CPAP Therapy tool (BTS)
Appendix 4
Patient Audit Proforma
Appendix 5
NIV Prescription Chart
Appendix 6
NIV Consumables
Appendix 7
NIV MEHST Acute referral flow chart
Appendix 8
NIV Physio Call Out
1.0
Purpose
1.1
This policy outlines the expected standard of care for all adult patients (over the age of 16 years) receiving Non – Invasive Ventilation (NIV) and Continuous Positive Airways Pressure (CPAP) across Mid Essex Hospital Services NHS Trust. Designated areas for NIV are A&E Resus GHDU ITU and Felsted Ward.
2.0
Definitions
2.1
Non Invasive Ventilation – Ventilation using a mask on the face to deliver set flows of air under pressure. An inspiratory and, expiratory pressure is set with pause to support a Patients’ respiratory cycle. It does not require invasive procedures to achieve expected outcomes.
2.2
BiPAP (Bi Level Positive Airways Pressure) – This is non-invasive ventilation delivered via a mask using a two level system of alternating pressures. This definition may only be used in conjunction with the use of Phillips Ventilators.
2.3
CPAP (Continuous Positive Airways Pressure) – is the use of positive airway pressure applied throughout the respiratory cycle, delivered to the spontaneously breathing patient for therapeutic reasons.
3.0
Scope of the Policy
3.1
This policy applies to all adult patients admitted to the Trust. Children are excluded.
3.2
All Healthcare Professionals working within the Trust undertaking NIV or CPAP are expected to work within this policy. This includes all Medical Staff, all Registered Nurses, Healthcare Assistants (HCA), Student Nurses, Therapy Services and Clinical Technicians.
4.0
Staff Training
4.1
All staff undertaking NIV and CPAP will attend a study session run by NIV Facilitator.
4.2
The NIV Nurse Facilitator will provide continued education; support and advice.
4.3
All staff undertaking NIV and CPAP will complete a Competency Framework document. This will be signed off by the NIV Nurse Facilitator or Band 6/7 competent with NIV in their clinical area.
4.4
All staff will complete a C.N.S.T. self assessment statement following training for the Phillips Focus and V60 Ventilators. (according to their area of Practice see 6.6.)
5.0
Policy
5.0
Designated areas for NIV are A&E Resus, ITU, GHDU and Felsted Ward. Patients must be identified as being suitable for NIV/CPAP using the NIV Referral Guidelines tool. Patients will either require CPAP or NIV (BiPAP) (Appendix 1). Patients identified for Acute CPAP due to Type 1 Respiratory failure need to go to ITU or GHDU.
5.1
NIV can be Registrar to Registrar referral. Patients identified for NIV or CPAP in A&E refer to the ITU team if for escalation and in extremis. All other Patients to Medical team Registrar or Consultant first.
5.2
If a Patient is for escalation to ITU, the ITU consultant needs to be made aware of this as soon as possible by the Medical team, as a Registrar/Consultant Registrar/Consultant referral.
5.3
NIV must be started for the patient as detailed in the Initiating NIV/ BiPAP Therapy tool (Appendix 2).
5.4
In pulmonary oedema secondary to acute left ventricular failure, CPAP is the treatment of choice and must be started as per the Initiating CPAP therapy algorithm (Appendix 3) and nursed on GHDU or ITU. The Patient should be transferred Directly to GHDU/ITU for CPAP.
5.5
The on call Physiotherapy team should not be called in for a CPAP Patient due to urgency of Treatment.
5.6
Patients requiring Acute NIV with above 35% oxygen need to be nursed on the GHDU or ITU. If stable or Palliative they can be maintained on Focus Ventilator up to 40% oxygen.
5.7
The Respiratory Ward has capacity for 3 Patients on Focus Ventilators. The Focus Ventilator cannot be removed from one Patient to another unless NIV has been stopped by a Senior Registrar/Consultant for the former Patient.
5.8
For a Patient in Acute Respiratory failure on an outlying ward, they must be referred to the Respiratory Registrar/Consultant on Felsted or to the ITU Registrar/Consultant for ITU based care via bleep system. The Nurse in Charge on Felsted Ward and ITU will need to be contacted to secure availability of Ventilator machine. In the event of clinical urgency on another Ward the Patient should only be started on NIV/CPAP by the NIV CNS, Trigger response team or on call Physiotherapist. The Patient should then be transferred to a designated area for NIV/CPAP within 2 hours.
5.9
If possible the Patient should be transferred to a designated area prior to commencement of therapy to avoid clinical risk. The bed co-ordinator must be contacted as soon as possible once decision made regarding ITU/GHDU or Respiratory Ward based care to arrange an appropriate bed for the patient as per bed protocol (Appendix 7).
5.10
The Clinician who sets up the NIV/CPAP is responsible for that Patient and must remain with them until transfer to a designated area or another MEHST NIV trained clinician takes over care.
5.11
The NIV service is supported by the on-call Physiotherapy Team and they can be contacted via switchboard 24 hours a day for referrals (Appendix 8). The Physiotherapist cannot be called in unless a designated destination of care is firmly decided.
5.12
The NIV CNS can also be contacted by switchboard or bleep for referrals in-hours on specific duty days. # 6400 587.
5.13
The senior nurse in charge of GHDU and the Respiratory Ward may use their discretion to determine whether the on-call Physiotherapy Service is required. The Night co-ordinator will need to be informed before calling in Physiotherapy staff.
5.14
The areas identified for NIV must ensure that an adequate number of staff have received training and that accredited staff are available at all times.
5.15
Patients who are admitted and NIV continued on their own machine must have continual oxygen saturation monitoring whilst on NIV when they are acutely ill. If the Patient is stable with their Respiratory condition there is no clinical need to use continual oxygen saturation monitoring.
5.16
The NIV prescription chart (Appendix 5) must be used for all patients receiving NIV/CPAP outside the adult intensive care units and used in conjunction with the NEW Score (New Early Warning Score). Treatment cannot commence without this form being completed by a senior doctor (registrar or above)
5.17
Documentation of limitations on treatment, weaning regime, further treatment proposals depending on response, and indications for treatment following NIV guidance, must be clearly documented in the patient’s medical records.
5.18
Patients requiring CPAP for sleep apnoea or sleep disordered breathing may be Nursed on Felsted Ward.
5.19
Patients on home ventilation NIV or CPAP for sleep apnoea who are self caring of their Ventilator machine may be nursed on any Ward if they are admitted for another issue Unrelated to their breathing.
5.20
Patients who are not independent or who require oxygen entrainment with their Ventilator machine must be nursed on the Respiratory Ward-Felsted or GHDU.
5.18
If the Patient on NIV/CPAP is assessed as needing 1 to 1 care, an extra trained member of staff can be requested via authorisation from the Lead Nurse for that clinical area.
6.0
Equipment
6.1
The Equipment required to carry out NIV and CPAP referred to in this policy includes: • • • • • • • • • • •
NIV ventilator device (BiPAP® Focus™ system on the Respiratory Ward or V60 ventilator on GHDU and ITU) The ventilator must never be attached to a Patient without a filter at the circuit port. First line option is the Phillips PerforMax Disposable Full Face Mask – Large or XL Phillips Respironics Disposable oro-nasal Mask Small Phillips Respironics Disposable oro-nasal Mask Medium Phillips Respironics Disposable oro-nasal Mask Large Ventmed Max shield full face mask Ventmed oro-nasal masks sizes small to extra large. Ventmed Disposable Circuit with filter and O2 port (Focus) Ventmed disposable circuit with filter and sensor tubing (V60) Bacterial Filter, Low Resistant (for use on exhalation port in contagious disease)
6.2
NIV equipment is located on the Respiratory Ward for use on the Respiratory Ward or in the NIV cupboard on the GHDU.
6.3
Patients in ITU will receive NIV/CPAP via the NIV equipment and consumables on ITU.
6.4
All Consumables can be sourced via NHS supplies for the Respiratory Ward, GHDU and ITU (Appendix 6).
6.5
An agreed minimum holding stock of 10 masks and circuits per clinical area must be maintained to ensure stock available at all times.
6.6
CNST documentation (Equipment Competency Self Assessment Statement) will be completed by all staff using the BiPAP® Focus™ system and Philips V60 ventilator.
6.7
Consumables need to be replaced as per manufacturer’s guidelines, mask and circuit every seven days.
7.0
Medical Records
7.1
All patients medical records will be managed confidentially at all times and stored securely.
7.2
All documentation relating to NIV and CPAP must be filed within the patient’s medical records when completely filled in or the patient no longer requires treatment; death or discharge.
7.2
All movement of patient records will be accurately tracked in accordance with the Trust's Case note Tracking Policy.
8.0
Equality and Diversity
8.1
The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals.
8.2
Where possible NIV/CPAP treatment will be fully explained to the Patient and or Relatives. As per prescription guidelines patient consent should be gained prior to commencement of NIV/CPAP. The patient with capacity has the right to refuse treatment.
8.3
For a patient without capacity a decision to treat must be made in their best interests and approached with compassion. Please refer to the appropriate Trust policy guidelines for each individual case.
9.0
Infection Prevention
9.1
All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands between each patient.
9.2
All NIV/CPAP equipment will be decontaminated between each patient and disposable attachments used where supplied.
9.3
Where patients are high risk of infection, disposable monitoring equipment should be used for single patient use. Disposable equipment should be disposed of as per Trust
policy, and any non disposable equipment should be decontaminated as per Trust policy. 10.0
Audit
10.1
Compliance with this policy will be audited annually by the NIV Nurse Facilitator. The on-call Physiotherapy Service will assist with audit. This will include gathering information regarding call outs and number of patients on NIV/CPAP. Any issues will be escalated to Clinical Directors and Divisional Managers for action.
10.2
This policy will be reviewed annually by the NIV Nurse Facilitator to recommend and implement changes / improvements where necessary (Appendix 4).
10.4
Any instances of non-compliance with this policy should be raised with the NIV Nurse Facilitator and recorded as a Datix if necessary.
11.0
Communication & Implementation
11.1
The policy will be made available on the Trust’s intranet & website by Governance. The NIV Nurse Facilitator will be responsible for issuing copies to all senior managers, general managers and ward sisters for dissemination within their departments.
11.2
The approved policy will be notified in the Trust’s Staff Focus that is sent via e-mail to all staff.
12.0
References British Thoracic Society (2008). The Use of Non-Invasive Ventilation in the Management of Patients with Chronic Obstructive Pulmonary Disease Admitted to Hospital with Acute Type II Respiratory Failure (with Particular Reference to Bilevel Positive Pressure Ventilation) Esmond G, Mikelsons C (2009). Non-Invasive Respiratory Support Techniques: Oxygen Therapy, Non-Invasive Ventilation and CPAP. Wiley-Blackwell. North East,Central London and Essex Health innovation and Education cluster (2011) Improving care for Patients with acute hypercapnic respiratory failure requiring noninvasive ventilation. National Institute for Health and Clinical Excellence (2010) The use of non-invasive ventilation in the management of Motor Neurone Disease. The Care Quality Commission (CQC) Guidance with compliance;Essential standards of quality and safety.(2015)
Appendix 1 NIV Referral Guidelines
Appendix 1 NIV referral guidelines 201
Appendix 2 Initiating BiPAP Therapy tool
Appendix 3 Initiating CPAP Therapy tool
Appendix 3 Initiating CPAP 2014.doc
Appendix 4 Audit Proforma for any area
Appendix 4 door to mask audit form.doc
Appendix 5 NIV Prescription Chart
Appendix 5 CPAP-NIV prescription
Appendix 6 NIV consumables
consumables 2015.doc
Appendix 7 MEHST NIV Referral flow chart
NIV flowchart 2015.docx
Appendix 8 NIV Physio call out
Appendix 8 NIV physio call out.doc
