2006 OPEN FORUM Abstracts
Improving Patient Safety and Outcomes with Non-Invasive Positive Pressure Ventilation (NPPV)
Diane
Brenessel BS, D.Ed, RRT, Reid Ikeda MD,
The Queen' s
Background: In June of 2004, a 4 year
retrospective analysis of patients that had received NPPV intervention was
done. The results of this analysis revealed that only 34% of these patients had
a successful outcome. A successful NPPV outcome is defined as stabilizing the
patient with mask ventilation during an acute respiratory event and therefore
preventing a possible endotracheal intubation. Room
for improvement was identified when our success rate was compared to a national
benchmark of 60%. Analysis of the 2000-2004 data also revealed inappropriate
ordering, patient selection and inappropriate set-up areas, resulting in
"near-misses". Work began in August 2004
on the development of new policies and procedures for NPPV.
Methods: In order to improve patient care and patient
safety, for patients in acute respiratory failure, an evidence-based clinical
pathway for the use of NPPV was developed and integrated as a best-practice in
the hospital This pathway provided a culture
of safety for the RCP through the introduction of evidence-based policies that
outlined patient specific safety parameters. With educational inservices and monitoring of practice changes, clinicians
were able to recognize appropriate patients for NPPV intervention and better
management for these patients towards a successful outcome. The practice
changes included: enhanced patient
inclusion and exclusion safety criteria, requiring a pre and post ABG pH of
>7.20 and set-ups only in ICU or monitored settings, standardized patient care progression and MD notification, the
development of decision-tree algorithms, improved
patient compliance with mask interface, introduction of the "Total" face
mask, improved NPPV tracking form, allowing
for enhanced monitoring and data collection, increased time allotted for the RCP to provide initial assessment, set-up and evaluation, and helping
to increase patient acceptance of intervention by reducing anxiety associated
with respiratory distress and the equipment interface.
Results: Within the first three months of
initiation of the RCS revised NPPV policy and procedure, the success rate for a
NPPV intervention rose from a historical 34% to 67%. NPPV data thereafter
demonstrated a sustained elevated success rate, averaging 71%. During this
period there were a total of 176 patients that had success with NPPV and an
additional 26 patients on comfort care that choose the option of NPPV and of
these patients 62% were also able to wean off NPPV and transfer out of the ICU.
Conclusion: Success with mask ventilation
(NPPV) can be enhanced greatly by the adoption of evidence-based practice
changes, re-education of clinicians, physician support and vigilant monitoring.
A successful NPPV program is vital to support choices for patients experiencing
respiratory distress and impending failure, as successful avoidance of
intubation and mechanical ventilation positively impacts patient care and
safety.