The Science Journal of the American Association for Respiratory Care

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 Medical Center, Honolulu, HI

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.

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