Improving access to ward-based respiratory failure management: a case study in the development of a respiratory care unit at an Australian metropolitan health service
Gavin Fahey A D , Maureen Goodwin A , Sanjeevan Muruganandan A , Katharine See A B and Liam M. Hannan
A B C
A Department of Respiratory Medicine, Northern Health, 185 Cooper Street, Epping, Vic. 3076, Australia. Emails: maureen.goodwin@nh.org.au; sanjeevan.muruganandan@nh.org.au; katharine.see@nh.org.au; liam.hannan@nh.org.au
B Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Vic. 3010, Australia.
C Institute for Breathing and Sleep, 145 Studley Road, Heidelberg, Vic. 3084, Australia.
D Corresponding author. Email: gavin.fahey@nh.org.au
Australian Health Review 45(5) 601-605 https://doi.org/10.1071/AH21005
Submitted: 5 January 2021 Accepted: 8 March 2021 Published: 22 June 2021
Abstract
This case study describes the implementation of a ward-based respiratory care unit to improve access to specialised respiratory failure management at an Australian metropolitan health service. Using a case study approach, we describe the conception, development and implementation of a respiratory care unit within a previously inexperienced ward. Key barriers and facilitators are explored and the importance of a safety culture and an aspiration for continuous quality improvement are detailed. Three key aspects of implementation were identified: physical environment, expertise and governance. Continuous review of clinical and quality data was also considered critical to success. Stakeholder engagement was identified as both a barrier and facilitator to successful implementation. Early success was demonstrated through increased utilisation of respiratory interventions but with less utilisation of the intensive care unit and no apparent deterioration in clinical outcomes. Successful implementation of ward-based management of respiratory failure can be undertaken within non-tertiary settings but requires a comprehensive plan. Essential aspects include the support of clinical champions, early and continuous stakeholder engagement and an aspirational culture of safety and continuous quality improvement.
What is known about the topic? Non-invasive ventilation and high-flow oxygen therapy are now established as key treatments in the management of acute respiratory failure. Access to these treatments is often limited to critical care locations (emergency department, intensive care unit (ICU) and operating theatre), but ward-based use can be safe and effective when applied with appropriate clinical policies, expertise and staffing.
What does this paper add? This report describes the successful and rapid development of a specialised respiratory care unit within an inexperienced ward at an Australian metropolitan health service. Prior to development of the unit, the health service only provided non-invasive ventilation and high-flow oxygen therapy within critical care locations. Successful implementation was associated with increased utilisation of these therapies with significantly less ICU utilisation and no apparent deterioration in outcomes.
What are the implications for practitioners? An explanation of a model for implementation is provided that may help health services improve access to complex respiratory failure management outside of critical care locations. Key factors in the success of the model are identified and examined.
References
[1] Sanchez D, Smith G, Piper A, Rolls K. Non–invasive Ventilation Guidelines for Adult patients with Acute Respiratory Failure: a clinical practice guideline. 1st edn. Sydney. NSW Agency for Clinical Innovation. 2014. Available at: https://www.aci.health.nsw.gov.au/networks/icnsw/intensive-care-manual/statewide-guidelines/non-invasive-ventilation-guidelines [Verified 7 September 2020][2] Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease Cochrane Database Syst Rev 2017;
| Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary diseaseCrossref | GoogleScholarGoogle Scholar | 28702957PubMed |
[3] Parker K, Perikala V, Aminazad A, Deng Z, Borg B, Buchan C, Toghill J, Irving LB, Goldin J, Charlesworth D, Mahal A, Illesinghe S, Naughton MT, Young A. Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study. Respirology 2018; 23 492–7.
| Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study.Crossref | GoogleScholarGoogle Scholar | 29224257PubMed |
[4] Davidson AC, Banham S, Elliot M, Kennedy D, Gelder C, Glossop A, Church A, Creagh-Brown B, et al BTS/ICS guideline for the ventilator management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 ii1–35.
| BTS/ICS guideline for the ventilator management of acute hypercapnic respiratory failure in adults.Crossref | GoogleScholarGoogle Scholar | 26976648PubMed |
[5] Miller D, Fraser K, Murray G, Thain G, Currie P. Predicting survival following non-invasive ventilation for hypercapnic exacerbations of chronic obstructive pulmonary disease. Int J Clin Pract 2012; 66 434–7.
| Predicting survival following non-invasive ventilation for hypercapnic exacerbations of chronic obstructive pulmonary disease.Crossref | GoogleScholarGoogle Scholar | 22512604PubMed |
[6] Frat JP, Coudroy R, Marjanovic N, Thille AW. High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure. Ann Transl Med 2017; 5 297
| High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure.Crossref | GoogleScholarGoogle Scholar | 28828372PubMed |
[7] Crossingham I. In defence of ward-based non-invasive ventilation. J Intensive Care Soc 2018; 19 4–5.
| In defence of ward-based non-invasive ventilation.Crossref | GoogleScholarGoogle Scholar | 29456594PubMed |
[8] National Confidential Enquiry into Patient Outcomes and Death. Acute Non-Invasive Ventilation: Inspiring Change. 2017 July 13. Available at: https://www.ncepod.org.uk/2017niv.html [Verified 3 December 2020].
[9] British Thoracic Society. National adult non-invasive ventilation audit. 2019. Available at: https://www.brit-thoracic.org.uk/quality-improvement/clinical-audit/national-adult-non-invasive-ventilation-audit-2019/ [Verified 2 November 2020]
[10] Carlucci A, Delmastro M, Rubini F, Fracchia D, Nava S. Changes in the practice of non-invasive ventilation in treating COPD patients over 8 years. Intensive Care Med 2003; 29 419–25.
| Changes in the practice of non-invasive ventilation in treating COPD patients over 8 years.Crossref | GoogleScholarGoogle Scholar | 12624663PubMed |
[11] Ergan B, Nasiłowski J, Winck JC. How should we monitor patients with acute respiratory failure treated with noninvasive ventilation? Eur Respir Rev 2018; 27 170101
| How should we monitor patients with acute respiratory failure treated with noninvasive ventilation?Crossref | GoogleScholarGoogle Scholar | 29898904PubMed |
[12] Gould LJ, Wachter PA, Aboumatar H, Blanding RJ, Brotman DJ, Bullard J, Gilmore M, Golden SH, et al Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. Jt Comm J Qual Patient Saf 2015; 41 387–95.
| Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement.Crossref | GoogleScholarGoogle Scholar | 26289233PubMed |
[13] Mathews S, Golden S, Demski R, Pronovost P, Ishii L. Advancing health care quality and safety through action learning. Leadersh Health Serv 2017; 30 148–58.
| Advancing health care quality and safety through action learning.Crossref | GoogleScholarGoogle Scholar |
[14] World Health Organization. Classification-of-diseases. Available at: https://www.who.int/classifications/classification-of-diseases [Verified 3 December 2020]
[15] Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000; 355 1931–5.
| Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial.Crossref | GoogleScholarGoogle Scholar | 10859037PubMed |
