Case Studies

Respiratory Support Unit Provision - Lister Hospital, East and North Hertfordshire NHS Trust

Establishing our Respiratory Support Unit: Our unit at Lister Hospital has been defined as a Respiratory Support Unit (RSU) since 2015.

We have a 7-day respiratory service and contribute to an unselected medical take. 

Admission criteria:  

Single organ respiratory failure (requiring 40-60% inspired oxygen and unable to maintain target saturations or potentially requiring advanced level respiratory support including:

• High flow nasal oxygen systems
• Continuous positive airway pressure
• Non-invasive ventilation
• Tracheostomy care

We admit predominantly, directly from accident and emergency and including all ward areas. The majority of patients having treatment escalation plans in place.

Population: - The Lister Hospital is a 730 bedded district general hospital within Hertfordshire. Our CCG demographics sit within national average for respiratory conditions; in essence, we represent "average England".

Driver for change: - In preparation for the COVID-19 pandemic we rapidly up-scaled our bed base, using our existing RSU model. Prior to the COVID pandemic we had a 4 bedded unit, which was due for expansion as identified by our national GIRFT (Oct 2019) but the pandemic accelerated this expansion.

Intervention: - During the 1^st wave, we initially moved to a different ward area, which provided single patient rooms. We were able to expand using a flex up and down model to a maximum of 12 beds.

We subsequently moved location again to a more permanent location in preparation for the second wave using the same model but using a more traditional mix of single rooms and 3/4 bedded bays providing up to 19 beds during the 2nd wave.

Outcome: -What is unique about our unit is that we have collected our outcomes using the Intensive Care National Audit and Research Centre (ICNARC) data base since 1^st April 2015.

Results:

Table 1. Number of admissions to RSU in the preceding 12 months  compared to 12 months during the COVID pandemic (1^st March 20 to 1^st March 21).

Table 2. RSU Patient Demographics pre-covid, compared to RSU first 1^st Wave COVID and ITU during the same time period (March 20-Sept 20, 6 mnths).

*Number different to Table 1, as patients readmitted to RSU weren’t included twice for baseline demographic data.

Conclusions

During the COVID pandemic the number of admission to RSU in 1 year almost doubled from 227 to 454 patients. This was enabled by a rapid expansion of the existing RSU using the same model of care. 206 patients had COVID but we also demonstrated we continued to provide level 2 respiratory support to our normal respiratory population as demonstrated by the similarity of the patient’s demographics.  The younger age, male predominance and increase in co-morbid patients admitted to RSU in the first wave we presume was driven by COVID infection.  

Since 2015 we have submitted our data to the ICNARC database and hence we have a consistent measurement of outcomes over a longer time period. We are now able to compare our data set and measure our mortality pre COVID, during COVID and subsequently post COVID, additionally we can compare our mortality outcomes and many other denominators of care as a hospital as a whole or as individual units.

When establishing a RSU unit we would recommend a data collection tool

Staff:

Respiratory Consultant ENH and nurse staff colleagues

Dr Alison McMillan PhD, Consultant Respiratory Physician
Dr She Lok
Prof Thida Win
Dr Safwat Hamad
Dr Peer Mohamed
Dr Alex Wilkinson
Dr Uruj Hoda
Dr Katie Chong
Dr Liana Pradan
Dr Tony Redington.

Respiratory Support Unit - Northumbria Healthcare NHS Foundation Trust

Driver for change: Acute NIV for respiratory acidaemia complicating a range of conditions is one of the most effective emergency medical interventions, but in the UK concern about service provision and outcome triggered a National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Previously three separate DGH’s in our Trust received acute admissions, fragmenting the service.

Intervention: The RSU opened on 16/06/15 within a new Specialist Emergency Care Hospital receiving all acute admissions. A key feature is 24/7 Respiratory Consultant and NIV Physio support. The acute NIV guidelines were revised to streamline the patient journey. Patients benefit from enhanced nurse-patient ratios (1:2 during acute NIV), monitoring within a dedicated unit and structured multidisciplinary review.

Delivery of key elements of the pre-existing service are more robust including: single point of contact (trained and competency assessed NIV physios); blended oxygen dedicated NIV ventilators (Philips V60: FiO2 21-100%); physios move to the patient to initiate NIV, stabilise and retrieve the patient (with monitoring); continuous rolling audit with capture of door-to-mask time and delays or other incidents investigated.

Training includes full simulation of challenging real-life cases. The RSU rapidly adapted to the COVID-19 pandemic, rescuing patients directly to protected beds for NIV/CPAP initiation and expanding capacity.

Outcome: The most common condition requiring acute NIV is COPD exacerbation; in-hospital and 30-day post discharge mortality below shows strong baseline performance, with a sustained improvement following the opening of the RSU (doi:10.1136/bmjresp-2018-000334). The 2019 BTS NIV audit included all conditions managed with NIV - in-hospital mortality: Northumbria RSU = 13%; national = 26%.

*NCEPOD: National Confidential Enquiry into Patient Outcome and Death for acute NIV.

Karen Brewin, Lead NIV Physio.
Dr Nick Lane, NIV Outcomes Research Fellow.
Prof Stephen Bourke, Consultant Physician and Clinical lead.

COVID-19 Medical Provision - Royal Victoria Infirmary, Newcastle Upon Tyne

Driver for change: Newcastle, in similarity to many regions, experienced a surge in COVID-19 related admissions.

Intervention: At the Royal Victoria Infirmary patients with COVID-19 were admitted through the Medical Assessment Unit. Of patients with significant Oxygen requirements, some were admitted directly to critical care areas but significantly larger numbers were admitted to two expanded respiratory ward areas, where there was expertise in the provision of CPAP and NIV.

These wards were staffed by existing respiratory ward nurses and supplemented by nurses from non-respiratory areas who were supported and upskilled, with training in advance of both junior medical and nursing staff by the respiratory physiotherapy team.

The wards were medically led by a team of ten respiratory physicians supplemented by one volunteer anaesthetist. The CPAP provision, including protocols and circuit set up, was led by the physiotherapy service supported by the respiratory and critical care teams. Early, proactive decision-making to initiate CPAP was undertaken in patients for whom critical care was felt not to be beneficial.

Outcome: This had the effect of maintaining critical care capacity at the RVI, increasing the confidence of non-respiratory and non-critical care staff in the provision of CPAP and NIV and ensuring effective treatment with CPAP and effective proactive decision-making.

All patients in whom critical care was felt not to be beneficial had a treatment escalation plan and a DNACPR. Hospital mortality in this group, who went onto receive CPAP, was 50% which compares favourably with national and international figures.

Kathy George Advanced Respiratory Physiotherapist, Royal Victoria Infirmary, Newcastle
Hilary Tedd, Consultant in Respiratory Medicine and Home Ventilation, Royal Victoria Infirmary, Newcastle.
Ben Messer, Consultant in Critical Care Medicine and Home Ventilation, Royal Victoria Infirmary, Newcastle

Acute Respiratory Care Unit - Watford General Hospital, Hertfordshire NHS Trust

Establishing our Respiratory Support Unit:

Following the NCEPOD 2017 Inspiring Change report, the trust was found to be compliant with 7/21 of the recommendations. Subsequently a business case for the 8 bedded ARCU was submitted Sept. 2018 by the respiratory consultant team and was implemented in November 2019. This was uprooted during the COVID-19 pandemic and subsequently post wave 1 (July 2020) was relocated within the trust as part of a site-wide shuffle/rejig (?) of the wards.

Population:

The ARCU is based at Watford General Hospital (WGH) which is 1 of 3 sites within the West Hertfordshire Hospitals Trust, including Hemel Hempstead and St. Albans City Hospital. WGH is at the heart of the Trust’s emergency services with an emergency department and Intensive Care Unit. The Trust serves a population of approximately half a million people across the West Hertfordshire and surrounding area.

Driver for change:

The main driver for change originally was the NCEPOD 2017 report and 2018 BTS guidance. After the ARCU’s establishment in the summer following the 1^st wave of the COVID-19 pandemic in 2020, the ARCU was initially protected from the 2^nd wave with the management of acutely unwell COVID-19 patients elsewhere on the site (As per the 1^st wave). This continued with the establishment of a COVID-ARCU to cohort those requiring CPAP/HFNO/NIV. However, due to the sheer weight of patient numbers the ARCU was then turned into the 2nd COVID-ARCU surging up to 12 beds. At the height of the demand, the trust was managing 28 patients on CPAP, NIV or HFNO across these 2 units.

Intervention:

The ARCU is part of the wider Respiratory Ward and in surge periods can increase to 12 beds from its day-to-day 8 bedded layout. Patients requiring acute Bi-level Non-Invasive Ventilation or CPAP therapy are transferred onto the ARCU unless requiring ITU. The unit is also able to deliver High Flow Nasal Oxygen therapy. Patients with a wide range of diagnoses are treated on the ARCU, with the main background of the NIV cohort being COPD, along with a mixture of neuromuscular disease, obesity hypoventilation syndrome and other causes of acute type 2 respiratory failure.

The unit has just completed recruiting its uplift in nursing staff to fully achieve the 1:2 nursing ratio for NIV patients. The NIV Practitioner has been in place since June 2020 to provide an outreach service to the A&E and other ward areas whilst supporting training and development of staff site-wide.

Outcome:

Data collection is ongoing, maintaining a database of all patients setup on NIV, CPAP or HFNO. These are all recorded on the Trust’s WardWatcher system, with a more detailed database maintained to include additional criteria such as Ceilings of Care, provision of domiciliary NIV post admission to support further analysis and shaping of the service.

Staff:

The following team oversee the respiratory service and wider ward (26 beds, inc. 8 bedded ARCU)

Respiratory Consultant Team – with a named Clinical Lead for NIV

Junior Medical Team

Band 8a - Advanced Respiratory Practitioner

Band 7 – Ward Manager (ARCU & Respiratory Wards)

Band 7 – 0.2 WTE NIV Lead Physiotherapist time

Band 6/5 registered nurse mix to achieve 1:2 ratios