Providing non-invasive ventilation outside of critical care

Introduction

In March 2020, at the infectious diseases unit of Liverpool University Hospitals NHS Foundation Trust at the Royal Liverpool site, we treated some of the UK’s first patients with Covid-19. As the pandemic worsened and the hospital’s critical care beds filled, it became clear we needed to use other areas of the hospital to offer patients the correct level of care and provide life-saving support. Nursing staff were keen to help achieve this. We looked after some early patients in the tropical and infectious diseases unit, when Covid-19 was still being treated as a high-consequence infectious disease.

In March 2020, the NHS (2020) introduced continuous positive airway pressure (CPAP) as a potential supportive treatment for patients with Covid-19 and respiratory failure; the move was supported by guidance from the National Institute for Health and Care Excellence the following month (NICE, 2021; Ashish et al, 2020).

In our unit, we were experts in infectious disease and highly trained in the donning and doffing of personal protective equipment, but we were not experts in respiratory disease or CPAP. We had available negative-pressure rooms (recommended as CPAP is an aerosol-generating procedure) and a newly installed continuous non-invasive monitoring system that was visible from outside the rooms, so it was agreed we would become a unit for treating Covid-19 patients needing CPAP.

As well as helping with the urgent need for level-2 beds (for patients who need more detailed observation or intervention) outside of the critical care unit, this approach would also help upskill staff for the long term.

Training

Repurposing the infectious diseases ward as a level-2 CPAP/Covid-19 surge unit required an extensive rapid training programme for the nursing staff and allied health professionals who would deliver this care. A joint working group between respiratory, critical care and infectious disease teams was set up. The goal was to use the skills, knowledge and resources of the infectious diseases unit, while having the support of other members of the multidisciplinary team (MDT).

The work to train staff began in March 2020 and is ongoing. We opted to train staff on a single type of CPAP device (Philips A30), which was felt to be the simplest to use. Nursing staff had to know how to size masks, set up the machine, start patients on the most appropriate settings, document the set-up, troubleshoot problems and recognise patient deterioration. Nursing staff were also trained in arterial gases, the physiology of respiratory failure (types 1 and 2), contraindications and the rationale for CPAP.

Competency training booklets were used, and specialist nurses and respiratory physiotherapists provided the training. We put in place 24-hour support, theory sessions, as well as practical sessions on CPAP and arterial gases.

Logistics

Some of the side rooms on the infectious diseases ward were converted to negative-pressure rooms by installing temporary industrial, high-efficiency, particulate-absorbing, filtered air-purifying units. We also considered the strain this service would put on the hospital oxygen systems – another benefit of the A30 device was that it uses less oxygen than other CPAP machines.

Recommended nurse–patient ratios for CPAP are 1:2, but because of the use of side rooms and staffing pressures due to the pandemic, we used remote video monitoring that relayed patients’ vital signs to a central nursing station.

Two expert clinicians (respiratory physiotherapist or nurse) covered the repurposed CPAP/Covid-19 ward 24/7 to support the staff delivering care. An MDT twice-daily handover was done with respiratory, critical care and infectious diseases staff.

“The passion was clearly evident to provide sick people a chance, who were otherwise unlikely to survive”
(Judges’ comments)

Outcomes

This nurse-led training programme allowed nurses to safely offer CPAP to patients, through the first, second and third waves of the pandemic, by providing an extra 20 beds in our infectious diseases unit. More than 120 staff have been trained across the trust and 20 infectious disease nurses, physiotherapists and healthcare assistants have passed higher-level competences. There was a 100% pass rate among trainees.

The repurposed unit treated 202 patients over three waves of the pandemic, and no patient who was clinically appropriate to receive CPAP was turned down for treatment. It has been estimated that this initiative saved 1,212 intensive care bed days (data provided by hospital quality assurance team).

CPAP treatment was used more widely in the second and third waves, after our data showed it helped patients avoid mechanical ventilation in more than half of cases. Our data has been used nationally and internationally to support use of this type of care. The unit provided care for patients who would not have been suitable for mechanical ventilation and, if the service had not been available, would not have received CPAP due to limited capacity in critical care.

Feedback from patients also showed that 94% felt safe on the ward and 93% said their privacy was maintained.

Challenges

It was challenging for the team to provide this enhanced package of training while dealing with the constant admissions of patients who were acutely unwell. This intense period of working often meant the specialised nurses leading the training also had to care for the new patients. We overcame this by adding two more specialised nurses and respiratory physiotherapists to support nurses on the ward.

Another challenge was gaps in the documentation around setting up the A30 machine. The nurses caring for these patients began to note that key information was missing; this included starting oxygen levels, respiratory rate, starting positive end-expiratory pressure and flow, post-one-hour CPAP settings, and oxygen settings related to size and type of mask. In response, the training nurses developed a proforma the nurses could follow.

It was also noted that some patients were failing after coming off oxygen; after review, it was felt that patients with Covid-19 needed a much slower wean than patients on CPAP for other reasons. A guide on weaning was developed and a flowchart created to standardise the process. These guides are still in use across the hospital.

The number of pneumomediastinums and pneumothorax was higher than expected and, as the pandemic progressed, it became clear this was a feature of Covid-19. We trained nurses to recognise surgical emphysema and to be aware of when to inform medical colleagues if a patient had any possible sign of a pneumothorax.

Conclusion

The aim of this initiative was to free up critical care beds and increase the provision of CPAP during the Covid-19 pandemic, through a rapid service redesign and enhanced staff training to provide safe patient care. The service has now treated hundreds of patients, helping many avoid mechanical ventilation on an intensive care unit; it has also saved many lives.

The unit is now fully equipped, trained and ready to recommence when needed. Nurses have gained clinical skills they can use in their daily nursing care, allowing them to work with more autonomy and helping relieve the pressure on other clinical staff. Infectious disease, respiratory and critical care teams are still collaborating to train and educate staff. This innovation gives the trust the flexibility to manage future pandemic surges.