Non-Invasive Ventilation – Improving patient experience and outcomes through understanding (INTU)

Our main aim was to use Quality Improvement (QI) tools to improve understanding of patient experience and the quality (timely, effective, patient-centred, and safe) of the acute NIV service for patients at Imperial College Health Trust (ICHT).

The aim was to use experience-based co-design to enhance service delivery within this project. QI tools were used to identify key stakeholders and process map the ideal pathway for a patient entering the acute hospital requiring NIV treatment. Emotional mapping was also used to explore stakeholder’s emotions at important touch points within the NIV pathway to ensure a patient-centred point of view. Our project specifically focused on improving both clinician and patient education and understanding of NIV, ensuring provision of high quality care to include recommendations from the NICE COPD guideline NG115 and the NCEPOD report ‘Inspiring Change’.

Furthermore, the NHS framework (2015-16) focuses upon improving patient experience of hospital care, including responding to patient needs. During a pilot patient experience questionnaire, prior to this project starting, we sought feedback from those who had experienced acute NIV and used their feedback to shape our interventions.

This resulted in 2 main objectives.

Main objective 1: Improve patient experience by improving understanding of NIV. This was accomplished by:

• Developing a validated evaluative patient experience questionnaire.
• Ensuring all patients receiving acute NIV at ICHT have the opportunity to feedback on their experience and to use this feedback to guide change and develop a patient information leaflet.
• Developing educational sessions for patients in the non-acute setting on NIV (e.g. in pulmonary rehab classes and charity groups).
• Producing an online video for patients and carers with information on NIV that is easily accessible.

Main objective 2: Improve NIV outcomes and provide high quality care. This was accomplished by:

• Developing and implementing a patient-centred NIV care bundle and algorithm in line with NICE, BTS and NCEPOD standards and recommendations.
• Developing a multidisciplinary education framework including acute NIV competencies.
• Developing a training video to be used by all clinicians caring for patients on NIV.
• Developing a central hub for all NIV resources to be available to staff online.
• Ensuring there is appropriate recording of ceiling of care decisions and discussions with patients regarding their NIV care.

Recently released BTS and ICS guidelines are clear - the delivery of NIV in the acute setting is frequently sub-optimal and outcomes often poor. Our local data demonstrates poor use of current evidence based protocols.

Baseline results, including confidence levels of educators providing NIV training and an extensive staff questionnaire, demonstrated low confidence amongst practice educators on the NIV service at ICHT and in teaching practical application of NIV as well as irregularity of training received by staff caring for patients on NIV including differing teaching styles, content of teaching and lack of understanding of the support that an established NIV service could provide.

These guidelines draw on multiple levels of evidence reflecting current practice. Research and audit have shown that poor NIV delivery is associated with poor outcome, including excess numbers of deaths. In line with these concerns NCEPOD are in the process of reviewing acute NIV deaths. It is clear things could and should be done better (NCEPOD 2016); our local area is no different.

ICHT incorporates three acute sites which provides NIV care, requiring the need to standardise care across all sites. A recent NIV audit at ICHT supports that poor delivery is associated with poor outcome including mortality. The guidelines stress the importance of locally derived protocols, not currently in regular use, and designated NIV staff and areas. Our establishment of an NIV bundle, algorithm and NIV champions would address this.

The implementation of the NIV care bundle and algorithm improve efficiency and productivity by highlighting the key recommendations from evidence-based resources and providing guidance on the initiation of NIV. Completion of the NIV bundle will help ensure appropriate patients receive NIV in an appropriate area and that care is high quality, safe and patient-centred. The bundle, along with other key interventions within this project aimed to improve efficiency through ensuring patients’ needs are met, they are treated safely in designated areas with the correct staff skill mix.

A team of wide ranging stakeholders was established. An Action Effect Method workshop facilitated discussion leading to the development of our main aims and consensus on how to achieve them. The team developed 21 measures including process, balance and outcome measures that would underpin the data collection.

 Key work streams were identified in order to achieve the project’s aims. These included developing, testing and implementing:

• An NIV care bundle.
• An NIV algorithm.
• A patient-centred multidisciplinary education framework, competencies and guideline, including experiential learning specifically on clinical application, patient experience and shared-decision making in NIV.
• Accessible patient information on NIV, co-produced with patients/carers through structured interviews and focus groups.
• A structure to gain and learn from ongoing patient feedback on the acute NIV service.

Our stakeholders included patients, clinical and non-clinical staff. NIV champions were key clinicians who work on the front line and were able to take an active role in the project supporting questionnaire collection, education and PDSA cycle testing of interventions.

The duration of the project saw more champions recruited including individuals from local charities supporting patients with long-term respiratory diseases. Continuous engagement throughout proved pivotal in making this project successful. The project team continually reviewed engagement and adopted new strategies to ensure effectiveness and project sustainability. An updated trust policy incorporated information on all key changes.

Development of a dedicated internal NIV resource page on the intranet allowed all project documents to be shared between colleagues. This page also allows monthly reporting of outcomes and patient feedback via a dashboard. An externally facing webpage to share our experience and educational resources is currently under development.

Getting the correct number of NIV episode coded appropriately was an ongoing challenge. Implementation of the bundle helps coders recognise an episode of NIV. Patients being put on NIV in a non-designated NIV area was also a problem at ICHT which the team have addressed. An external QI research grant from CLAHRC NWL funded a full-time project manager for 1 year, IT support and paid for the patient video. This helped the team focus and achieve a lot of work in a short period of time.

Data of 21 defined measures was collected daily. A macro-enhanced spreadsheet allowed weekly production of run charts per measure. The project team have tracked progress of the outcomes and linked PDSA cycles and periods of change to any special or common causes seen within the data. Clinicians receiving training was monitored over the year, with approximately 250 clinicians working in NIV designated areas receiving standardised training.

A new centralised process of recording competency completion was set-up as part of the project. A pilot study demonstrated NIV plan documentation at 42%. Further data collected prior to key implementations demonstrated an average of 51% of NIV episodes having documented parameters and prescription for NIV. Since implementation of key interventions this has further increased to an average of 74%.

Furthermore, preliminary results via run-charts show a 70% completion rate of the NIV care bundle for those admitted requiring acute NIV. Data demonstrates an average of 84% of our patients are now treated in an NIV designated area.

Since collecting data at the beginning of the project, data has shown three special causes outside the upper limits for patients receiving optimal medical management for an hour prior to NIV commencement. This optimal medical management is included within the NICE quality standards. Furthermore, correct identification of patients requiring NIV and through introduction of our bundle, teaching programme and algorithm we currently have a 94% average of patients being placed on NIV for an evidence based reason. Thematic analysis of patient experience feedback has improved from 16% positive responses to 56% in the last year. This includes positive comments on communication, information provision and decision-making.

Further collection of this data will hopefully see continuous improvement. This project has provided a pivotal point to addressing the ongoing challenge of correct coding and through data, better communication and collaboration the number of episodes that remain incorrectly coded are now far less.

Correct coding (E85.2) for NIV has had a positive cost implication for the trust and we continue to monitor the number of spells between each un-coded episode. Ongoing review of the data is a necessity for the sustainability of the project. Regular data reviews and current production of the NIV dashboard will ensure this data is reaching both clinicians and service users.

Several key aspects have contributed to the success of this project.

• Clinician, patient, carer and service user engagement within this project has been pivotal in ensuring momentum and ensuring interventions are rigorously tested prior to implementation.
• The use of quality improvement tools has allowed this project to scale up, from testing and implementing the key interventions in one clinical area to another to a wider scale of other acute hospital sites within the trust. Production of a robust data collection tool has further guided the project to review the impact of these tests of change. Without the expertise, view points and collaboration of all different stakeholders within this project, the production of the main interventions would not have been possible.
• Without the commitment of our NIV ward champions this project would not have progressed. Recruitment of stakeholders and champions enthusiastic in developing their quality improvement skills has supported the project team to embed a number of key interventions. Support from both the ICHT QI hub and CLAHRC NWL has proved a helpful resource in guiding the project to achieving its initial aims and ensuring the NIV care provided at ICHT remains in line with recommendations from national standards.
• Although further efforts are required to fully achieve sustainability of this project and project manage greater roll out of the project to our neighbouring acute sites, this project has demonstrated how effective use of collaboration, engagement and quality improvement tools can really make a difference to patient experience and care.
• There is an apparent lack of research into the use of patient experience to drive projects within NIV care, which inspired this project. By completing this project, we not only had we planned to improve the service for our patients at ICHT but plan to be able to share this work wider for other trusts to use as a model for improvement.