HSIB: Treating COVID-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit (18 November 2021)

Summary

The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the management of patients with COVID-19 being treated with non-invasive respiratory support, for example continuous positive airway pressure (CPAP), in non-critical care settings.

The HSIB investigation reviewed the experience of Terry, who was admitted to hospital with symptoms of COVID-19 and required support with is breathing using CPAP. On the second day after his admission to hospital, Terry was found on the floor next to his bed, having called for assistance. Terry’s CPAP tubing had become disconnected from his mask, meaning that Terry’s breathing was not supported. Staff attempted to resuscitate Terry, however they were unsuccessful, and he died.

Content

Background

CPAP is often used to support a patient’s breathing in critical care or high dependency units, where there are high numbers of staff to patients. Staff in these units are trained and familiar with the use of non-invasive respiratory support.

During the first and second waves of the COVID-19 pandemic, however, many more patients needed CPAP than there were beds in critical care and high-dependency units. Thus, hospitals had to create alternative areas and arrangements for delivering and caring for patients who needed CPAP.

This investigation looked at the use of CPAP outside of critical care and high dependency units during the COVID-19 pandemic, specifically focusing on care for acutely unwell patients require CPAP in the side rooms at general wards.

Findings

Key findings of in the investigation included:

• The treatment of patients with COVID-19 with CPAP in side rooms on general wards poses a patient safety risk without central monitoring, with staff not able to clearly see the patient and often unable to hear the equipment alarms designed to alert them to a problem.
• The impact of the COVID-19 pandemic on staffing levels, through illness and self-isolation requirements, created a challenge to caring for acutely unwell patients requiring non-invasive respiratory support outside of critical care of high-dependency units.
• Staff caring for patients with COVID-19 requiring CPAP on general wards need training and competency assessment to feel confident in delivering care.

Recommendations

This HSIB report makes no specific recommendations. It notes that documents have been published by the Intensive Care Society, the British Thoracic Society, Getting It Right First Time and others during the course of its investigation that have made recommendations that have address the safety risks it has identified.

HSIB lists the following recommendations in these other reports that it also endorses in response to its findings:

• Hospitals should establish respiratory support units that are staffed in line with existing national recommendations. This includes a minimum nurse-to patient ratio of 1:4, with nurses trained in administering CPAP and high-flow nasal oxygen.
• Patients requiring non-invasive respiratory support such as CPAP should be centrally monitored. Central monitoring allows patients to be observed and equipment alarms to be heard at the central nurses’ station.
• Hospitals should have protocols that define the frequency of nursing review (that is, how often a nurse checks on a patient), especially for acutely unwell patients located in side rooms.
• Hospitals should have checklists for the safe use of CPAP/NIV outside of critical care and high-dependency units. For example, the British Thoracic Society and Intensive Care Society (2021a) guidance on establishing respiratory support units includes a checklist for the safe use of CPAP/NIV outside of critical care and high-dependency units.
• Minimum safe staffing levels should be followed when caring for patients who require non-invasive respiratory support.
• Where possible, organisations should procure CPAP devices that allow remote monitoring.
• Staff caring for patients requiring non-invasive respiratory support outside of critical care settings should meet training and competency requirements.