Treating Covid-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit

Background

This investigation looked into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units.

A significant proportion of people attending hospital with COVID-19 need help with their breathing. Often this takes the form of oxygen therapy which is given through a face mask or through little tubes that sit in the nose. Despite oxygen therapy, some patients still struggle to take in enough oxygen to breathe on their own and become exhausted. This is known as respiratory failure. These patients’ breathing may be assisted with the use of a special device, which delivers a flow of oxygen-enriched air at a constant pressure, and is connected to a mask, or hood, worn by the patient. This is known as CPAP.

There was an increase in numbers of people requiring hospital admission because of respiratory failure and requiring breathing support using CPAP during the peaks of the COVID-19 pandemic. CPAP is an aerosol-generating procedure (AGP) because it can result in the release of airborne particles (aerosols) from the respiratory tract. When someone is suspected or known to be suffering from an infectious agent like coronavirus these infectious particles pose a risk of infection to others. Therefore, this required the creation of safe environments and efficient patient pathways to reduce the risk of infection when using this form of respiratory support.

Reference event

The investigation was launched after HSIB became aware of a patient with COVID-19 requiring CPA, who was found on the floor of a side room having called for assistance. The CPAP tubing had become disconnected from the mask meaning the patient’s breathing was not supported. Sadly, the patient died.

Investigation summary

This investigation sought to:

Understand the contextual factors surrounding the care of people with coronavirus requiring CPAP in hospital.
Describe the systemic factors influencing the risks associated with using this form of non-invasive respiratory support during the pandemic.
Identify whether recent national guidance addressed identified safety issues.

Safety recommendations

As part of our final investigation report we have provided six safety questions to improve patient care and outcomes.

Safety question 1

Do you have an operational policy that includes the areas of the hospital where non-invasive respiratory support can be provided? Does your operational policy include the minimum safe level of staff competencies, the minimum nurse-to-patient ratio for patients receiving non-invasive respiratory support on the ward, and the minimum frequency of clinical review?

Standard requirements that should be included in an operational policy can be found in the ‘Inspiring change’ report (National Confidential Enquiry into Patient Outcome and Death, 2017), joint guidance by the British Thoracic Society and Intensive Care Society (2021a) on developing and implementing respiratory support units, and the Getting It Right First Time (2021) review of respiratory medicine.

Safety question 2

Do you use side rooms to care for patients requiring non-invasive respiratory support? If so, how do you ensure that monitors and alarms can be seen and heard by staff when outside of the room? Do you have central monitoring?

Safety question 3

Do your continuous positive airway pressure (CPAP) devices have the capability for remote monitoring?

Safety question 4

Do you have the required staff and skill mix to care for patients requiring non-invasive respiratory support in side rooms on a general ward? How are issues with staffing and workload escalated and responded to? Are senior trust personnel aware and involved?

Safety question 5

Do your staff have the required training and competency assessments to care for patients requiring non-invasive respiratory support? Examples of appropriate training and competency assessments include the ‘COVID-19 skills preparation course’ (European Society of Intensive Care Medicine, 2021) and the ‘National competency framework for registered practitioners: level 1, patients and enhanced care areas’ (National Outreach Forum and Critical Care Networks – National Nurse Leads, 2018).

Safety question 6

Do your staff complete a checklist (for example, the ‘SAFER NIV/CPAP – a checklist for use in pandemic response and on respiratory support units’ or similar) (British Thoracic Society and Intensive Care Society, 2021a) when a decision has been made to initiate non-invasive ventilation/continuous positive airway pressure (CPAP) and at every shift change?