An audit shows that only 55% of patients started on NIV have a documented escalation plan before treatment begins. You have been asked to improve this. Outline your approach.

Question

You are the respiratory registrar. A recent mortality review identified two patients who deteriorated on NIV overnight with no documented ceiling of care, leading to inappropriate and distressing resuscitation attempts.

Accepted Answer

I would start by acknowledging that this is not a documentation problem in the abstract — two patients received distressing and inappropriate resuscitation because of it, and that is the reason to fix it. My diagnostic phase would establish who actually starts NIV in this trust, at what time of day, and whether the person who can make an escalation decision is available at that moment. I would segment the 55% by hour of initiation, by day of week and by initiating team, because in almost every unit the gap is concentrated in out-of-hours starts by the acute medical team when no respiratory or critical care consultant is immediately at hand. I would talk to the people who start NIV — the medical registrars, the HDU nurses and the respiratory physiologists — and ask what stops them, because the barrier is usually structural rather than attitudinal. My aim would be SMART: to increase documented escalation plans before NIV initiation from 55% to 95% within six months. My outcome measure would be that percentage on a run chart, process measures would include the proportion with consultant sign-off within 12 hours and the proportion where the plan was made before rather than after initiation, and my balancing measure would be the quality of the plans, sampled and reviewed, because mandating a field reliably produces meaningless entries if that is all you measure. The core intervention would be to make the escalation plan a mandatory field within the NIV prescription itself, so that NIV cannot be started without one, supported by an initiation checklist covering the whole bundle and a clear route to a consultant decision out of hours. I would test that in small PDSA cycles on one ward first, involve critical care and the mortality review group, and before rotating embed it in the SOP, in induction and in the ongoing audit programme with a named owner.

Improving Compliance With the NIV Care Bundle

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