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Effective and Efficient Utilization of Noninvasive Ventilator Support in Patients With Acute Respiratory Failure: Opportunities for Improvement FREE TO VIEW

Vijay Vanam; Priya Debnath; Naga Swetha Bommisetty; Viswanath Vasudevan; Qammar Abbas; Praveen Jinnur; Ameer Rasheed
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Brooklyn Hospital Center, Brooklyn, NY

Chest. 2014;146(4_MeetingAbstracts):538A. doi:10.1378/chest.1994710
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SESSION TITLE: Quality & Clinical Improvement Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM

PURPOSE: The study was undertaken to ascertain compliance with The Brooklyn Hospital CPAP/NiPPV policy/protocol (adapted from Canadian Medical Association evidence based guideline publication CMAJ 2011, 183(3) & Journalof Respiratory care). Identify opportunities for improvement in safe, effective and cost-efficient utilization of NiPPV/CPAP in acute respiratory failure.

METHODS: Design: Cross sectional cohort study. All hospitalized patients who were treated with application of CPAP/NiPPV during the period from October 2012 to January 2013 were included. Inclusion Criteria: >18 years who received NIPPV/CPAP. EMR were reviewed for compliance with the following audit criteria: 1) Valid indications 2) Timely & adequate monitoring of response to therapy. 3) Timely discontinuation of therapy, when it was no longer needed. 4) Timely transition to invasive ventilation, when NiPPV/CPAP had failed. 5) Outcome: success and failure

RESULTS: Of 85 patients, 63 (73 %) were treated with BIPAP, and 22(25%) with CPAP. Mean age, 65 years. Of 63 on BIPAP, 5 received nocturnal BiPAP for OSA. 21 patients for Acute Ventilatory failure- 13 for COPD exacerbation, 4 for Asthma, 2 for post op atelectasis, 2 for post extubation. 37 patients for acute severe Oxygenation failure ( P/F ratio <300)- 4 for ESRD , 3 NSTEMI, 16 for CHF exacerbation, 11 for Pneumonia, and 2 for pleural effusion. Among BIPAP group 31 patients got Pretreatment ABG and 29 got FU ABG to assess the response to BIPAP therapy. Of 22 patients on CPAP, 19 for OSA. 3 for CHF. Of all the patients only 6 got Post-ABG with first hour. Only 10 patients were reevalauted for use of NIPPV within first 24 hrs. Only 1 among 10 intubated patients got FU ABG within an hour of NIPPV. 8 patients are expired. 7 patients were on BiPAP.

CONCLUSIONS: There was significant protocol violations with respect to appropriate clinical indications, patient selection, timely and adequate monitoring with arterial blood gas analysis, timely discontinuation and transitioning to invasive positive pressure ventilation. Poor Physician compliance- only 30% among BIPAP group have valid indications of BIPAP. 39% or 23 pts has no Pre-ABG on BIPAP group. 43% or 25 pts has no post ABG on BIPAP group. 44% of pts got post ABG after an hour. .

CLINICAL IMPLICATIONS: Provider education can improve compliance with safe effective and cost-efficient utilization of Non invasive positive pressure ventilation. Mandatory pulmonary consultations and concurrent audit by respiratory therapist can enforce provider compliance.

DISCLOSURE: The following authors have nothing to disclose: Vijay Vanam, Priya Debnath, Naga Swetha Bommisetty, Viswanath Vasudevan, Qammar Abbas, Praveen Jinnur, Ameer Rasheed

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