Ceiling Of Care Research Articles

Short-term Non-invasive Ventilation for Children with Palliative Care Needs

Objectives: Non-invasive ventilation (NIV), namely continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), delivers mechanical ventilation without endotracheal intubation. Short-term NIV (planned for <21 days during initiation) can be used for the management of acute respiratory distress (ARD) among paediatric palliative patients with “Do Not Resuscitate or Intubate” (DNI) as the ceiling of care. This study aimed to describe the usage of short-term NIV among paediatric palliative patients in a woman and child hospital with a paediatric palliative subspecialty. Materials and Methods: A retrospective and observational study was conducted on all paediatric palliative patients who received short-term NIV in Tunku Azizah Hospital Kuala Lumpur, Malaysia, from March 2020 to May 2022. Results: During the study period, short-term NIV was offered on 23 occasions for 20 different children. Indications for short-term NIV include 16 (69.6%) occasions of potentially reversible ARD (NIV Category 1) and 7 (30.4%) occasions of comfort care at the end of life (NIV Category 2). The main cause of ARD was pneumonia (90.3%) due to either aspiration or infection. The modality of NIV used was BiPAP only (14 occasions, 60.9%), CPAP only (three occasions, 13%) and both BiPAP and CPAP (six occasions, 26.1%). The median duration of NIV usage was four days (minimum one day and maximum 15 days). NIV was initiated as an escalation from nasal prong, Ventimask or high-flow mask oxygen on 22 occasions and as weaning down post-extubation on one occasion. For the 22 occasions of escalating therapy, there was significant improvement at six hours compared to pre-NIV in the median heart rate (136 to 121, P=0.002), respiratory rate (40 to 31, P=0.002) and oxygen saturation (96% to 99%, P=0.025). All 17 documented parental impressions of the child’s condition post six hours of NIV were that the child had improved. Adverse events during short-term NIV include five episodes (21.7%) of stomach distension, four episodes (17.4%) of skin sores on the face and one episode (4.3%) of excessive drooling. Three patients passed away while on NIV in the hospital. For the other 20 (87%) occasions, patients were able to wean off NIV. Post-weaning off NIV, three patients passed away during the same admission. On 17 occasions, patients were discharged home after weaning off NIV. Conclusion: Usage of short-term NIV in paediatric palliative care, where children have an advanced directive in place indicating DNI, as seen in our study, can be a valuable modality of management for distressing symptoms, in addition to the pharmacological management of breathlessness. This is shown through our study to be of benefit in potentially reversible ARD as well as comfort care at the end of life. Further rigorous studies will need to be conducted for a clearer understanding of short-term NIV that would enable the formulation of guidelines to improve the quality of life and death in children.

1882 Treatment Escalation Plans (TEP): benefits in adult in-patient facilities

Abstract Introduction Treatment escalation plans (TEP) guide level of life sustaining therapeutic interventions that should occur for each patient admitted to hospital and can prevent inappropriate and undignified interventions. However, implementation of TEP in routine clinical practise has been ad hoc partly due to the paucity of literature on their benefits. Our aim was to systematically review the literature to ascertain the use and benefits of TEP in adults. Methods A systematic search for studies reporting TEP use were performed in the databases OVID Medline, Embase, Scopus and Web of Science. Search terms were ‘Treatment Escalation Plan’ Treatment Limitation, ‘Therapy Escalation’, ‘Escalation of Care’, ‘Palliative’, End of Life’, ‘Advanced Care Plan’. Exclusion criteria included studies prior to 2007, systematic reviews, case reports and letters. Results 468 records were retrieved, 117 duplicates removed, 351 records were screened. 302 were excluded by date or relevance. Of 49 eligible records, 39 were excluded by criteria or unavailability of full text articles. 10 Studies using case control and quality improvement methodology conducted between 2010-2022 involving 1614 patients were subject to a narrative review. 8 different TEP proformas were used. All studies reported an increase in TEP use across all clinical settings and after each PDSA intervention ranging from 78%-100%. TEP reduced the frequency of non-beneficial interventions and was associated with an average saving of £220 per patient. Conclusions TEP lead to more frequent and proactive discussions with patients on ceilings of care and provide clear guidance to clinical staff out of hours, facilitate patient handover over successive shifts and enable proactive discussions with critical care. We identified the need for TEP to be successfully implemented in a unified manner across all healthcare facilities in order to improve patient care, reduce the burden of non-beneficial interventions and align with the NHS Long Term Plan.

HPB O03 ERCPs and Biliary Stenting for Ductal Stone Disease: A Call for a National Database

Abstract Background According to the European Society of Gastrointestinal Endoscopy, in the context of complicated biliary stone disease, plastic stenting of the biliary tree via endoscopic retrograde cholangiopancreatography (ERCP) temporarily provides drainage of a blocked or infected biliary system. However, there is high mortality and morbidity associated with long-term endoprostheses; cholangitis as one of the main complications. Therefore, plastic stenting should only be used for a period of up to 6 months, according to latest guidelines. Our aim was to compare Trust practice with international recommendations, identifying potential causes for prolonged stent placement in patients with choledocholithiasis, and to discuss possible solutions. Methods Patients who underwent an ERCP across a 3-year period from NHS secure server records were identified, with further analysis of patients undergoing plastic biliary stent insertion. Results Of the 1118 ERCPs performed, 281 underwent plastic stenting for choledocholithiasis. Some patients were not suitable for cholecystectomy, so stents were accepted as the ceiling of care. 29 had stents in situ for over 6 months, while waiting for surgery. Of the 75 who had proceeded to cholecystectomy, 57 subsequently had stents removed in the trust. 18 still had plastic stents in situ. 5 had stents removed elsewhere, one of whom developed cholangitis and sepsis, requiring removal of the infected stent at a tertiary centre. Two patients were no longer fit for removal, and two had spontaneously passed their stents. Conclusions Retained biliary stents is not a rarity. There are many factors leading to delays, including long waiting lists for surgery, lack of requests to the endoscopy department and patient choice. Extrapolation of this single-trust audit would suggest that many sites are not meeting international guidelines for the duration of indwelling plastic stents. We suggest the implementation of a national database to monitor all patients with biliary endoprostheses to reduce morbidity associated with retained stents. We also recommend that incidents where harm is caused by plastic stents remaining in situ for greater than six months be treated as a Never Event.

ThTP3.2 Introducing a ward round template to improve the quality of documentation on the general surgery ward round

Abstract Aims We aimed to improve documentation on general surgical ward rounds, through the introduction of a ward round template at a single UK surgical unit. Methods The structure of the template was adapted from the ‘Surgical Assessment for Emergencies Ward Round Tool’ produced by the RCSEd, with modifications based on local requirements. A retrospective audit was performed of 4 weeks of electronic ward round notes prior to, and 4 weeks after the introduction of the template. Ward round notes on 2 chosen days (Wednesdays and Saturdays) during the 4 week study periods were included for analysis. We observed how frequently specific important clinical information was documented. Results 378 electronic ward round notes were analysed (176 before, and 202 after the introduction of the template). The ward round template was used, either in part or in full, in 72% of ward round notes following it’s introduction. An pre-existing structured electronic ward round note had previously been used in only 1% of cases. How frequently each of the following components was documented when using the template was: important admission events (86%), VTE prophylaxis (93%), nutritional status (76%), review of prescribed antibiotics (91%) and ceiling of care (65%). We demonstrated statistically significant improvements for each of these components (p<0.05) from pre-template rates (73%, 16%, 63%, 51% and 2% respectively). Conclusion The introduction of a ward round template vastly improved the frequency with which a structured approach to ward round was taken. In doing so, significantly improving the documentation of important clinical information.

Improving documentation regarding ceilings of care upon intensive care unit discharge: a quality improvement project

Improving documentation regarding ceilings of care upon intensive care unit discharge: a quality improvement project

776 INTRODUCING TREATMENT ESCALATION PLANS (TEP) FOR OLDER PERSONS: RESPONSE TO THE COVID-19 PANDEMIC

IntroductionTEP detail appropriate ceilings of care and guide treatment of patients based on shared decision making. TEP documentation was not standard within our trust up to 2018. We aimed to design and introduce a standardised TEP proforma and evaluate its use in older persons aged ≥80.MethodsData was obtained from patient notes and questionnaires within the Medicine for Older Persons department (MOP) from four PDSA cycles between 2018–2020. Cycle 1 was a service evaluation. Based on this data, a TEP form was created and approved for use in all adult patients. Cycles 2, 3 and 4 evaluated TEP after introduction of the proforma.ResultsThere was a 239% increase in TEP after introduction of the proforma, compared to baseline (cycle 1: n = 14/47 [29.8%], cycle 2: n = 17/112 [15.2%], cycle 3: n = 30/97 [30.9%], cycle 4: n = 42/59 [71.2%]). The increase in TEP between cycles 3 and 4 coincided with the COVID-19 epidemic. Clinicians were more confident in actioning TEP based on the proforma, compared to those written in the notes (cycle 2: 83% confidence vs 54%, cycle 3: 100% vs 35%, Cycle 4: 98% vs none written in the notes). An improvement in understanding the purpose, comprehensiveness and location of TEP forms was observed. Feedback suggested TEP provided clear guidance for 1. ceilings of care; especially useful out of hours 2. discussions with critical care and 3. patient handover between staff and successive shifts.ConclusionTEP forms offer clear guidance on ceilings of care. Introduction of the TEP proforma has led to more frequent and proactive discussions with patients on ceilings of care and have facilitated a culture change in the management of older persons. Use of the forms increased during the COVID-19 pandemic but are now viewed as an essential component of patient safety and have been successfully implemented trustwide.

794 STANDARDISED SOCIAL HISTORY DOCUMENTATION IN MEDICAL CLERKING IMPROVES IDENTIFICATION OF FRAILTY

Abstract Background Thorough social history is a crucial component of a medical admission. Understanding a patient’s functional status enables better assessment of their Frailty and better decisions about aims of treatment, rehabilitation, appropriate escalation and ceilings of care. Introduction The Medical Unit at St John’s Hospital Livingston, Scotland admits approximately 11,280 patients per year, of whom 55% are aged ≥65 years. Following a medical clerk-in, all admissions aged ≥65 years are screened for Frailty by a dedicated Frailty Nursing team using the Clinical Frailty Score (CFS) based on information in their electronic casenotes. Methods We assessed the quality of social history documentation and the accuracy of CFS in 202 medical admissions ≥65 years clerked in by medical staff over a 2 week period from 14th to 31st December 2020. Patients at end of life and those reviewed by the Frailty Advanced Nurse Practitioner prior to medical clerk-in were excluded. 3 months later this was repeated for 188 medical admissions from 12th–26th March 2021 following interventions below. Interventions An education session was delivered to trainee doctors and consultants at the Medical Unit Meeting. A pre-populated proforma was added to the electronic medical clerking document containing these prompts • Accommodation • Mobility/use of aids • Activities of daily living • Support family, district nurses • Cognition A dedicated field for Clinical Frailty Score was also added. Results Following intervention, documentation of social history and CFS increased from 22% to 35%. The pre-populated proforma was used in 21% of patients. In these patients, 95% had all areas of social history documented enabling accurate classification of CFS. Conclusion Using the pre-populated proforma significantly improves social history documentation and accuracy of CFS scoring. A change of culture is required particularly amongst junior doctors on the importance of this information, so we can deliver better patient-centred care.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach.

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

A propensity score matching analysis for CPAP versus conventional oxygen therapy as a ceiling of care in COVID-19-associated type 1 respiratory failure

Background Continuous positive airway pressure (CPAP) is increasingly used as a ward ceiling of care. Nevertheless, little is known about its effectiveness. Objective A retrospective study to explore whether CPAP therapy as a ceiling of care improves outcome in coronavirus disease 2019 (COVID-19)-infected patients with acute respiratory failure. Methods A retrospective cohort study was conducted on adult COVID-19-infected patients admitted to two UK hospitals from the March 1 to June 30, 2020. All patients experienced type 1 respiratory failure and were not suitable for intubation. They were divided into two groups: patients for CPAP versus conventional oxygen therapy (COT). Results A total of 39 patients received CPAP, whereas 247 received COT. CPAP group patients were more hypoxic (mean SpO2 86.5% vs. 91%, P=0.003), younger (mean±SD: 71.8±8.8 vs. 80.7±9.8 years, P<0.001), and less frail than the COT group [median (interquartile range) clinical frailty score 4 (3–5) vs. 6 (4–7), P<0.001]. Overall, 35 patients died in the CPAP group (89.7%) compared with 185 patients in the COT group (74.9%) (P=0.041). Propensity score matching of the two groups showed that CPAP was still associated with higher mortality (90.3 vs. 67.7%, P=0.029). Length of hospital stay was similar in both groups (mean±SD 9.2±7.3 vs. 9.7±8.6 days, P=0.719). Conclusion In COVID-19-infected patients presenting with type 1 respiratory failure and deemed not suitable for escalation to intubation, the use of CPAP therapy does not carry extra benefit than COT. In such patients, COT appears to be the appropriate measure. Further studies are required to corroborate these findings.

27 A COLLABORATIVE QUALITY IMPROVEMENT PROJECT BETWEEN AN NHS TRUST AND INDEPENDENT PROVIDER TO DEVELOP A CARE-HOME SPECIFIC TREATMENT ESCALATION PLAN

BackgroundThe COVID19 pandemic highlighted deficiencies in information exchange around treatment escalation plans (TEP) in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.TEP documentation is a component of RESTORE2 use, as recommended in the British Geriatric Society Good Practice Guide for Managing COVID19 in Care Homes.MethodsSemi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of TEP.An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for a TEP. Three iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.ResultsAreas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 90%, Cardiopulmonary Resuscitation (CPR) status clarity; 90%, treatment ‘ceiling of care’ e.g. ‘conveyance to the Emergency Department in any situation that the clinical team deem necessary’; 40%, conversations with out-of-hours services/external clinicians around appropriate actions; 30%, conversations with nominated persons around appropriate actions.ConclusionThe TEP incorporates more than just CPR status and contributed to increased nursing team confidence in responding to the acutely deteriorating adult appropriately in a care home environment. Clear documentation of: capacity assessment; patient prioritisation (using ReSPECT principles); and agreed treatment escalation and limitation, enabled information exchange. Standardisation of language, and cross-fertilisation with Nursing Handover, facilitated conversations with external clinicians and nominated persons.Tailoring the TEP to the care-home environment and rendering it generalisable to non-intermediate care, non-geriatrician supported care home microsystems was considered in the iterations.

COVID-19 Mortality in Patients with a Ward-Based Ceiling of Care

Objectives: COVID-19 patients thought unlikely to benefit from organ support, thereby having a ward-based ceiling of care (WBCoC), represent a distinct subgroup. There are no associated studies in mortality. We sought to identify clinical risk factors for inpatient COVID-19 mortality. Design and setting: this was a retrospective observational study of patients admitted to Northumbria Healthcare NHS Foundation Trust. Clinical variables were associated with inpatient mortality via logistic regression. Participants: all patients admitted with COVID-19 infection and who had a WBCoC at point of admission were included (n = 114). Main outcome measures: the outcome measure was inpatient death.

Physiotherapy-led awake proning for a frail elderly patients with COVID-19: A case study

Coronavirus disease (COVID-19) can cause significant damage to the lungs, potentially resulting in acute respiratory distress syndrome (ARDS) (Weatherald et al. 2020). An adjunct of treatment for this is awake proning to improve oxygenation and may prevent intubation (Paul et al. 2020). This case report describes a self-ventilating 85-year-old gentleman with COVID-19 and acute hypoxemia, who experienced significant improvements in oxygenation with proning. His ceiling of care was high flow oxygen therapy (HFNC) on the ward and it was deemed clinically appropriate to commence a trial of physiotherapy led awake proning. Although the patient failed to meet the criteria outlined by the Intensive Care Society (ICS) guidelines for awake proning, after multi-disciplinary (MDT) discussion, it was felt a trial of awake proning should be piloted in the patient’s best interest. He was on 15L oxygen via non-rebreather mask for a number of days as he was acutely delirious and not tolerating HFNC. With proning, an average reduction in oxygen of nearly 20% was noted with an increase in SpO2 of 4.6%. Over a 3-week period his oxygen requirements and saturation levels improved dramatically which could be assosicated with awake proning. Our case study illustrates that awake proning can form a vital part of the COVID-19 management plan. It played a crucial role in the patient’s recovery despite not meeting the criteria set out by the ICS. This highlights that guidelines are recommendations and need to be considered on a case-to-case basis along with clinical judgement and MDT discussion.

EP.TU.481Quality of Surgical Ward Rounds in a District General Hospital: an audit

Abstract Aims The fast-paced surgical ward round, alongside numerous competing distractions and demands, can result in poor rounds and subsequent imperfect documentation. This carries significant medico-legal implications. This audit assessed the standard of surgical ward round documentation at a district general hospital, against Royal College and other published guidelines. Methods A retrospective data collection of adult general surgical patients was undertaken over a period of eight weeks. We excluded bank holiday, weekends and paediatric cases. Documentation during ward rounds in patient notes were analysed and compared against the guidelines. Results 166 patient notes were included. Percentage compliance was assessed as a total, minus cases where not applicable. Good compliance ( > = 75%) was achieved in the majority of data points, including: date (100%), time (83%), ward round lead (99%), legibility (88%), early warning score (78%), current issues (80%) and management (100%). Poor compliance ( < = 25%) was seen in: presenting complaint (25%), fluid balance (16%), intravenous fluid review (21%), catheter review (23%), radiology results (25%), urinalysis (4%), beta HcG (0%), drug chart review (23%), antibiotic review (15%), assessment of venous thrombo-embolic risk (0%) and ceiling of care (1%). Conclusion Accurate, clear and complete documentation is crucial for patient safety and continuity of care, as well as for medico-legal reasons. This study shows there are several areas requiring improvement. The authors propose a proforma including the essential criteria to be integrated into the daily ward rounds.

783 Digital Weekend Handover an Effective Documentation

Abstract Aim To assess quality of completion for weekend handover for surgical weekend and to plan and design a Digital handover, the implementation and effect of which is studied. Method Data collection from TRAKCARE for documentation completion criteriae including diagnosis, further investigations to chase (e.g., bloods, imaging), discharge plans, escalation and DNAR status identified. First cycle collected in August 2020 for pre-implementation status and standard. Second cycle was collected after implementation and raising awareness about new system in October 2020. Exclusion criteria: patients discharged prior to weekend Results 32 (10f 22m) and 22 (9 f 13m) patients were studied in first and second cycle with a respective median length stay of 243 hours and 161.5 hours. Handover entries had improved from 40.6% completion rate to 77.3% these included a diagnosis and management plan. Required blood investigation plans were recorded in 54.5% patients (previously 9.4%). Escalation plans including DNACPR and ceiling of care were improved from 25% to 31%. Conclusions Digital Medical recording left a gap in documentation for weekend ward rounds when personnels are thinned and busy. To optimize clinical care, the use of a E weekend handover has improved documentation greatly. Future Ongoing project includes improving escalation plans further.

670 Documentation and Communication of National Emergency Laparotomy Audit (NELA) Mortality and Morbidity Scoring with Patients Prior To Consenting: Are We Following the Best Practice?

Abstract Aim Patients presenting as an emergency have a greater risk of dying than those admitted electively. The ability to stratify risk and calculate a percentage chance of death, not only gives the clinical team a common language to be able to formulate a management plan but also enables them to communicate this with patients and their families. This includes a full explanation of potential risks, benefits, a ceiling of care and management alternatives. In this project, we assessed if the NELA score has been properly calculated, documented prior to surgery for every emergency laparotomy patient and whether such patients were aware of NELA risk predictions prior to consenting. Method This was a retrospective audit based on the NELA guidelines of pre-operative risk stratification and the fifth report NELA recommendations. We assessed 50 case notes of patients who had laparotomies from January 2019 to April 2020 in a busy district general hospital in the UK. Results We noted that NELA risk prediction score was not utilised/documented in most of the patients with compliance of only 26%. We also found that, in the majority of notes, no NELA score discussion with the patient/family was documented, even with patients who had their NELA score calculated preoperatively. Compliance was only 14% in relation to this category. Conclusions A formal assessment of the risk of mortality and morbidity should be made explicit to each patient and should be recorded clearly in the consent form and medical record.

799 Do Not Attempt Cardiopulmonary Resuscitation Decisions in Neck of Femur Fractures – Is Documentation Adequate?

Abstract Introduction ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation is essential to communicate decisions regarding ceilings of care for patients to the clinical team. Patients admitted to hospital with a fractured neck of femur (#NOF) are often elderly with multiple comorbidities, and so robust and clear anticipatory care plans are especially indicated. Method All patients admitted to a large district general hospital in Scotland with a #NOF over a three-week period between 23/10/2020 and 12/11/2020 were identified prospectively and included in this audit. Patients’ demographic information, DNACPR status and the quality of their DNACPR documentation was recorded. Results 20 patients (85% Female, 15% Male) were identified and included. Median ASA grade was 3, with 77.8% of patients ASA grade 3 or 4. 63.2% of patients had DNACPR documentation in place, all of which were ASA grade 3 or above. Most DNACPR documentation had patient information clearly identifiable (91.7%), was completed preoperatively (90.9%), and involved either the patient or appropriate relative or power of attorney (91.6%). However, only 75% of patients’ documentation had the rationale for the DNACPR decision documented and only 25% of DNACPR decisions were reviewed by a senior clinician within 72 hours. No DNACPR decisions were documented as having been communicated to the wider healthcare team. Conclusions DNACPR documentation is a crucial for anticipatory care planning in #NOF patients. This audit shows improvement is needed in documenting whether decisions have been reviewed by senior clinicians, and if they have been communicated to the wider healthcare team.

Natural language word embeddings as a glimpse into healthcare language and associated mortality surrounding end of life

ObjectivesTo clarify real-world linguistic nuances around dying in hospital as well as inaccuracy in individual-level prognostication to support advance care planning and personalised discussions on limitation of life sustaining treatment...

Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation.

BackgroundContinuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV.MethodsThis retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale ≤ 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1st March to May 31st, and from 1st September to 31st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO2 ≥0.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering.FindingsSeven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it.InterpretationNo survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting.FundingL Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre.

CPAP delivered outside critical care during the second wave of COVID-19: outcomes from a UK respiratory surge unit

BackgroundNHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling...

Outcomes of Continuous Positive Airway Pressure in the Management of Patients with Coronavirus (COVID-19) Pneumonia who are not Suitable for Invasive Ventilation.

Background:The optimum management of respiratory failure in patients with coronavirus (COVID-19) infections has been a challenge for physicians across the globe. Many scientific societies have suggested the use of CPAP (continuous positive airway pressure) in severe cases in an effort to reduce invasive ventilation. We investigated mortality outcomes in patients who needed CPAP but were not suitable for invasive ventilation.Methods:We retrospectively evaluated the mortality outcomes of all consecutive COVID-19 cases with severe type 1 respiratory failure requiring FiO2 >0.6 who were admitted to our hospital between 12th March and 04th May’20. British Thoracic Society guidelines were followed for identifying patients needing CPAP. Their outcomes were recorded and compared with a similar group of patients who had oxygen as a ceiling of care. Prospectively collected data between 5th May and 7th June’20 in similar but smaller groups of patients was also analyzed.Results:A total of 104 COVID-19 patients with documented Do Not Attempt Resuscitation (DNAR) decision required high fraction of inspired oxygen (FiO2) >0.6(to maintain peripheral oxygen saturation (SpO2)> 92%(SpO2> 88% in COPD patients). Twenty-four patients received CPAP as the ceiling of care, with a mortality rate of 92.5%. The remaining 84 patients who were on oxygen as a ceiling of treatment had 91.7% mortality. Both population groups had a similar number of comorbidities but were less favorable in terms of age in the control group with standard O2 therapy than those who had CPAP support. Overall mortality outcomes from using CPAP therapy did not bring significant mortality benefit (p-value-0.89).Conclusion:CPAP did not appear to improve the survival of patients with severe respiratory failure due to COVID-19 related pneumonia and were not suitable for invasive ventilation. Further studies are warranted to adequately inform appropriate management strategies for this group of patients.