CPAP machine

Report examines COVID-19 breathing equipment safety risk

by Communications team

Our latest report shows that monitoring patients who need special equipment to support their breathing when they are not in a critical care unit is crucial to ensuring their safety.

This comes after we undertook an investigation focused on treating COVID-19 patients with Continuous Airway Pressure (CPAP). CPAP is a form of respiratory support that is used when a patient is awake and able to breathe on their own. This is usually delivered via tubing and a mask or hood.

The investigation explores the use of the CPAP outside of critical care and high dependency units during COVID-19 and specifically the risks of caring for patients in the side rooms of general wards. The report highlighted that in critical care units, staff are trained and familiar with CPAP and also there is a higher number of staff to patient ratio. However, during the first and second wave of the pandemic, many more patients needed CPAP than there were beds in critical care and hospitals had to create alternative areas and arrangements for delivering and caring for patients that need CPAP.

To illustrate the potential safety risks of caring for patients in the side rooms of general wards, we examined the reference case of Terry, a 73-year old man. He was admitted to hospital with symptoms of COVID-19 and needed CPAP to support his breathing. On the second day after admission, 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 his breathing was not supported. Staff attempted to resuscitate him but they were not successful and Terry died.

The national investigation emphasised that patients with COVID-19 who require CPAP need a close level of supervision. Caring for patients inside side rooms on general wards poses a safety risk as staff can’t easily see the patient. This is unless there is central monitoring - staff at the central nurses’ station - who can observe patients via monitors that duplicate the bedside monitors screens and alarms.

In addition, equipment alarms designed to alert staff to a problem often cannot be heard outside of the room. Central monitoring on a general ward is also reliant on staff being at the central nurse’s station to see the monitor, which is not always possible in busy ward environments.

The investigation highlights areas that have been recognised as significant during the NHS response to the COVID-19 pandemic to date, in particular:

  • workforce gaps and skills needed to meet demand, both on general wards and in critical care environments.
  • challenges with delivering treatment outside normal clinical areas.
  • challenges for staff working outside their normal clinical areas.
  • the use of equipment that may have design limitations, particularly if used outside the environment for which it was intended.

The investigation identified that recommendations to address safety risks have already been made by national organisations and doesn’t make any further safety recommendations. The report highlights what the guidance is and asks the NHS to act on that national guidance when treating patients outside of a critical care setting. The report also poses six ‘safety questions’ that Trusts can use to consider their own policies and process.

Kathryn Whitehill, Principal National Investigator at HSIB says; “ The sheer number of patients with COVID-19 needing respiratory support meant the NHS had to adapt and make the best use of their space and resources to meet the demand and minimise the risk of spread of infection. This highlighted a safety risk outside of critical care and high dependency areas and particularly for patients requiring breathing support like CPAP in side rooms on general wards. In a side room, monitor alarms cannot be heard and the patient and monitoring equipment they are connected to cannot be seen unless a healthcare professional is present at all times.

“This investigation emphasises the enormous pressure placed on staff and is a reminder of the devastating impact the pandemic had on patients and families like Terry and his family. This investigation is a detailed analysis of the safety risk, with findings that can be shared at national level and across NHS trusts. We encourage organisations to examine their own practice, and act on the existing guidance and resultant recommendations to ensure the safest possible care for patients going forward.”

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