Implementing ReSPECT during the pandemic – our experience and lessons learnt

IntroductionReSPECT was implemented in The Royal Wolverhampton NHS Trust and across the wider Wolverhampton health economy on 1st September 2021. This was the culmination of a year's planning and preparations during the first and second waves of the COVID pandemic.MethodsA ReSPECT implementation group was established across the organisation in September 2020 which focused on areas including writing a revised resuscitation policy, agreement for and design of one-off mandatory modules for awareness and authorship training and development of a trust wide communications campaign. Amendments to the policy have allowed expansion of authorship to selected groups of non-medical staff including senior specialist nurses and ACPs with appropriate expertise.The group liaised with partners to ensure a successful city-wide launch including primary care and hospice colleagues. An organisation wide roll out was supported by ward ‘ReSPECT Champions' in each area.Results and Lessons Since LaunchMandatory training modules for ReSPECT authorship and awareness training were developed for approximately 7000 clinically facing staff with a target of 75% training compliance prior to launch. Training compliance was monitored weekly in preparation for launch and then subsequently, monitored monthly once target compliance was achieved. Over the last year ReSPECT has become embedded within the organisation and across the city. This has included a change in culture from the previously used DNACPR forms. Developments following launch include an addition to e-discharge document to include whether a ReSPECT form is in place and from this a monthly quantitative audit has begun across inpatient areas. Collaborative working has continued across the city to enable clear communication regarding ReSPECT and shared resources e.g., Top tips newsletters. Future ongoing work focusses on improving the quality of ReSPECT forms and education surrounding the ongoing review of ReSPECT forms during acute admissions and at significant milestones in a patient's condition.

NIV withdrawal during the COVID-19 pandemic: a palliative care team’s experience

BackgroundThe COVID-19 pandemic required clinical teams to rapidly adapt to emerging healthcare challenges.1 Non-invasive ventilation (NIV) has a key role in managing respiratory failure secondary to COVID-19,2 but mortality remains high.3 There was a lack of national guidance on managing deteriorating patients where NIV was the ceiling of treatment.4 The Royal Wolverhampton NHS Trust’s Palliative Care and Respiratory teams developed local guidelines to provide high-quality symptom control and end-of-life care for these patients. An audit was conducted to assess the effects of implementing this protocol during the pandemic’s second wave.MethodsA retrospective case note review was conducted on all patients who received NIV on the acute Respiratory ward during 01/08/2020–31/03/2021. Data was collected on initiation and duration of NIV support, Palliative Care input, reasons for and medications used during NIV withdrawal, and provision of holistic care.Results588 COVID-19 patients were admitted during this time. 239 received NIV, and 136 died during this admission. The Palliative Care team were involved in 63 of 293 patients who received NIV. NIV was withdrawn in 82.5% (n=52) of patients known to Palliative Care, most frequently due to clinical deterioration (60.0%, n=31). All patients known to Palliative Care were prescribed anticipatory medications;71.4% (n=45) were commenced on a continuous subcutaneous infusion (CSCI). In all Palliative-Care-led NIV withdrawals (n=24), symptoms were managed effectively with PRN opioids/benzodiazepines. Patients remained comfortable at the time of death, and no concerns were raised by patients, families or clinical teams regarding the decisions or process of NIV withdrawal. 11 remained on NIV until death due to several reasons, including patient request.ConclusionsLocal guidelines were adhered to during NIV withdrawal and provided a clear strategy for symptom management in critically unwell COVID-19 patients. Early involvement of Palliative Care team allowed a holistic and proactive approach in complex cases.ReferencesEvans L, Atkinson C, Byrne A: Lessons from the First Wave: Developing symptom control guidance for COVID-19 patients who are deteriorating despite non-invasive ventilation (NIV) as their ceiling of treatment). BMJ Supportive & Palliative Care. Nov 2020 https://blogs.bmj.com/spcare/2020/11/16/lesson-from-the-first-wave-developing-symptom-control-guidance-for-covid-19-patients-who-are-deteriorating-despite-non-invasive-ventilation-niv-as-their-ceiling-of-treatment/National Health Service (NHS). Guidance for the role and use of non-invasive respiratory support in adult patients with coronavirus (confirmed or suspected). NHS, 2020. https://anaesthetists.org/Portals/0/PDFs/COVID-19/CLEARED_Specialty-guide_-NIV- respiratory-support-and-coronavirus-v2-26-March-003.pdfAshish A, Unsworth A, Martindale J, et al. CPAP management of COVID-19 respiratory failure: a first quantitative analysis from an inpatient service evaluation. BMJ Open Respiratory Research 2020;7:e000692. doi: 10.1136/bmjresp-2020-000692Webber N, Avari M, Harridge G, et al. Implementing a novel protocol for withdrawal of CPAP support in COVID-19 patients: a case series. Clinical Medicine 2021;21(3). doi:10.7861/clinmed.2020-1086