Are junior doctors struggling to gain experience in non-invasive ventilation?

Josheel Naveed, Alexandros G. Mathioudakis, Thomas Bongers
Respiratory Department, Southport and Ormskirk NHS Foundation Trust

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Cite as: Naveed J, Mathioudakis AG, Bongers T. Are junior doctors struggling to gain experience in non-invasive ventilation? Alveolus 2013; 1(2):19-21

Introduction

According to the National Institute for Health and Clinical Excellence (NICE) guidance, there should be local arrangements for the prompt assessment and delivery of non-invasive ventilation (NIV), by appropriately trained staff in a dedicated setting in every hospital[1]. NIV refers to the provision of ventilatory support through the patient’s upper airway using a mask or similar divice. NIV has been proved to reduce the mortality, need for intubation and hospital and ICU lenght of stay, in selected patient groups. In our hospital, the medical team indicates the need for NIV and afterwards well educated nurses or the respiratory team usually takes over. The purpose of our study was to investigate the current knowledge and competence amongst doctors of various grades expected to come across an NIV patient in our hospital.
 

Methods

An anonymous questionnaire-based survey was handed out to doctors of various grades, in Southport and Ormskirk NHS Trust, between October and November 2012. Only medical doctors and foundation trainees with medical rotations were included. The questionnaire was designed to primarily test knowledge, experience, contraindications and some of the common problems surrounding NIV use, in different levels of medical training.

Results

The response rate was 82.9% (58/70). 52% of the responders were foundation programme trainees, 33% were core medical trainees, 12% medical registrars and 2 were consultants. 7(12%) doctors received no teaching/training about NIV. 19(32%) rated their NIV training as poor. 34(59%) doctors who had used NIV stated that they had low confidence when using it but knew what IPAP and EPAP stands for. A considerable proportion of the participants (17%) were not able to recall what do IPAP and EPAP stand for. Only 23(40%) doctors were able to change the appropriate settings to correct hypercapnia or hypoxia. 53% of the doctors recognised contraindications for NIV. Only 22.5% were able to distinguish between relative and absolute contraindications. 11 doctors felt confident in setting up NIV on a patient. A total of 41% of the participants were able to adjust correctly the settings of Bi-PAP in order to correct hypoxia or hypercapnia. Senior doctors were more confident and scored better in the contra-indications and basic settings (p<0.05). Doctors with previous or current placements in respiratory medicine also scored better.

Figure 1. Training in using NIV

Figure 2. Basic knowledge on NIV

 

Discussion

Our study highlights a lack of experience and training, among junior medical doctors, in using NIV. On the other hand, current guidance and targets of the Royal College of Physicians (UK) suggest that every emergency admission should be seen by a consultant during the first 12 hours and every inpatient every 24 hours[2]. In this time-span, the management of the patients is lead by junior or middle grade doctors, who must consequently be adequately trained and experienced.

Conclusion

This study has highlighted that junior doctors have poor knowledge, lack of training and low confidence in using NIV. Currently, improvements need to be made in delivering the training to achieve competency in administering and managing a patient on NIV, especially outside of normal working hours. However, these could be easily remedied with simple education. We propose that training sessions are organized for trainees by integrating NIV scenario into simulation training days.

References:
[1] Non-invasive ventilation in acute respiratory failure. British Thoracic Society Standards of Care Committee. Thorax 2002;57:192–211
[2] Royal College of Physicians. Care of medical patients out of hours – RCP position statement. London, 2010.

Conflicts of interest: None to declare