NIV could be used on medical wards for patients with pH 7.16 or greater on their first admission, although more conservative values should continue to be used for those with a second or subsequent episodes of AHRF.

Introduction and objectivesOptimal utilisation of critical care resources requires timely discharge of patients from critical care to appropriate wards. This represents a challenging and high risk transition. Local audits revealed that a few multimorbid patients with difficult respiratory weans accounted for 30% of critical care bed days. A weekly ventilation multidisciplinary team (VMDT) meeting combining respiratory and critical care expertise was established at a 692-bed hospital to improve management and resource use for this patient group. The effect was compared to a 2nd hospital within the same trust without VMDT.MethodA retrospective comparison of 6 month periods before (period 1: 1/10/07–31/3/08) and after (period 2: 1/10/12–31/3/13) introducing VMDT was carried out using data collected for Intensive Care National Audit and Research Centre. The same data was collected for a sister hospital, belonging to the same trust, without VMDT. The numbers of discharges to a respiratory ward with non- invasive ventilation (NIV) facilities were compared with Chi-Square test. The numbers of level 1 critical care bed days were compared with T test.ResultsIn period 1, hospital 1 discharged 458 patients from critical care and hospital 2 discharged 456. In period 2 these figures were 494 (p = 0.30) and 495 (p = 0.84) respectively. There was no change to background parameters. The number of discharges to respiratory ward with NIV facilities increased significantly in hospital 1 (36 to 65, p = 0,011) after VMDT. Whilst the number of patients discharged to respiratory ward increased in hospital 2 this was not significant (9 to 19, p = 0.13). The number of level 1 bed days fell significantly (208 to 18, p < 0.0000000001) in hospital 1. Hospital 2 saw an increase in level 1 days over the same period.ConclusionIntroduction of VMDT increased the proportion of respiratory patients discharged to a respiratory ward from critical care and reduced level one bed days in hospital 1 by expediting the discharge of complex respiratory wean patients thereby increasing patient flow and liberating critical care resources. The same reduction was not observed in the hospital 2 suggesting this effect was not due to trust wide changes in critical care practice.

Introduction NIV for acute hypercapnic respiratory failure (AHRF) in COPD, obesity related morbidity, chest wall and neuromuscular conditions has become widespread in the UK over the past decade. In terms of acute NIV set up, the BTS/Royal College of Physicians/Intensive Care Society 2008 guidance recommends starting with an inspiratory positive airway pressure (IPAP) of 10 cm H2O and expiratory positive airway pressure(EPAP) of 4–5 cmH2O, with small increments in IPAP aiming for apressure target of 20 cm H2O or until therapeutic response is achieved. We felt it necessary to analyse trends in maximum pressures achieved in the evolution of a respiratory ward-based NIV Unit (established2004). Methods Comparison of the in-house NIV registry data01/08/2004 –31/01/2006(Period 1) with 01/01/2011–30/06/2012 (Period 2) at an 11-bedded ward-based NIV unit within a1000-bedded hospital Trust in central England, looking at maximum IPAP and maximum EPAP achieved. There were 281 episodes of AHRF treated in Period 1 and 240 in Period 2 with similar distribution of gender. Results Maximum IPAP achieved for period 2 was significantly higher than period 1 (median IPAP max achieved=20 cmH2O vs. 14 cmH2O; Wilcox on rank sum test p=2.2 × 10–16) and the maximum EPAP achieved for period 2 was higher than period 1 (median EPAP max achieved=5 cmH2O vs. 14 cmH2O; Wilcoxonrank sum test p=8.068 × 10–6). Discussion We have previously shown that we achieved adequate therapeutic response with median IPAP max of 16.7 and median EPAP max of 5.2 cmH2O (Ali A et al. Pressure support in acute hypercapnic respiratory failure in an acute clinical setting. European Respiratory Journal 2011; 38:55. 683s.). However, as the ward-based, physiotherapy-intensive, multidisciplinary NIV service matures over an 8-year period, we are achieving significantly higher maximum IPAP and maximum EPAP. This is probably (a) in keeping with the increasing severity of AHRF that is being treated in the unit with similar in-hospital mortality (around 22%) and (b) demonstrates a learning curve. Further analysis of population characteristics and comparison with units of similar size may give further insights intoorganisational learning in relation to NIV. Abstract P220 Figure 1 Comparison of the distribution of the maximum IPAP achievedComparison of the distribution of the maximum EPAP achieved

Wilcoxon rank sum test: p=0.03134; pH significantly lower in Period 2 Wilcoxon rank sum test: p=0.