Respiratory Support Units: guidance on development and implementation
The British Thoracic Society (BTS) and the Intensive Care Society (ICS) have published guidance that aims to set the standards for the establishment and operation of Respiratory Support Units across the UK.
A Respiratory Support Unit (RSU) is a dedicated area of a respiratory department where enhanced respiratory care and monitoring can be provided to patients, by highly specialised multi-professional teams, using techniques including Non Invasive Ventilation (NIV), Continuous Positive Airway Pressure (CPAP), High Flow Nasal Oxygen (HFNO) and other complex respiratory support. RSUs function at the interface between respiratory and critical care, and provide optimal care for these patients in the correct environment by facilitating transfer of patients from one care area to the other depending on the severity of their condition, optimising resources in the patients’ best interests.
Similar arrangements were already in existence in various forms and under different names in some hospitals before the pandemic, and proved instrumental in caring for some of the most acutely ill COVID-19 patients outside of critical care, and so preserving critical care capacity. NHS GIRFT (2) reported that hospitals that had established RSUs-like services showed lower mortality during the pandemic, and in the light of their success in dealing with complex respiratory conditions, has recommended their establishment across the NHS as a standard service.
As the size and location of RSUs will vary, depending on local circumstances such as number of patients and available facilities, the document published today provides general principles and scalable details of the workforce and infrastructure necessary for the safe and effective operation of an RSU, which can be adapted to fit different settings. To ensure the highest quality of patient centred care is provided in every RSU, the guidance also includes criteria on how and which patients should be admitted, pathways for treatment, monitoring and discharge as well as safety considerations and administrative support.
Dr Ben Messer, Consultant in Critical Care and Home Ventilation, one of the report’s authors, commented:
“The document provides guidance to inform planning and business cases for the development of RSUs as well as acknowledging and strengthening the key link between critical care medicine and respiratory medicine.”
Professor Andrew Menzies-Gow, National Clinical Director for Respiratory Disease, NHS England and NHS Improvement, said of the new guidance: “During the pandemic, respiratory teams have helped to manage the majority of acute COVID-19 patients. Respiratory Support Units have worked closely with Intensive Care teams to ensure patients receive optimal care in the correct environment.”
“This integrated way of working has proven effective and is an example of how the approaches established over the past year will have an ongoing benefit for patients.”
Professor Jon Bennett, Chair of the British Thoracic Society, said: “Respiratory Support Units have been, and will continue to be an essential tool in the response to COVID-19, but their scope is much broader and their applications more numerous.
“If widely established and properly resourced, as we recommend, they will also bring real improvement to the way we manage patients admitted to hospital with acute respiratory illnesses, especially during the winter surges (‘Winter Pressures’).”
ICS President, Dr Stephen Webb, says: “Respiratory Support Units (RSUs) have played an essential part in our fight against COVID-19. Oxygen therapy, CPAP and NIV have been used for many years to support the care of our patients and even more so since the pandemic began.
“Intensive Care and Respiratory Medicine have never been so closely connected and we are delighted to work together to release this joint BTS and ICS guidance which provides all UK hospitals with guidance on which RSUs can be developed so that we can continue to provide the best possible care for our patients.”
ARNS Statement (download here):
The Respiratory support unit (RSU) is an area where the Respiratory nurse’s role is paramount in ensuring that patients receive a high level of monitoring and respiratory intervention. The complexity of respiratory disease, means that nurses may be caring for patients, with pulmonary hypertension, pneumothoraces, pneumonia, Asthma, COPD, sleep and ventilation disorders, cystic fibrosis, interstitial lung disease, lung cancer, tuberculosis and COVID amongst other respiratory diseases and co-morbidities. Respiratory nurses provide a wide range of caring interventions from ventilation to palliative care, yet the role of the respiratory nurse has not been clearly delineated (Alonso et al, 2020) .
Despite the banding of the nursing staff there should be a basic competence level in respiratory nursing and a pathway to direct development. The BTS document ‘A professional developmental framework for respiratory nursing’ (BTS, 2020), sets out a potential career path for Respiratory nurses within the four pillars
- Clinical expertise
- Education and training
Lawlor (2019), document ‘Fit to Care’ although focusing on primary and community care emphasises the essential skills, knowledge and training for healthcare professionals providing respiratory care and can be used in conjunction with the BTS (2020) framework. In using this framework to enable the professional development and identify the scope of the respiratory nurses role in the RSU, patients may be provided with optimum care. However, the nature of an RSU will be subtly different across the many NHS providers, and the way that units are designed and managed will impact on the level and provision of care. In view of the challenging and broad scope of an RSU, aspects of the role of the respiratory nurse, level of care provision for patients, and staffing elements of expertise can be gained from the critical care field. The BACCN (2010) Standards for nurse staffing in critical care and the Intensive care Society and Faculty of intensive care medicine (2019) Guidelines for the provision of intensive care services considers many of these factors and should be used in conjunction with the BTS RSU document.