Gloucestershire Hospitals

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1 Gloucestershire Hospitals NHS Foundation Trust TRUST CLINICAL POLICY In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. The Policy framework requires that the policy is fully reviewed on the date shown, but it is also possible that significant changes may have occurred in the meantime. The most up to date policy will always be available on the Intranet Policy web site and staff are reminded that assurance that the most up to date policy is being used can only achieved by reference to the Policy web site. 2 March 2010 Adult In Hospital Cardio-Pulmonary Resuscitation Procedure This document may be made available to the public and persons outside of the Trust as part of the Trust's compliance with the Freedom of Information Act 2000 Date of Issue: October 2008 Review Date: October 2011

2 Gloucestershire Hospitals NHS Foundation Trust TRUST CLINICAL POLICIES Authorisation Form DOCUMENT: Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Authorisation Name and Position Date Approved Responsible Author Policy Sponsor Ben King Resuscitation Officer Shân South Assistant Director of Nursing Policy & Practice Development October 2008 October 2008 Assured by Clinical Policy Group October 2008 Consideration at authorised groups (e.g. Board, Board sub committees, Policy Group, Clinical policies Sub Group, Departmental meetings etc) Name of Group Minute details Date considered Resuscitation Committee Minute 3 CPR Policies 12 October 2005 Chair Dr David Gabbott Clinical Policy Group 7 16 November 2005 Senior Nurse Committee 159/ December 2005 Reviewed/Updated: February 2007 Clinical Policy Group Senior Nurse Committee 23/ March 2007 Amended July 2007 Amended Clinical Policy Group September 2008 Senior Nurse Committee 127/ October 2008 Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 2 of 10:

3 Gloucestershire Hospitals NHS Foundation Trust Adult In Hospital Cardio-Pulmonary Resuscitation Procedure 1. Aim The aim of this policy is to inform expected clinical practice of staff who may be involved in resuscitation of an adult in the acute hospital setting. 2. Nationally Recognised Resuscitation Courses If any staff members have successfully completed nationally recognised resuscitation courses, such as the Resuscitation Council (UK) s Advanced Life Support (ALS) Course, they will be deemed competent to carry out aspects of resuscitation covered in that course. They will not require updates in those skills on an annual basis for the time that the qualification remains valid. The time the course remains valid is set by the overseeing national body who determine when recertification is required. For example, the Resuscitation Council (UK) requires that ALS is recertified after 4 years. If staff members are an accredited instructor for any courses they will be deemed competent whilst they remain so. 3. Statement of Policy All staff who come into direct patient contact should be competent to perform adult basic life support if called upon to do so. (A specific breakdown of appropriate staff groups for whom this is applicable, can be found as Appendix 1.) Initial training on induction will be offered to all appropriate groups of staff. See Appendix 1. These staff members who receive CPR training should ensure these skills are maintained and are required to attend updates annually unless otherwise indicated in Appendix 1. It is the individual s responsibility to ensure they are trained on equipment they will need to use in their clinical practice and seek re-training to ensure their competence is maintained. The skills and knowledge required by these staff members is laid out in Appendix 2. Low risk areas are those areas where, based on audit data, the risk of encountering a patient in cardiac arrest is remote. All staff who attend CPR training must, at the end of the session, know when and how to call the Resuscitation Team and demonstrate effective chest compressions. All skills and equipment training must be entered on the central training record database. It is staff member s manager who is responsible for ensuring records are updated. This policy was written in accordance with the document Cardiopulmonary Resuscitation - Standards for Training and Clinical Practice (1) Process for Monitoring Compliance The Resuscitation Department is responsible for ensuring that all resuscitation training undertaken within the Trust is entered on the central training record. This information will be used by the Resuscitation Department to audit attendance. Regular audit of calls for the Resuscitation Team will be undertaken by the Resuscitation Department. This will collect data on nature of calls, care up to and including cardiac arrests and also patient outcomes from such events. Other auditing on issues related to resuscitation, for example compliance with policy on Do Not Attempt Resuscitation, will also be undertaken by the Resuscitation Department. Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 3 of 10:

4 4. Resuscitation Service The day to day running of the resuscitation service is dealt with by the Resuscitation Department and this department is in turn overseen by the Trust s CPR Committee. This committee is made up of key specialists within the Trust who include: Chairman Consultant who is Trust-wide clinical lead for resuscitation Resuscitation Officers Consultant representatives from Medicine, Intensive Care Unit (ITU), Anaesthetics, Emergency Services and Paediatrics Nurse representatives from ITU, cardiology, emergency services and Hospital at Night Pharmacist In addition, other specialists may attend to discuss specific issues such as the Do Not Attempt Resuscitation (DNAR) policy. The Resuscitation Department will carry out audits to analyse resuscitation practice and to investigate Adverse Critical Incidents (ACIs) associated with resuscitation. 5. The Resuscitation Team The aim of the Resuscitation Team is to provide a rapid response to a clinical emergency in any area of the Trust. Reasons for calling the Resuscitation Team: - cardiac arrest - respiratory arrest - patients who meet the Revised Resuscitation Team calling criteria - for anyone needing urgent medical attention For acutely deteriorating patients, the team s role is prevention of cardiac arrest for those in cardiac or respiratory arrest it is to restore effective circulation and ventilation. The team will be made up of the following staff: - Doctors from Acute Medicine, or covering for medical patients out of hours (This team member, if appropriately trained, should be the team leader) - Doctor from ITU with skills in advanced airway management - Nurse from ITU (GRH only) - Critical Care Outreach Nurse - Duty Lead Nurse - Porters - Night Practitioner / Night Sister - Resuscitation Officer (if available) 6. Recognition of Cardiac Arrest The only signs that are required to diagnose Cardiac Arrest are:- Unconsciousness Absence of effective breathing Absence of visible signs of life (Checking carotid or femoral pulse may also be used in controlled circumstances by those with experience) Note The patient may still have agonal gasping but this does not exclude a cardiac arrest. 7. Communication The Resuscitation Team should be called when encountering a patient who: a) Has a Cardiac Arrest b) Has a Respiratory Arrest c) Meets the Resuscitation Team Calling Criteria (Pre-arrest call - Appendix 3) d) needs urgent assistance Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 4 of 10:

5 Different methods are used in different parts of the area for contacting the Resuscitation Team. All staff should ensure they know how to call the team in their area. 7.1 Telephone 2222 and clearly state Resuscitation Team to, the ward/department and which hospital site. E.g. Resuscitation Team to Emergency Department, Cheltenham General Hospital The staff member making the call should listen to the switchboard operator repeating this message back to them before replacing the receiver. 7.2 Some areas have Cardiac Arrest Call Bells. These link directly to switchboard and alert the operator to the location of the emergency. The operator will then dispatch the Resuscitation Team without a phone call from the ward being required. Note These call bells are only on the Gloucestershire Royal site and are not found anywhere else across the Trust. 7.3 Some areas, away from the acute hospital sites, will activate the ambulance service via a 9999 call. This will either be in addition to or instead of the 2222 call. 8. What Do You Do First Follow the in-hospital Basic Life Support guidelines. If the rescuer is alone when they find a patient who has collapsed they should call for help immediately. If no-one arrives to offer assistance by the time they have completed their assessment of unresponsiveness and absence of effective breathing and signs of life, they should telephone for help immediately BEFORE starting CPR. Placing the call and returning to the patient quickly will ensure uninterrupted Basic Life Support and a rapid response from the team. 9. Ward / Departmental Emergency Equipment Each ward / clinical area will have emergency equipment and it is the responsibility of the manager of each area to ensure that the equipment is checked on a regular basis. The amount of equipment will be determined by the Resuscitation Department and emergency equipment should be checked daily. If the ward / department does not have a defibrillator, they should be aware of where their nearest one is. 10. Procedure for cardiac arrest 10.1 Staff must ensure their own safety is not compromised The first responder calls for help 10.3 The first responder confirms the diagnosis of cardiac arrest by: a) assessment of responsiveness calling out to patient and tapping on their shoulders. b) check and clear the airway including head tilt and chin lift. c) assess for signs of life by: assessing for effective breathing (look, listen and feel) and signs of circulation (consider pulse check) whilst ignoring agonal gasping If the first responder is alone they should summon the Resuscitation Team either by phone or by the Cardiac Arrest call bell. They should then commence uninterrupted chest compressions at a rate of 100 per minute, depth 4-5cm in the center of the chest If more than one member of staff is present one should summon help whilst the other commences uninterrupted chest compressions at a rate of 100 per minute, depth 4-5 cm in the Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 5 of 10:

6 centre of the chest On arrival of more staff and emergency equipment cardiopulmonary resuscitation (CPR) should continue at a ratio of 30 compressions to 2 ventilations Ventilations should be performed using a bag valve mask (BVM). If BVM unavailable a pocket mask could be used in its place CPR should be continued at a ratio of 30:2 and stopped only if the patient shows signs of life After the arrival of the attending Resuscitation Team the Team Leader for the emergency should be identified. The Team Leader should be the most experienced Advanced Life Support trained doctor in attendance and is usually a member of the Acute Medical team on take The Team Leader is responsible for co-ordinating all further actions of the team, including advanced airway management, safe defibrillation and the use of emergency drugs. They should ensure that in appropriate interruptions in CPR are kept to a minimum The doctor on call for ITU should take responsibility for managing the airway. They should intubate the patient s trachea when appropriate to do so. If no one present possesses skills of intubation a suprglottic airway may be used, eg. an Laryngeal Mask Airway (LMA) or igel It is the team leader s responsibility for deciding when to stop resuscitation. Ideally the views of the resuscitation team should be taken into consideration before decision is made The team leader should ensure that the details of the event are recorded in writing in the patient s notes, ideally using the Resuscitation Audit Form The staff member in charge of the ward should take responsibility for ensuring the patient s relatives are contacted and cared for by the most appropriate staff member Following successful resuscitation the patient will require close observation and may need to be transferred to a critical care area. The decision for taking the patient to a higher level of care will be discussed with the appropriate staff members. These will include a medical representative from the patient s own team (sometimes by phone), the team leader, the doctor attending from ITU (plus their respective consultants) and the ward nurse with responsibility for the patient. The team leader should ensure the patient s safety during the transfer The nurse in charge of the ward should ensure that following the use of the resuscitation equipment it is restocked (as local policy), cleaned (if necessary) and replaced in its normal location. It is also necessary to include suction equipment when cleaning and restocking the resuscitation equipment. Correct defibrillator pads must replace those that have been used and if the defibrillator needs to be on charge it should be plugged in to the mains It is important for experienced and senior staff to be aware of the need to offer support and counseling for those witnessing or involved with the resuscitation event. These may include: Junior/inexperienced staff Other patients Relatives 11. The Patient with a Tracheostomy If resuscitating an unknown patient and it is not possible to inflate the patient s chest (assuming the airway is clear) check for the presence of a tracheostomy. Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 6 of 10:

7 Patients with tracheostomies on wards should have with them an Emergency Tracheostomy Box. These boxes are stored in ITU in both CGH and GRH. They should accompany patients leaving ITU for the ward and also patients with tracheostomies admitted to general wards. Emergency Tracheostomy Boxes (sealed) contain the following: 2 x Tracheostomy tubes (1 same size, 1 smaller) Tracheal dilators Catheter mount 10ml syringe New ties. 12. Laryngectomy patients Some patients will have had a permanent tracheostomy following a laryngectomy. These patients are neck breathers meaning that ventilation must always be performed through the stoma. A size 2 paediatric resuscitation face mask (that fits around the stoma) connected to an adult resuscitator bag must always be available to areas caring for laryngectomy patients. An alternative is to insert a tracheal tube (with the cuff inflated) into the stoma. Further information for staff caring for these patients can be found in the Policy on the Care and Management of Tracheostomy References Cardiopulmonary resuscitation standards for clinical practice Resuscitation Council (UK) Published:Resuscitation Jan;64(1):13-9 Nursing & Midwifery Council (April 2002) Code of Professional Conduct. Resuscitation Guidelines 2005, Resuscitation Council (UK) December 2005 Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 7 of 10:

8 BLS Training ESSENTIAL Nurses all incl. senior nurses ODAs/ODPs Midwives Doctors PRHOs SHOs Staff grades SpRs Consultants (except histopath/microbiologists) Hospital linked GPs Technicians Audiologists Lung function Cardiac Optometrists Nuclear medicine Wards/clinics (MAU/max.fax) Theatres Health psychologists cardiac rehab only OTs + assistants Physios + assistants Radiotherapists Dietitians Speech therapists Porters Phlebotomists NON-ESSENTIAL Ward clerks Receptionists Bereavement officers Hospital Chaplains Social workers Voluntary workers Child psychotherapists? Chiropodists?community Works Department electricians Secretaries/PAs Audit staff Clinical projects team Estates Finance Health records Hotel services IT staff Librarians Medical Physics/electronics/engineering Pathologists Pharmacists CSSD Switchboard Pathology Laboratory Appendix 1 PBLS Training ESSENTIAL Nurses Emergency Department Theatres Paediatric Wards (incl specialist nurses) SCBU Midwives Anaesthetic/recovery ITU Doctors Paediatrics SHOs/SpRs/Consultants Anaesthetists SHOs/SpRs/Consultants (Specific) All other staff NON-ESSENTIAL Neonatal Resuscitation ESSENTIAL Nurses Nursery Nurses Neonatal nurse Practitioners All neonatal nurses attending births with paediatric staff Midwives Doctors Obstetricians all grades Paediatricians all grades Anaesthetic staff permanent members of staff who cover NON-ESSENTIAL All other staff Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 8 of 10:

9 maternity Appendix 2 Standard Basic Life Support training for all staff (except those working in areas of low risk cardiac arrest) will include the following components COMPONENTS TRAINING DETAILS 1 Maintaining safety of staff and patients in a clinical emergency 1 a. Checking for safe environment b. Awareness of potential hazards (sharps/electricity) c. Risks from moving unconscious patients 2 Recognition of cardiac arrest 2 a. Assessing level of consciousness b. Opening airway c. Assessing signs of life 3 How to summon help 3 a. Importance of early shout for help b. Use of emergency call bells c. Phoning for Resuscitation team 4 Awareness of role of arrest team 4 a. Which staff make up the Resuscitation team b. Priorities once team members arrive. 5 Technique of performing chest compressions 6 Importance of performing chest compressions 7 Technique of bag/valve/mask ventilation 8 Familiarisation with process of defibrillation 5 a. Demonstrate and supervised practice in external cardiac compressions 6 a. Awareness of survival rates from in-hospital arrests b. Use of Early Warning System (EWS) in arrest prevention c. Use of Revised calling criteria for Resuscitation Team 7 a. Demonstration and supervision in the 2 person technique of using the bag/valve/mask for assisted ventilations 8 a. Awareness of safety issues b. Awareness of importance of speeding up time to delivery of first shock 9 Related issues to resuscitation 9 a. Awareness of Trust s DNAR policy b. Effective audit of cardiac arrests and clinical emergencies c. Importance of upkeep and replacement of emergency equipment Basic Life Support training for staff from low risk areas will include the following skills and knowledge COMPONENTS TRAINING DETAILS 1 Maintaining safety of staff and patients in a clinical emergency 1 a. Checking for safe environment b. Awareness of potential hazards (sharps/electricity) c. Risks from moving unconscious patients 2 Recognition of cardiac arrest 2 a. Assessing level of consciousness b. Opening airway c. Assessing signs of life 3 How to summon help 3 a. Importance of early shout for help b. Use of emergency call bells c. Phoning for Resuscitation team 4 Awareness of role of arrest team 4 a. Which staff make up the cardiac arrest team b. Priorities once team members arrive 5 Technique of performing chest compressions 5 a. Demonstrate and supervised practice in external cardiac compressions Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 9 of 10:

10 Appendix 3 FOR THE RESUSCITATION TEAM (Previously Cardiac Arrest Team) DIAL 2222 ON FINDING ANY ADULT IN Cardiac Arrest Respiratory Arrest OR IF THEY ARE Unrousable / Only responding to pain With one or more of the following signs: - Respiratory Rate < 8 per minute - Respiratory Rate > 30 per minute - Heart Rate < 40 per minute - Heart Rate > 150 per minute - BP <90mmHg Systolic - Oxygen Saturation <90% Adult In Hospital Cardio-Pulmonary Resuscitation Procedure Page 10 of 10: