RESUSCITATION POLICY Version 5.2 Resuscitation

EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This policy has therefore been equality impact assessed by the clinical governance and assurance committee to ensure fairness and consistency for all those covered by it regardless of their individual differences, and the results are shown in Appendix 2. Version: Authorised by:

5.2 Managing the Deteriorating Patient Group Date authorised: 22nd January 2015 Next review date: 22nd January 2017 Document author: G. Pogson Lead Resuscitation Officer

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resuscitation policy

VERSION CONTROL SCHEDULE Resuscitation Policy Version : 5.2 Version Number 1 2

Issue Date

3

Sept 2007

4

Sept 2009

4.1

March 2010

4.2

March 2010

4.3

March 2010

4.4

January 2011

5

December 2011

5.1

December 2011

5.2

December 2014

Sept 2005

Revisions from previous issue Original Issue Addition of new guidelines. Removal of any reference to pre 2005 resuscitation guidelines. Corporate formatting, reference to the Mental Capacity Act 2005, update of the training matrix, reference to the NHSLA Resuscitation Policy template. Corporate formating, reference to current NHSLA/CNST Resuscitation Policy template. Future proofing document to accommodate new resuscitation guidelines due for publication Nov 2010 Review of mandatory training matrix and monitoring. No longer a mandatory requirement for non clinical staff to attend BLS training. Inclusion of training requirements as instructed by NHSLA assessor. PARS and PEWS policy reference added. Addition of 2011 guidelines, removal of any reference to 2005 guidelines. Review of references. Resuscitation Committee agreed the policy update on 12/12/11 policy start date amended accordingly. Spelling errors corrected. Resuscitation Committee dispanded and replaced by the Managing the Deteriorating Patient Group (MDPG). New quality standards for cardiopulmonary resuscitation ACUTE CARE published by the Resuscitation Council (UK) Nov 2013.

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New decisions relating to cardiopulmionary resuscitation published by the Resuscitation Council (UK) Oct 2014 New DNACPR policy TGH. Introduction of the National Early Warning System EWS. Launch of the MDPG stratergy and escalation plan.

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TABLE OF CONTENTS INTRODUCTION ........................................................................................................ 5 PURPOSE .................................................................................................................. 5 SCOPE ....................................................................................................................... 6 DEFINITIONS ............................................................................................................. 6 DUTIES ...................................................................................................................... 6 POLICY STATEMENT ................................................................................................ 7 THE POLICY ITSELF ................................................................................................. 7 1 RISK MANAGEMENT.............................................................................................. 7 2 CARDIOPULMONARY ARREST PREVENTION .................................................... 7 3 RESUSCITATION TRAINING ................................................................................. 8 4 POST RESUSCITATION CARE. ............................................................................. 8 5 COMMUNICATION ................................................................................................. 8 6 RESUSCITATION EQUIPMENT ........................................................................... 10 7 AUDIT ................................................................................................................... 11 8 DECISIONS RELATING TO CARDIOPULMONARY RESUSCITATION AND DO NOT ATTEMPT RESUSCITATION (DNAR) ............................................................. 12 9 RELATIVES WITNESSING RESUSCITATION ..................................................... 12 POLICY DEVELOPMENT & CONSULTATION ........................................................ 12 IMPLEMENTATION .................................................................................................. 12 MONITORING ............................................................. Error! Bookmark not defined. REFERENCES ......................................................................................................... 13 REVIEW ................................................................................................................... 13 APPENDICES .......................................................................................................... 14 EQUALITY IMPACT ASSESSMENT TOOL.......................................................... 14

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INTRODUCTION Hospitals have a duty of care to provide an effective resuscitation service, to ensure that all staff are trained appropriately and regularly updated to a level compatible with their expected degree of competence. Resuscitation Council (UK), November 2013 The Resuscitation Service within the hospital will follow current Resuscitation Council (UK) guidelines for the recognition and management of acute illness and cardiorespiratory arrest. National guidance will be followed with reference to decisions relating to cardiopulmonary resuscitation and the current standards for clinical practice used as a benchmark standard.

PURPOSE This document outlines the organisational structure of the Resuscitation Service within the Trust. Where appropriate individual responsibilities are outlined and monitoring systems described that will be employed to study service delivery and efficacy. This document should be read in conjunction with the following Trust policies and clinical guidelines which are available on the Trust intranet:         

Resuscitation Council (UK) current resuscitation guidelines. Trust DNACPR Policy. Managing the deteriorating patient stratergy and escalation plan. Trust Outreach Policy. Maternity Early Warning System. Paediatric Early Warning System. Trust Transfer policy (Adults). Trust Transfer policy –Neonates and paediatrics. Mandatory and Induction Training policy

OBJECTIVES   

To provide a reference document for all staff; embracing current national guidelines for decisions relating to resuscitation; the resuscitation process; training implications and equipment deployment. Form a frame work whereby external organisations can identify the Trust’s activity against their identified standards. Identify what processes are employed to monitor service efficacy and the

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

resuscitation policy

evidence collected to satisfy scrutiny. To ensure that the resuscitation service at Tameside Hospital embraces national and local drivers, promotes best practice and maximises patient outcomes from episodes of acute illness or cardiac arrest.

SCOPE For all Trust staff who may be involved with the management of an acutely ill casualty or victim of cardio-respiratory arrest.

DEFINITIONS Cardiopulmonary arrest is defined clinically by unconsciousness in association with no established breathing pattern and no other signs of life. Resuscitation Council (UK) 2011 Presumption in favour of attempting resuscitation: where no advanced decision has been made about appropriation, or otherwise, of attempting resuscitation prior to a patient suffering cardiac arrest. There should be a presumption that the health professional will make a reasonable effort to revive the patient. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision: describes a situation where a decision has been taken not to resuscitate a patient in the event of a cardiorespiratory arrest. Early Warning Score (EWS): a patient assessment tool. The current adult EWS tool used in the Hospital is the National Early Warning Score (NEWS).

DUTIES The Chief Executive is responsible for ensuring there is an appropriate clinical response for the acutely ill patient or victim of cardiac arrest. The Resuscitation Committee has been desolved and now replaced by the Managing the Deteriorating Patient Group (MDPG). They have a duty to set its terms of reference, decide an appropriate membership and publish up-to-date policies and guidance for all members of staff involved in the management of deteriorating patients and victims of cardiorespiratory arrest. The MDPG must be involved in the audit process and evaluation of service efficacy. Relevant reports will be submitted for circulation through the Patient Safety Programme Board. The Resuscitation Officer will ensure that all training events follow current national resuscitation guidelines and accurate training registers are submitted to the FINAL VERSION 5.2 January 2015

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Education Department for collation. In addition the LRO will monitor service efficacy which will include audits of resuscitation equipment; local cardiac arrest outcomes; supply data to the National Cardiac Arrest (NCAA); DNACPR decisions and EWS compliance. Reports will be reviewed by the MDPG and then escalated to the Patient Safety Programme Board. Education Department will maintain accurate training records from submitted registers and will provide figures to assist with the training needs analysis process. Managers& Staff should adhere to the Trust’s Mandatory and Induction Training Policy.

POLICY STATEMENT Tameside Hospital will adopt national guidelines and standards published by the Resuscitation Council (UK) in the delivery and development of its resuscitation service.

THE POLICY ITSELF 1 RISK MANAGEMENT The Trust will follow where possible the current national Cardiopulmonary Resuscitation Standards for Clinical Practice and Training RC (UK). Any clinical incidents related to the delivery of resuscitation interventions should be reported through the clinical incident reporting system.

2 CARDIOPULMONARY ARREST PREVENTION The resuscitation service will where possible promote the early recognition and management of the deteriorating patient and the prevention of respiratory or cardiorespiratory arrest from occurring by: 2.1 Establishing firm communication bridges between the Outreach and Resuscitation Services. The Outreach service will have representation on the MDPG. 2.2 Promoting the assessment and treatment of the sick patient by following current Resuscitation Council (UK) guidelines. 2.3 Embracing the concept of early warning scores (EWS) and the associated assessment process. Reference will be made to the Outreach Service and the Trust EWS scoring system in all appropriate resuscitation training events. 2.4 Sharing outcomes data with the wider multiprofessional team.

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3 RESUSCITATION TRAINING Please refer to the Education Policy to determin mandatory training requirements.

4 POST RESUSCITATION CARE. Immediately after a successful return of spontaneous circulation, most patients are clinically unstable and likely to require admission to a Coronary Care or Critical Care Unit. Continuity of care during this period is vital and will depend on factors such as previous health, severity of illness and underlying diagnosis. The Resuscitation Team must make provisions for those patients who require transfer to higher care facilities following successful resuscitation. This may involve the following steps: 4.1 StabIlising the patient as far as possible, but this should not delay definitive treatment. 4.2 Referral to an appropriate specialist. 4.3 Preparation of equipment to facilitate transfer. This may require the involvement of other organisations such as the paramedic service, or other hospitals. 4.4 A full and complete handover to the receiving team, either in-hospital or inrahospital. 4.5 The allocation of staff as outlined in the Transfer Policy. 4.6 Communication with relatives. 4.7 Use of the dedicated transfer trolley, located on ITU where appropriate. 4.8 The use of theraputic hypothermia post arrest should be considered. (Equipment and cooling protocols located on ITU)

5 COMMUNICATION The Resuscitation team should be summoned by dialing 2222, in the event of either the following. 

Respiratory or cardiorespiratory arrest as defined by the Resuscitation Council (UK).



Sudden collapse due to acute clinical deterioration of a casualty where local resources require aditional support to deal with the situation

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There are three dedicated on call emergency teams opperating in the hospital all day and every day.   

Adult cardiac arrest team. Paediatric cardiac arrest team. Obstetrict cardiac arrest team.

It is the responsibility of each line manager in all clinical and non-clinical areas to identify the nearest resuscitation equipment and have an action plan established for dealing with the emergency situation. This information should be disseminated to all individuals working within that area. Where any clarification is required individual managers should consult the Lead Resuscitation Officer. The Lead Resuscitation Officer will take every opportunity to raise the issues of ‘human factors’ and pre emergency action planning during all training sessions.

5.1 The resuscitation team should assess, treat and stabilise the patient at the scene where possible. If the patient requires transfer to another location, the Trust Transfer Policy must be followed. 5.2 The Anaesthetic department will respond to obstetric and/or paediatric cardiac arrest calls. For all other incidents a specific requst needs to be made directly to the on call anaesthetist. This can be done by using the emergency 2222 number and making the direct request through switchboard. 5.3 If a cardiac arrest/sudden collapse occurs in a non-clinical area or hospital grounds, the cardiac arrest team should be summoned if possible. It may be necessary to call for an emergency ambulance to support the incident and facilitate the transfer of the patient to A&E. Common sence should prevail and rescuers must take every opportunity to alert the hospital’s emergency response at all times. 5.4 Where it is impossible to access the hospital’s emergency telephone system but a rescuer has a mobile phone they should ring 999 and summon an ambulance. 5.5 The crash bleep system is tested randomly on a weekly basis. Bleep holders must call switchboard on 2222 as instructed. Switchboard will maintain weekly response rates for the specific cardiac arrest bleeps. 5.6 Cardiac arrest bleeps should be handed over at shift changes. Problems with cardiac arrest bleeps should be directed straight to switchboard. 5.7 If a second arrest call is made during an ongoing resuscitation event, the team should decide how to effectively split their resources so that support can be given to the second event. 5.8 If no cardiac arrest response occurs having made a 2222 call, repeat calls must be attempted. In the unlikely event that there is no response then a 999 call should be made to summon a paramedic ambulance. An incident form must must be submitted immedialey and the on call hospital administrator notified. FINAL VERSION 5.2 January 2015

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Cardiac arrest bleep numbers Speciality Medicine Medicine RMO2 Block/Directorate specific Nurse Porter Security Night nurse Practitioner:

Bleep 1505 1504 1509 1507/1400/1500/1406/ 1002/1404/1000/1200/1403/1506/ 1523/1409/1402/1513/1066/1045 1503 1313

Orthopaedic. Medicine. Surgery. Resuscitation training officers:

1203 1204 1206

Lead. Associate. Paediatrician Paediatrician Porter

1502 1794 1599 1598 1527

6 RESUSCITATION EQUIPMENT 6.1 A red “adult” emergency equipment box should be located in all clinical areas. These boxes normally remain in their designated area at all times, but can be moved if required to support an emergency situation. 6.2 Blue “ paediatric” emergency equipment boxes should be deployed on the Childrens Unit, ITU and Outpatients Department. Theatres and A&E have their own dedicated trolley. 6.3 Following use, equipment boxes should be returned to HSDU. A new one should be secured before the used one is returned. The portering service will attend to this even outside office hours. 6.4 Each dedicated emergency trolley must be re-stocked by clinical staff after use. 6.5 The Trust operates a two tier defibrillator system. Automated machines or “tier one” defibrillators are found in most clinical locations and some non clinical buildings. All clinical areas are supported by a “second tier” defibrillator/monitor which can be used to manage rarer peri arrest scenarios. 6.6 Defibrillators must not be moved from their station unless required in an emergency. 6.7 Defibrillator clocks will remain on British summer time settings throughout the FINAL VERSION 5.2 January 2015

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year. 6.8 Apart from battery operated automated machines, defibrillators should always be connected to the mains supply when not in use. 6.9 Second tier defibrillators must be returned immediately after use to their home location. 6.10 There is a defibrillator and transfer trolley located on the ITU. 6.11 If a defibrillator is found to be broken during office hours, contact the Medical Electronics Department immediately. 6.12 If a defibrillator is found to be broken out of hours contact the Night Nurse Practitioner to source the nearest available machine. There is an on call medical electronics engineer who is contactable through switch. Complete an incident form and e-mail [email protected] immediatley notifying the Lead Resuscitation Officer that a problem has occurred. 6.13 Resuscitation equipment must only be used by appropriately trained staff. 6.14 Pharmacy and HSDU will maintain records to recall boxes when products expire. Six-monthly checking of equipment boxes remains the responsibility of the HSDU manager. Both equipment and drug boxes will have expiry date stickers applied to the security tags. 6.15 Clinical areas are encouraged to purchase additional defibrillator pads however HSDU can be approached in an emergency. 6.16 Resuscitation equipment should be checked daily and recorded on the appropriate checklist found in the resuscitation checklist file. These records should be archived in line with information storage guidelines for 8 years. Any issue with equipment must be resolved as quickly as possible. 6.17 The resuscitation officer will perform an equipment audit annually. Additional audits will be conducted in the event of poor practice being identified. It remains the responsibility of individual areas to check and maintain the integrity of their resuscitation equipment.

7 AUDIT 7.1 The LRO will be activley involved in the assessment and evaluation of the resuscitation service. This will involve the formulation of the following audit reports. Cardiac arrest outcomes, DNACPR policy compliance, equipment and EWS. These will receive peer review by the MDPG, then be escalated to the Patient Saftey Programme Board. 7.2 Each report will as a minimum be produced annually. However the LRO will increase the frequancy of study depending on service need or failure to adhear to local policy or national standards. 7.3 An outcomes audit form must be returned to the LRO every time the 2222 emergency system is activated. 7.4 All Do Not Attempt Resuscitation (DNACPR) decisions must be recorded in the patient’s notes and a DNACPR audit form completed for each event. This audit form must be placed in the ‘ALERTS’ section of the patients notes. All decision makers must read the Trust DNACPR policy. FINAL VERSION 5.2 January 2015

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8 DECISIONS RELATING TO CARDIOPULMONARY RESUSCITATION AND DO NOT ATTEMPT CARDIORESPIRATORY RESUSCITATION (DNACPR) DNACPR decisions apply only to CPR and not to any other aspect of treatment. Where no explicit decision has been made in advance there should be a presumption in favour of CPR. (Resuscitation Council (UK) et al (2014) 8.1 The Trust has an established DNACPR policy which embraces the national guidelines published by the RC(UK), BMA and RCN. 8.2 Practitioners are encouraged to adhear to the legal implications of the Mental Capacity Act (2005) when making any decision regarding resuscitation interventions. 8.3 It is essential to identify patients for whom cardiopulmonary arrest is an anticipated terminal event and in whom cardiopulmonary resuscitation (CPR) is inappropriate, and patients who do not want to be treated. 8.4 Where there is no resuscitation plan and the wishes of the patient are unknown, resuscitation should be initiated if cardiac arrest occurs. 8.5 The overall responsibility for DNACPR decisions rests with the Consultant in charge of the patients care.

9 RELATIVES WITNESSING RESUSCITATION There are some situations where relatives may wish to witness the resuscitation of a loved one. Where possible these wishes should be accommodated with appropriate support and supervision. However the final decision rests with the Resuscitation Team Leader.

POLICY DEVELOPMENT & CONSULTATION This policy was developed by the Lead Resuscitation Officer working in collaboration with members of the MDPG. The draft policy was circulated to MDPG membership for comments and amendments made where necessary. The final copy of the policy was forwarded to the Patient Safety Programme Board.

IMPLEMENTATION The MDPG will ensure that the document is submitted for publication on the Trust intranet. The Lead Resuscitation Officer will archive a paper copy of the documentation that FINAL VERSION 5.2 January 2015

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has been superseded. The Lead Resuscitation Officer will make reference to the policy’s existence and access routes during all training events.

REFERENCES Mental Capacity Act 2005 Department of Health. NHS Resuscitation Policy template. Resuscitation Policy. Health service Circular (HSC) 2000/028. London Department of Health. Decisions relating to cardiopulmonary resuscitation. Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal Collage of Nursing. (October 2014) Cardiopulmonary Resuscitation Standards for Clinical Practice and Training (ACUTE). Resuscitation Council (UK). (November 2011) Resuscitation Guidelines 2011. Resuscitation Council (UK) (2011) Guidance for Safer Handling during Resuscitation in Hospital. Resuscitation Council (UK) (2009)

REVIEW This policy will be formally reviewed 22nd January 2017

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APPENDICES PACT ASSESSMENT TOOL Yes/No 1.

Comments

Does the policy/guidance affect one group less or more favourably than another on the basis of:  Race

No

 Ethnic origins (including gypsies and

No

travellers)  Nationality

No

 Gender

No

 Culture

No

 Religion or belief

No

 Sexual orientation including lesbian,

No

gay and bisexual people  Age

No

 Disability - learning disabilities, physical

disability, sensory impairment mental health problems

No

and

2.

Is there any evidence that some No groups are affected differently?

3.

If you have identified potential N/A discrimination, are any exceptions valid, legal and/or justifiable?

4.

Is the impact of the policy/guidance likely to be negative?

5.

If so can the impact be avoided?

6.

What alternatives are there to N/A achieving the policy/guidance without the impact?

7.

Can we reduce the impact by taking N/A different action?

N/A

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