Quality and Safety Committee Meeting On: 1 st September 2016 AGENDA ITEM: 4.4

Transcription

1 SUMMARY REPORT ABM University Health Board Quality and Safety Committee Meeting On: 1 st September 2016 AGENDA ITEM: 4.4 Subject Prepared by Approved & Presented by Resuscitation Policy and Training Strategy Mr Mark Dawson, Resuscitation Service Manager Professor Rory Farrelly, Director of Nursing & Patient Experience Purpose To consider the Resuscitation Policy and Training Strategy for approval. Corporate Objectives Decision Approval Information Other X Healthier Communities Executive Summary Excellent Patient Outcomes & Experiences Sustainable & Accessible Service Strong Partnerships A fully Engaged & Skilled Workforce Effective Governance X X XTH The Resuscitation Policy and Training Strategy has been reviewed and updated by the Resuscitation Service Manager and are attached as Appendix 1 and 2 respectively for approval. Consultation has been carried out with the Service Delivery Units through the Assurance & Learning Group. Key Recommendations The Quality & Safety Committee are requested to consider the revised Resuscitation Policy and Training Strategy and approve the same subject to any amendments identified. Assurance Framework Resuscitation training is part of the health board statutory / mandatory training. The policy and training plan outlines the requirement and operational approach Next Steps Once the Policy and Training Strategy have been approved the next steps are to distribute the documents within the Health Board and then deliver the training in accordance with the strategy.

2 MAIN REPORT Health Board ABM University Health Board Meeting On: 1 st September 2016 AGENDA ITEM: 4.4 Subject Prepared by Approved & Presented by Resuscitation Policy and Training Strategy Mr Mark Dawson, Resuscitation Service Manager Professor Rory Farrelly, Director of Nursing & Patient Experience 1. PURPOSE The report provides the Quality & Safety Committee members with the Resuscitation Policy (Appendix 1) and Training Strategy (Appendix 2) for approval. 2. INTRODUCTION The HB quality strategy, Changing for the Better, outlines our commitment to improving patient safety by improving the way we identify and manage deteriorating patients. The current Resuscitation Policy focuses on the recommendations of the Resuscitation Council (UK); the recognition and management of the deteriorating patient through the delivery of the Immediate Life support (ILS) course. However well intentioned, it is not inclusive of all staff within the Health Board, neither does it acknowledge Welsh Governments endorsement of the Health, Core Skills Training Framework (March 16). The aim of this update is to realign the HB resuscitation training programme in order to deliver training to all staff. The policies was circulated to Service Delivery Units for consultation via the Director of Nursing and Patient experience, May 2016 and duly updated as appropriate. 3. KEY ISSUES The changes will provide an framework for all staff to have access to training which is appropriate to their role The levels of training will mirror the recommendations of the Core Skills Training Framework (March 16), attendance figures will be reported to Welsh Government. An outline of the training content is as follows- Level 1 Basic CPR skills, via e-learning for all staff, annually Level 2 - CPR, advisory defibrillators & basic observation recording. Face to face training for clinical staff excluding bedside nurses, every second year Level 3 ILS. Identify and managing the deteriorating patient (including level 2) bedside nurses, every second year

3 To enable broader access to training the recertification periods of certain courses will be extended from one to two years e.g. the Resuscitation Council (UK), certificate ILS for one year There will also be paediatric version of the training available at levels 1-3 Advanced Life Support training will be unaffected Changes to the Resuscitation Policy only reflect the proposals within the training strategy Only minor changes were made following consultation 4. RECOMMENDATIONS The Quality & Safety Committee are requested to note the contents of the report and approve subject to amendments the Resuscitation Policy and Training Strategy.

4 Appendix 1 RESUSCITATION POLICY Version: May 2016 Author Mark Dawson Resuscitation Service Manager Approved by Quality & Safety Committee Changing for the Better Board TBC Review Date TBC Document number EQUALITY IMPACT ASSESSMENT STATEMENT This policy has been screened for relevance to equality. No potential negative impact has been identified so a full equality impact assessment is not required.

5 CONTENTS Page 1. Policy Statement 3 2. Scope of Policy 4 3. Aims & Objectives 4 4. Responsibilities 4 5. Training 6 6. Operational Guidance/Implementation of Policy Summoning Help Early Warning Scores SBAR Sepsis Screening Tool DNACPR Relatives Witnessing Resuscitation Post Resuscitation Care Anaphylaxis Resuscitation Equipment (Defibrillators & Procurement) Infection Control Manual Handling Audit/Incident Reporting Documentation 16 7 Useful Contacts 16 8 Cardiac arrest team structure 16 9 References Appendices 19 Resuscitation Policy version : May 2016 Page 2 of 31

6 1. POLICY STATEMENT The purpose of this policy is to provide direction and guidance for the planning and implementation of a high quality and robust resuscitation service to the organisation. Healthcare institutions have an obligation to provide an effective resuscitation service and to ensure that their staff receive training and regular updates for maintaining a level of competence appropriate to each individuals employed role. This requires appropriate equipment for resuscitation, training in resuscitation, managerial and secretarial support, financial planning and continual appraisal of standards and results....as outcome from cardiac arrest remains poor, an important aspect of institutions resuscitation planning is the delivery of timely and effective treatment to make it less likely that critically ill patients deteriorate to the point of cardiopulmonary arrest. Resuscitation council (UK) ABMU will incorporate national guidelines and standards in the delivery and development of its resuscitation service. In addition, this resuscitation policy fully supports the: Resuscitation Council (UK) 2015 Guidelines NICE 50 guidelines on the recognition and management of the acutely ill patient. (2007) 1000 Lives Plus Campaign, which aims to improve patient safety and increase healthcare quality across Wales Recommendations for Clinical Practice and Training in Cardiopulmonary Resuscitation published by the Resuscitation council UK (2010) Health Inspectorate Wales standards National Patient Safety Agency standards NHS Wales. Do Not Attempt Cardio-respiratory Resuscitation (DNACPR) Policy October 2014 Resuscitation Policy version : May 2016 Page 3 of 31

7 2. SCOPE OF POLICY This policy applies to all of the multidisciplinary health care teams involved in patient care within ABMUHB. 3. AIMS AND OBJECTIVES It is the aim of this policy: to assist in the provision of an effective Resuscitation Service that provides appropriate staff support and equality of care for patients across the organisation to provide a reference document for all staff embracing current national guidelines to promote best practice and maximise patient outcomes from episodes of acute illness or cardiac arrest 4. RESPONSIBILITIES It is the responsibility of the Resuscitation Service. to ensure adherence to national resuscitation guidelines and standards to ensure resuscitation equipment and drugs are available to formulate the Resuscitation Policy, monitor and evaluate that policy to provide advice to executive bodies and purchasers to follow the audit trail in order to assess the clinical effectiveness of resuscitation policy and guidelines to record and report critical incidents in relation to resuscitation to ensure policy distribution, implementation and compliance throughout the organisation Resuscitation Policy version : May 2016 Page 4 of 31

8 to review the policy either annually or when national policies/guidelines change (whichever occurs first), and to ensure re-ratification when necessary to disseminate this policy throughout the organisation immediately following ratification, including publication on the organisations Intranet site, ensuring access to this document is open to all to ensure the availability of all documents relating to the Resuscitation Service on the organisations Intranet site to plan adequate provision of training for staff with clinical responsibilities, including Advanced and Specialist Courses (see Training) to maintain training records to encourage clinical staff to participate fully in the organisations endeavours to improve patient safety and outcome to promote attendance by Resuscitation Officers at 2222 calls wherever possible It is the responsibility of all staff to to adhere to this policy to be responsible for their own actions to attend training appropriate to their role (see Training) to work within their expected role to notify line managers of any training needs It is also the responsibility of all clinical staff To identify, treat and document the management of acutely ill patients within their sphere of practice, following the NICE 50 guidelines for the accurate measurement and recording of physiological observations linked to a track and trigger system (National Early Warning Score (NEWS)). To provide cardiopulmonary resuscitation/defibrillation to the standard described in the current Resuscitation Council guidelines, at a level appropriate to their role Resuscitation Policy version : May 2016 Page 5 of 31

9 To consider the resuscitation status of all patients and in the case of medical practitioners, to make a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order where appropriate and record and communicate decisions as outlined in the national policy It is the responsibility of all directors and managers responsible for the delivery of care to ensure that their staff are aware of this policy, how to access it and to ensure that the policy is implemented. 5. TRAINING All training dates and venues will be advertised on the organisation s intranet. Training should be accessed as described in 5.1 Staff may contact the Resuscitation Service Co-ordinator if unsure of the training requirements for their role (see useful contacts in appendices) Training will be provided at the following hospital site; Morriston, Princess of Wales, Neath Port Talbot and Singleton Additional Advanced Life Support Courses held regularly in the ABM UHB include: ALS Advanced life Support (RCUK) EPLS European Paediatric Life Support (RCUK) NALS - Neonatal Advanced Life Support (RCUK) MOET Management of Obstetric Emergency and Trauma EMSB- Emergency Management of Severe Burns (British Burns Association) Resuscitation Policy version : May 2016 Page 6 of 31

10 5.1 Structure and content of training sessions Summary Level 1 training Adult All staff, e-learning based, available on induction and on demand. Paediatric Face to face, for all patient facing staff with responsibility for caring for children. Level 2 training Adult & Paediatric. For clinical, patient facing staff only (not registered nurses working substantively at the bedside or those who hold/require ALS provider certificates). This training includes the use of the National Early Warning Score (NEWS) and the use of Automated External defibrillators (AED). For example this group might include- OPD Registered Nurses, Health Care Support Workers, Physiotherapists, Occupation therapists, Radiographers, Community Nursing & Mental Health Teams, Medical staff who are not part of the cardiac arrest team. Pre-course requirement, valid Level 1 certificate (adult) Recommended, once every two years Level 3 training- Resuscitation Council (UK) Immediate Life Support Course (ILS). For registered nurses working substantively at the bedside; specific staff groups for whom ILS is mandated by their professional bodies; nurses undertaking invasive procedures. For those who require Advanced Life Support training, ILS should be used as interim training between ALS recertification. (see below) Pre-course requirement, valid Level 1 certificate (adult) Recommended, once every two years ALS, EPLS* - Emergency Team members or resuscitation team leader *certificates are valid for four years. However it is recommended to undertake regular refresher training as required. The Resuscitation Service will promote the use of standard operating procedures, for the recognition and care of the deteriorating patient; NEWS, Sepsis Screening and SBAR used within the Health Board. The Service will encourage and support Quality Improvement initiatives focussed on prevention of harm and risk reduction. Resuscitation Policy version : May 2016 Page 7 of 31

11 5.2 Patients with tracheostomies or permanent tracheal stomas/laryngectomies Staff caring for patients with tracheal stomas/tracheostomy tubes (e.g. emergency department, ENT wards) should receive additional training in airway management and equipment for these patients. Information regarding this training should be accessed from the ABMUHB ENT specialist nurses. For care algorithms, see appendix Post surgical cardiothoracic patients Staff caring for patients in the Cardiothoracic Intensive Care Unit should adhere to the recommendations from the Resuscitation Council UK with regard to post cardiac surgical cardiac arrest management. See appendix 3. 6 OPERATIONAL GUIDANCE & POLICY IMPLEMENTATION 6.1 SUMMONING HELP The Resuscitation Team should be summoned by dialling 2222 in the event of: Confirmation of a Respiratory or Cardiopulmonary arrest, as defined by the Resuscitation Council (UK). Cardiopulmonary resuscitation (CPR) should always be provided immediately after help is summoned. Acute clinical deterioration of a patient in peri-arrest stage, following an ABCDE assessment If the NEWS score indicates a 2222 call If a member of staff makes a decision based on the clinical situation, following assessment When making the 2222 call the precise location of the patient must be communicated clearly and concisely to the switchboard operator. For adult patients state adult cardiac arrest Resuscitation Policy version : May 2016 Page 8 of 31

12 For pregnant patients state obstetric emergency and in the event of a cardiac arrest also state adult cardiac arrest For paediatric patients state paediatric cardiac arrest For neonates state neonatal emergency For trauma patients state trauma team If a cardiac arrest/sudden collapse occurs outside the main hospital building but within the hospital grounds, help should be summoned via a 2222 call. On receipt of the call switchboard will alert the cardiac arrest team and contact the Ambulance Service to support the incident and/or facilitate the transfer of the patient of the nearest Emergency Department. If, on arrival at the incident, the 2222 team deem the attendance of an ambulance unnecessary they should be encourage to inform the Ambulance Service as soon as it is practically possible. In the event of a paediatric emergency/arrest in any hospital/clinic that has no access to a paediatric emergency team call 2222 and request the adult cardiac arrest team. If in Singleton ask also for the neonatal team. Call 999 and liaise with the Paediatric team in either Morriston or Princess of Wales for transfer If a second arrest call is made during an ongoing resuscitation attempt, the Resuscitation Team should decide how to effectively split their resources so that support can be given to the second event 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 to a 2222 call, at the first possible opportunity inform switchboard and complete an incident form If pressing the emergency buzzer to summon the cardiac arrest team it should at all times be backed up with a 2222 phone call Peripheral hospitals All staff need to be aware of local procedures when working in peripheral hospital/clinics. Peripheral hospitals will generally have nurse led resuscitation teams, supported when available, by medical staff and the Ambulance Service. A majority of these areas have automated external defibrillators (AED s) and annual training is available to all qualified nurses in the use of this equipment. Resuscitation Policy version : May 2016 Page 9 of 31

13 6.2 EARLY WARNING SCORES (NEWS) NEWS is a standard operating procedure that should be adhered to for all patients with few exceptions* All patients must have vital signs recorded on admission The NEWS score dictates minimum actions that must be followed *Where clinical judgement indicates deviation from the standard operating procedure, this should be clearly documented in the medical/nursing record The NEWS chart is included as appendix S.B.A.R (Situation, Background, Assessment, Recommendation) The Resuscitation Council UK suggest that up to 80% of adverse incidents or near miss reports in hospitals are caused by problems with communication. It has also been suggested that the request for help is often inadequate, with a resulting failure to communicate the seriousness of the situation. The ABMUHB Resuscitation Service encourages the use of the S.B.A.R tool for patient handover. (see appendix 5 ) This tool facilitates effective, timely communication between individuals enhancing clear and concise information. This in turn allows the clinician to prioritise workload, in effect triaging patients. 6.4 SEPSIS SCREENING TOOL The United Kingdom Sepsis Group states that sepsis claims 37,000 lives annually, more than bowel, breast and prostate cancers combined. Early interventions and simple treatments can half the risk of mortality. (UK Sepsis Trust) The Resuscitation Service is committed to ensuring the recognition and treatment of sepsis. NEWS score actions include a trigger for Sepsis Screening (see appendix 6). If sepsis is confirmed, the prescribed course of action within the sepsis six should be followed. Resuscitation Policy version : May 2016 Page 10 of 31

14 6.5 DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION (DNACPR) The all Wales NHS NOT ATTEMPT CARDIO PULMONARY RESUSCITATION 2015 must be used to record all DNACPR new decisions (Appendix 7) DNACPR decisions should always be recorded on the new form The form only becomes active when signed by the senior responsible clinician caring for the patient, who has also provided their GMC number Decisions made and recorded prior to 1st August 2015 remain valid. Existing decision do not need to be transferred to the new forms. The Policy, Quick Reference Guide for clinicians, Patient Information Leaflet and guidance on how to complete the form is available on COIN If there is any doubt about the resuscitation status of any patient in cardiac arrest, the presumption should always be to immediately summon help and start CPR. 6.6 RELATIVES WITNESSING RESUSCITATION There may be situations where relatives may wish to witness the resuscitation of a family member. Where possible these wishes should be accommodated with appropriate support and supervision. However the final decision on this issue rests with the Resuscitation team leader. 6.7 POST RESUSCITATION CARE Immediately after resuscitation, 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: Resuscitation Policy version : May 2016 Page 11 of 31

15 Stabilising the patient as much as possible, though this should not delay definitive treatment Referral to an appropriate specialist The allocation of staff to facilitate safe transfer Preparation of equipment to facilitate safe transfer. This may require the involvement of other departments, the ambulance service, or other hospitals A full and complete handover to the receiving team Communication with patients Next of Kin 6.8 ANAPHYLAXIS The management of suspected anaphylactic reactions should be conducted in accordance with the Resuscitation Council UK guidelines for the management of anaphylaxis (see appendix 8) Wales NHS approved training is available on demand at Learning@wales.nhs.uk All Resuscitation Council courses provided by this organisation include the recognition and management of anaphylaxis The drugs recommended in the treatment of anaphylaxis will be available in clinical areas. It is the responsibility of clinical staff to know where to access this medication in an emergency situation In the west side of the organisation clinical areas are provided with anaphylaxis drug trays the contents of both adult and paediatric trays is included as appendix 9 In the east side of the organisation at present there no pre prepared anaphylaxis drug trays, but the drugs are stocked in ward/department drug cupboards It is the aim of the Resuscitation Committee to liaise with relevant departments in an endeavour to standardise drug trays across the organisation. Resuscitation Policy version : May 2016 Page 12 of 31

16 6.9 RESUSCITATION EQUIPMENT Resuscitation equipment must only be used by appropriately trained staff Medical Electronics are responsible for the maintenance of all defibrillators within the organisation. There are four departments located on the four main sites but they are responsible for equipment in the peripheral hospitals and local clinics. Hospital/Site Singleton Tel. No ext Morriston Tel. No Neath Port Talbot Tel. No Princess of Wales Tel. No Remit Cefn Coed - Garngoch Hill House Clydach Gorseinon Tonna Glanrhyd - Maesteg The defibrillator must be operationally checked in accordance with the manufactures recommendations. Medical Electronics must be contacted if any problems are highlighted during checking procedures. Apart from battery operated automated machines, defibrillators should always be connected to the mains supply. New batteries for Automated External Defibrillators (AED s) are provided by the medical electronics department. They will also dispose of the old one Checking Procedures for ward/department based resuscitation trolleys/bags The organisation s standard for resuscitation trolleys are included as appendix 12. The list of contents of emergency trolleys will be maintained by the Resuscitation Department (see appendix 10). This list is based on recommendations from the Resuscitation Council UK and should only be altered by agreement with the Resuscitation Department and the Resuscitation Policy version : May 2016 Page 13 of 31

17 Resuscitation Committee. The organisations Standard for emergency trolleys is included as appendix 11. A contents list will be available on every emergency trolley and should be checked according to the following schedule: Daily Checks include; Check defibrillator Check portable oxygen and suction if available Check sharps bin is empty Check general cleanliness Check stock list and expiry dates Record your signature on documentation provided It is the responsibility of the Department/Ward Manager to ensure that piped oxygen and suction (i.e. behind bed areas) is equipped and ready for use in an emergency ABM West (Singleton and Morriston Hospitals) Following use, the trolley should be exchanged for a fully stocked replacement from the trolley exchange room as soon as possible. Expired or individual items can be replaced from the equipment store (trolley exchange room). Morriston Hospital Replacement cardiac arrest drugs will be stored in the trolley exchange room. Singleton Hospital Replacement cardiac arrest drugs can be collected from the Pharmacy department or the emergency drugs cupboard accessed by the out of hours team. See appendix 13 for list of resuscitation drug tray contents ABM East (Princess of Wales and Neath Port Talbot Hospitals) POW Replacement equipment can be obtained from the Resuscitation store, off the main corridor, ground floor near the short stay unit. NPT Replacement equipment can be obtained from the Resuscitation store area. Situated the corridor to ward F and G. Key can be obtained from the porters For all clinical sites where emergency bags are provided in place of trolleys, these should be restocked as soon as possible following use. Princess of Wales and Neath Port Talbot Hospitals - Replacement drug boxes can be obtained from the Pharmacy Department or the emergency drug cupboard accessed by the out of hours team. Resuscitation Policy version : May 2016 Page 14 of 31

18 If any problems are encountered, contact the Resuscitation Service (see Useful Contacts) Procurement All resuscitation equipment purchasing is subject to the organisation s standardisation strategy. The Resuscitation Service must approve all resuscitation equipment purchased INFECTION CONTROL Please refer to the organisation s policies and procedures on infection control MANUAL HANDLING In situations where the collapsed patient is on the floor, in a chair or in a restricted/confined space the organisational guidelines for the movement of the patient must be followed to minimise the risks of manual handling and related injuries to both staff and the patient. Please also refer to the Resuscitation Council (UK) statement, which can be found at AUDIT AND INCIDENT REPORTING All events to which a cardiac arrest/rapid response team have been called must be audited (DoH HSC 2000/028). Across the four main sites the Audit Department review every call and report the collated data to the Resuscitation Service Manager. Every month 30 random samples of notes are reviewed and the event examined in retrospect to determine if care preceding the Cardiac Arrest was appropriate. If any anomaly is found, a Datix report is completed and education needs revisited. In the event of a 2222/999 call in one of the peripheral hospitals, it is the responsibility of the nurse in charge at the event to complete a cardiac arrest audit form (see appendix 13) and return it the Resuscitation department. The Resuscitation Service Manager will produce annual audit reports for cardiac arrest outcomes and the DNACPR process, which will: Identify the incidence and presentation of cardiac arrest Differentiate between episodes of cardiac arrest and acute illness Resuscitation Policy version : May 2016 Page 15 of 31

19 Identify where the crash team has been summoned to patients who have triggered the EWS system Identify survival rates from the event (i.e. those patients surviving to discharge) Monitor compliance with the Health Boards DNACPR guidelines The Resuscitation Committee will: Lead on the monitoring of all the minimum requirements within the Health Inspectorate Wales (HIW) standards 6.13 DOCUMENTATION Documentation relating to resuscitation can be located in the appendices (see Appendix 14 for algorithms) or can be accessed from the Resuscitation Council UK ( 7. Equality Impact Assessment EQUALITY IMPACT ASSESSMENT STATEMENT This policy has been screened for relevance to equality. No potential negative impact has been identified so a full equality impact assessment is not required. 8. CARDIAC ARREST TEAM STRUCTURE 8.1 Adult Emergency or Cardiac Arrest team On call Medical Registrar or equivalent On call Medical F1 or equivalent On call Medical F2 or equivalent On call Anaesthetist On call Anaesthetic nurse or equivalent if available Porter (Singleton, NPT & POW) Resuscitation Policy version : May 2016 Page 16 of 31

20 Senior Ward/Department Nurse Resuscitation Officer (RO) if onsite NPT Specialty Doctor and two Nurse practitioners 8.2 Paediatric Emergency or Cardiac Arrest team On call Paediatric Registrar or equivalent On call Paediatric F1 or equivalent On call Paediatric F2 or equivalent On call Anaesthetist On call Anaesthetic nurse or equivalent if available Porter Senior Ward/Department Nurse RO if onsite 8.3 Neonatal Emergency or Cardiac Arrest team Neonatal or Paediatric Registrar Neonatal/Paediatric SHO Neonatal Nurse Practitioner/Nurse in charge Senior Midwife Porter 8.4 Obstetric Emergency team Duty Obstetric Registrar and F2 Duty Obstetric Anaesthetist Neonatal Registrar and F2 On call maternity Theatre team Senior Midwife Porter 8.5 Obstetric Cardiac Arrest team Duty Obstetric Registrar and F2 Duty Obstetric Anaesthetist Neonatal Registrar and F2 On call maternity Theatre team Senior Midwife On call Medical Registrar or equivalent On call Medical F1 or equivalent On call Medical F2 or equivalent Porter RO if onsite Resuscitation Policy version : May 2016 Page 17 of 31

21 8.6 NPT Birth Centre (Midwife Lead) - Summon appropriate help and start resuscitation 9. REFERENCES AND BIBLIOGRAPHY Department of Health. (2000). HSC 2000/028. Resuscitation Policy. London:Department of Health. Available at: Mental Capacity Act London: The Stationery Office. Available at: National Institute for Health and Clinical Excellence (NICE). (2007). CG50. Acutely Ill Patients in Hospital. London: NICE. Available at: Resuscitation Council (UK). (2008[2004]). Cardiopulmonary Resuscitation Standards for Clinical Practice and Training: A Joint Statement from the Royal College of Anaesthetists, the Royal College of Physicians of London, the Intensive Care Society and the Resuscitation Council (UK). London: The Resuscitation Council (UK). Available at: Resuscitation Council (UK). (2007). Decisions relating to cardiopulmonary resuscitation: A joint statement from the British Medical Association, the Resuscitation Council (UK) and Royal College of Nursing. London: BMA. Available at: The United Kingdom Sepsis Group (UKSG). Available at: lives plus campaign Resuscitation Policy version : May 2016 Page 18 of 31

22 10. APPENDICES Appendix 1 - Abbreviations Cardiopulmonary Resuscitation (CPR) Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Early Warning Score (EWS) Patient at Risk Score (PAR) Medical Early Warning Score (MEWS) National Early Warning Score (NEWS) Allied Health Care Professionals (AHP) Health Care Support Worker (HCSW) Automated External Defibrillator (AED) Basic Life Support (BLS) Emergency Life Support (ELS) Paediatric Basic Life Support (PBLS) Advanced Life Support (ALS) Advanced Trauma Life Support (ATLS) (EMSB) Immediate Life Support (ILS) Paediatric Immediate Life Support (PILS) European Paediatric Life Support (EPLS) Health Inspectorate Wales (HIW) Appendix 2 Tracheostomy & Laryngectomy emergency algorithms Resuscitation Policy version : May 2016 Page 19 of 31

23 Appendix 3 CALS algorithm calsprogram.org Appendix 4 NEWS chart Resuscitation Policy version : May 2016 Page 20 of 31

24 Appendix 5 SBAR communication tool Resuscitation Policy version : May 2016 Page 21 of 31

25 Appendix 6 Sepsis screening tool Resuscitation Policy version : May 2016 Page 22 of 31

26 Appendix 7 DNCPR form Resuscitation Policy version : May 2016 Page 23 of 31

27 Appendix 8 Anaphylaxis algorithms Appendix 9 Contents list for anaphylaxis drug tray Drug Adrenaline 1 in 1000 Chlorphenamine 10mg in 1ml Hydrocortisone 100mg Salbutamol 2.5mg Quantity 10 x 1ml ampoules 5 x 1ml ampoules 10 vials 5 nebules Water for injection 5ml 20 1ml syringe and needle (1 blue & 1 orange) N.B. prime syringe and needle first. Resuscitation Policy version : May 2016 Page 24 of 31

28 Appendix 10 Contents list for emergency trolleys Gratnall Type TOP OF TROLLEY Tray 4 - CIRCULATION Defibrillator 2 of each (with one set of pads attached to manual defib). Do not attached to FR2 (red defib) 1 IV Cannula size 16,18,20 Sharps box 1 Sterets 4 Gloves/Aprons/Visors 1 Pack IV Cannula dressings 2 (Attached to side of trolley) Micropore 1 Tray 1-MISCELLANEOUS Blood Products IV giving set 2 Emergency drug tray 1 Sodium chloride 0.9% 500ml 1 Defibrillation pads 1 Colloid 500ml 1 Electrodes 1 pack Syringes 2ml 5ml 1 of each ECG paper roll 1 Syringes 10ml 20ml 2 of each Razor 1 Green Safety needle 21g 2 of each (IM/Sub cut use only) Checklist 2 Blunt fill needle 18g 2 of each (for drawing up fluid only) Audit form 1 Blood gas syringe 2 Scissors 1 Gauze 2 Tray 2-AIRWAY Saline 10mls 4 Oropharyngeal airway size 2,3,4 1 of each Nasal airways size 6 and 7 1 of each End Tidal CO2 Detector 1 Laryngoscope handle + size 3 blade 1 Laryngoscope handle + size 4 blade 1 Adult size Bougie/Introducer (taped to side of trolley) 1 Catheter mount 1 20ml syringe 1 Magils forceps 1 Cotton tape 1 Lubrication jelly 1 Gauze swabs 1 ET tubes 7,8,9mm (cuffed) 1 of each Suction catheters Size 12 & 14 2 of each Yankauer suction 2 Tray 3- BREATHING Pocket mask 1 Oxygen mask - non rebreathe 1 Adult Ventilation bag 1 Please note that ALL equipment is single use disposable Face masks size 3 and 4 1 of each Oxygen tubing 1 Resuscitation Policy version : May 2016 Page 25 of 31

29 Red Trolley TOP OF TROLLEY Tray 3 - CIRCULATION Defibrillator and Pads x2 1 IV Cannula size 16,18,20 2 of each (with one set of pads attached to manual defib). 4 Sterets Do not attached to FR2 (red defib) Trolley Base-MISCELLANEOUS IV Cannula dressings 2 Emergency drug tray 1 Micropore 1 Gloves/Aprons/Visors 1 Pack Blood products IV giving set 2 Electrodes 1 pack Sodium chloride 0.9% 500ml 1 ECG paper roll 1 Colloid 500ml 1 Sharps Box 1 Syringes 2ml 5ml 1 of each Razor 1 Syringes 10ml 20ml 2 of each Checklist 2 Green Safety needle 21g 2 of each (IM/Sub cut use only) Audit form 1 Blunt fill needle 18g 2 of each (for drawing up fluid only) Scissors 1 Blood gas syringe 2 Tray 1-AIRWAY Gauze 2 Oropharyngeal airways size 2,3,4 1 of each Saline 10mls 4 Nasal airways size 6 and 7 1 of each End Tidal CO2 Detector 1 Laryngoscope handle + size 3 blade 1 Laryngoscope handle + size 4 blade 1 Please note that ALL Adult size Bougie/Introducer (taped to side of trolley) 1 Catheter mount 1 equipment is single use 20ml syringe 1 disposable Magils forceps 1 Cotton tape 1 Lubrication jelly 1 Gauze swabs 1 ET tubes 7,8,9mm (cuffed) 1 of each Tray 2- BREATHING Suction catheters Size 12 & 14 2 of each Yankauer suction 2 Adult Ventilation bag (on side of trolley) 1 Face masks size 3 and 4 1 of each Oxygen tubing 1 Pocket Mask 1 Oxygen Mask-non rebreathe 1 Resuscitation Policy version : May 2016 Page 26 of 31

30 Appendix 11 Emergency trolley standard Resuscitation Policy version : May 2016 Page 27 of 31

31 Appendix 12 Contents list for resuscitation drug trays ABMUHB Adult Emergency Drug Tray Drug Adrenaline 1mg in 10mL (1:10,000) Amiodarone 300mg in 10mL Quantity 5 syringes 1 syringe Doses Adrenaline 1mg in 10mL every 3-5 min Amiodarone 300mg (after 3rd shock) Kept on ward/emergency cupboard Calcium Chloride 10% (1000mg in 10mL) (6.8mmol Ca 2+ per 10mL) Or Calcium Gluconate 10% (1000mg in 10mL) (2.26mmol Ca 2+ per 10mL) Sodium Bicarbonate 8.4% (50mmols in 10mL) Glucose 50% (25mg in 50mL) Magnesium sulphate 50% Atropine sulphate 1mg in 5mL Resuscitation Policy version : May 2016 Page 28 of 31

32 Expiry date / / For guidelines see reverse side Resuscitation Policy version : May 2016 Page 29 of 31

33 Appendix 13 Cardiac arrest audit form Resuscitation Policy version : May 2016 Page 30 of 31

34 Appendix 14 Resuscitation algorithms Resuscitation Policy version : May 2016 Page 31 of 31

35 Appendix 2 Resuscitation Training Strategy Document Author: Mark Dawson Approved by: Quality & Safety Committee Approval Date: Review Date: 1

36 1. EXECUTIVE SUMMARY 1.1 Abertawe Bro Morgannwg University Health Board (ABMUHB) expects all staff to undertake regular resuscitation training, at a level which is appropriate to their role. The Health Board is committed to making training available to all members of staff. 1.2 All training will be delivered to the standard recommended by the Resuscitation Council (UK) and at levels outlined in the Welsh Governments Core Skills Training Framework (CSTF) Resuscitation Training ~ for the purpose of this strategy the term Resuscitation Training includes- 2. SCOPE 3. AIM Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) Recognition & prevention of deterioration using A-E assessment and/or National Early Warning Score (NEWS) Defibrillation Sepsis screening & treatment Human factors & communication tools Courses such as ILS & ALS 2.1 This strategy applies to all permanent staff within the Health Board, clinical locums, and bank or agency staff. 2.2 The strategy will outline mandatory and recommended training requirements for all staff. 2.3 Recommends monitoring and reporting of measurement against agreed standards. 3.1 The founding principle of this strategy is to prevent harm and promote recovery, by providing staff with the necessary skills to recognise and respond to deteriorating patients in a timely manner. 3.2 It is a widely accepted principle that early recognition and interventions can prevent patients deteriorating to the point of cardiac arrest. 3.3 In the event of cardiac arrest the rapid delivery of CPR & early defibrillation provides the greatest chances of survival. 2

37 4. OBJECTIVES 4.1 Adult To provide all staff with training in cardiopulmonary resuscitation, (CPR), Level 1. Level 1 Mandatory annual training for all staff Accessible via internet at Learning@wales.nhs.uk Endorsed by the Resuscitation Council (UK) Recorded via ESR/OLM Reported to Welsh Government Additional, optional, opportunities to undergo hands on practice will be offered across the Health Board. 4.2 Level 2 For clinical, patient facing staff only (not registered nurses working substantively at the bedside or those who hold/require ALS provider certificates). This training includes the use of the National Early Warning Score (NEWS) and the use of Automated External defibrillators (AED). For example this group might include- OPD Registered Nurses, Health Care Support Workers, Physiotherapists, Occupational Therapists, Radiographers, Community Nursing & Mental Health Teams, Medical staff who are not part of the cardiac arrest team. Pre-course requirement, valid Level 1 certificate (adult) Recommended, once every two years Provided regularly on all across the Health Board hospital sites and Resuscitation Training Centre 4.3 Level 3 Resuscitation Council (UK) Immediate Life Support Course (ILS). For registered nurses working substantively at the bedside; specific staff groups for whom ILS is mandated by their professional bodies; nurses undertaking invasive procedures. For those who require Advanced Life Support training, ILS should be used as interim training between ALS recertification. (see below) Pre-course requirement, valid Level 1 certificate (adult) Recommended, once every two years Provided at Swansea and Bridgend localities 3

38 4.4 Advanced Life Support (ALS) Resuscitation Council (UK) Advanced Life Support Course (ALS). For medical staff and registered nurses, likely to be involved in the care of acutely unwell patients. Pre-course requirement, valid Level 1 certificate (adult) Strongly recommended for medical staff who form part of the 2222 team Valid for 4 years 4.5 Paediatrics Provided regularly at the Training Centre, Swansea Foundation Programme doctors are allocated places during first year of appointment Paediatric BLS For all patient facing staff with responsibility for caring for children. Mandatory annual training Pre-course requirement, valid Level 1 certificate (adult) Provided regularly on all main hospital sites and the Resuscitation Training Centre. 4.6 Paediatric ILS Resuscitation Council (UK) Paediatric Immediate Life Support Course (PILS). For registered paediatric nurses, working substantively at the bedside. Not for those who hold/require EPALS provider certificates. Pre-course requirement, valid Level 1 certificate (adult) Recommended, once every two years Provided at Swansea and Bridgend localities. 4.7 European Paediatric Advanced Life Support (EPALS) or equivalent Resuscitation Council (UK) Advanced Life Support Course (ALS). For medical staff and registered nurses, likely to be involve with the care of acutely unwell medical patients. Pre-course requirement, valid Level 1 certificate (adult) Strongly recommended for medical staff who form part of the 2222 team Valid for 4 years 5. RESPONSIBILITIES Provided regularly at the Training Centre, Swansea 5.1 Resuscitation Service Will schedule adequate teaching sessions to allow all staff access to appropriate training at the frequency described. E.g. appendix 1 4

39 Monitor training attendance and maintain appropriate records Will produce annual reports for the Q&S Committee. 6. IMPLEMENTATION This policy will be widely circulated across The Health Board and approved by the relevant Boards. 7. AUDIT Monitoring and evaluation will be an essential part of the process. It will provide assurance to the Executive Board that we are delivering targeted appropriate training for all staff within the organisation, contributing to improved clinical outcomes. Compliance with Level 1 training will be reported to the Executive Board and Welsh Government. Compliance with this policy will be monitored and performance managed through Locality / Directorate Governance processes. 5

40 Appendix 1 Annual Training Delivery Level 2 Hospital Site & numbers requiring level 2 training Requirement by group (other inc. Drs, therapists, etc) Non Secondary care allocation of 3612* Sessions Per week Places per session RN places per session HCSW places per session Other clinical per session Non secondary care places per session Places per year Morriston 3452 Singleton 1948 POW 1981 NPT RN 425 HCSW 1328 Other 769 RN 238 HCSW 941 Other 871 RN 149 HCSW 961 Other 544 RN 198 HCSW 401 Other Phillips Parade n/a n/a n/a n/a Totals The table outlines level 2 training, as an example of how it will be provided. The non secondary care places are Community, Mental Health etc based on figures from finance/hr. The numbers of places per session, by type, is an attempt to illustrate roughly how many staff will need to be sent by manager to meet an annual target. In summary, places will be available to Community based staff at all locations and at every session provided, including at Phillips Parade 6

41 Annual training delivery (Level 1&2 paediatrics) Hospital Site & numbers requiring level 2 training(other inc. Drs, therapists, etc) Non Secondary care allocation of 787 Sessions Per month Places per session RN places per session HCSW places per session Other clinical per session Non secondary care places per session Places per year Morriston Singleton POW 211 LD/MH 332 Community NPT Phillips Parade n/a n/a n/a

42 Annual training delivery (Level 3 ILS) Hospital Site Numbers qualifying Places per session RN places per session Courses per year Places per year Morriston Singleton POW NPT CCH, Glanrhyd, Maesteg,Tonna, Gorseinon