Healthcare Improvement Scotland 2013 ISBN First published July 2013

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2 Healthcare Improvement Scotland is committed to equality and diversity. We have assessed this indicator for likely impact on the nine equality protected characteristics as stated in the Equality Act 2010 and defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. A copy of the impact assessment is available upon request from the Healthcare Improvement Scotland Equality and Diversity Officer. Healthcare Improvement Scotland 2013 ISBN First published July 2013 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document s date and title specified.

3 Contents 1 Introduction 2 2 Background 4 3 Format of the DNACPR indicator 5 4 DNACPR indicator 6 5 References 8 Appendix 1: NHS board DNACPR leads 9 Appendix 2: NHS board executive leads for palliative and end of life care 10 Appendix 3: Membership of the DNACPR implementation group 11 Appendix 4: About Healthcare Improvement Scotland 12

4 1 Introduction Purpose The purpose of this document is to specify a minimum high level measure or indicator for healthcare services in Scotland on do not attempt cardiopulmonary resuscitation (DNACPR) decision-making and communication. An indicator is a measure of an outcome which demonstrates delivery of person-centred, safe and effective healthcare. An indicator should also promote understanding, comparison and improvement of that care. Scope The indicator supports implementation of the NHSScotland Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy 1 and the NHSScotland Resuscitation Planning Policy for Children and Young People (under 16 years): Children and Young Persons Acute Deterioration Management (CYPADM) 2. The indicator applies to: all NHS territorial boards with responsibility for delivering resuscitation services Scottish Ambulance Service State Hospitals Board for Scotland NHS National Waiting Times Centre, and all resuscitation services provided in primary, secondary and tertiary care settings, whether directly provided by the NHS board or secured on behalf of the NHS board. The indicator does not apply directly to the following organisations, but may have implications for them: Healthcare Improvement Scotland NHS Education for Scotland NHS Health Scotland, and NHS National Services Scotland. The indicator has highlighted the integral part the DNACPR policy plays in many other national initiatives and workstreams, including the following: Electronic Palliative Care Summary 3 and Key Information Summary (KIS) 4 advance and anticipatory care planning palliative and end of life care indicators 5 Reshaping Care for Older People 6 Person-Centred Health and Care Collaborative Hospital Standardised Mortality Ratios (HSMR) 7, and patient safety work for deteriorating patients in acute health care 8. 2

5 Data reporting DNACPR indicator The DNACPR implementation group has developed a data collection form so that healthcare providers can record relevant data against the indicator. The form is available from: It is expected that healthcare providers will use existing local mechanisms (such as clinical governance and quality improvement forums) to collect and analyse the data, discuss areas that need further attention and develop improvement plans to action them. Healthcare providers may find it helpful to liaise with: DNACPR leads (see Appendix 1) resuscitation leads executive leads for palliative and end of life care (see Appendix 2), and clinical audit departments and patient safety leads. This will ensure an integrated and consistent approach to the implementation of the policies 1, 2 and improvement in resuscitation practice and anticipatory care planning over time. These collaborations will allow data to be accessed from ongoing supported workstreams such as Liverpool Care Pathway (or equivalent) projects, HSMR audits, Scottish Patient Safety Programme audits, and the Palliative Care Direct Enhanced Service (DES). Healthcare providers should use consecutive cardiac arrest audit data for Area of Improvement 1 and a sample audit approach for Areas of Improvement 2 and 3. 3

6 2 Background In 2009, the Scottish Government Health Directorates convened a national steering group to develop an integrated adult policy for DNACPR decision-making and communication of those decisions. This project was prompted by the successful implementation in NHS Lothian of the UK s first fully integrated do not attempt resuscitation (DNAR) policy 9, which supported national good practice guidance in cardiopulmonary resuscitation decision-making and communication across all patient care settings. A separate, but closely aligned, national group was also convened to develop a policy for children and young people. In 2010, the Scottish Government published the NHSScotland Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy 1 and the NHSScotland Resuscitation Planning Policy for Children and Young People (under 16 years): Children and Young Persons Acute Deterioration Management (CYPADM) 2. Healthcare Improvement Scotland was tasked with supporting the implementation of both policies 1, 2 in collaboration with NHS boards, NHS Education for Scotland (NES) and Scottish Partnership for Palliative care (SPPC). In 2011, Healthcare Improvement Scotland reconvened the DNACPR adult policy group of 2009 as the DNACPR implementation group which included representatives from children and young people s services (see Appendix 3 for group membership). The group developed the DNACPR indicator to support and assess the ongoing implementation of the DNACPR and CYPADM policies across Scotland. Development of the DNACPR indicator The DNACPR implementation group, chaired by Dr Juliet Spiller, Consultant in Palliative Medicine, Marie Curie Hospice Edinburgh and NHS Lothian, developed and published a draft DNACPR indicator in The group agreed two rounds (6 months each) of testing the draft indicator to ensure it was robust and fit for purpose. The first phase of testing the draft DNACPR indicator was completed in June This provided an opportunity to check the validity of the indicator, gauge feasibility of data collection and engage more widely with the clinical community. The second phase of testing, focusing on establishing a baseline of Scotland-wide data, was completed in April In June 2013, the implementation group met to consider the feedback from the second phase of testing and to review and finalise the indicator. Patient, carer and public engagement The two key policies 1, 2 underpinning the indicator were developed following extensive engagement with patients, carers and interested members of the public

7 3 Format of the DNACPR indicator 5

8 4 DNACPR indicator Cardiopulmonary resuscitation (CPR) could, theoretically, be used on every individual prior to death. Therefore, it is essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their illness and for whom CPR will fail and/or is inappropriate. The DNACPR indicator measures whether there has been a reduction in the number of inappropriate CPR attempts. Rationale Implementation of the NHSScotland DNACPR and CYPADM policies should prompt and facilitate the decision-making process around resuscitation status and the appropriate communication of that decision. These policies facilitate person-centred end of life care planning and should result in fewer patients receiving inappropriate CPR treatment, irrespective of their clinical setting. How to measure the indicator The indicator is made up of four areas of improvement. Area of Improvement 1 All resuscitation attempts are carried out in line with the national resuscitation guidelines 14 of the Resuscitation Council (UK) and DNACPR or CYPADM policy Numerator 1.1 Number of CPR attempts for which a DNACPR form was completed Denominator 1.1 Number of all adult CPR attempts Data source CPR records, for example cardiac arrest or resuscitation databases Exclusions None Numerator 1.2 Number of resuscitations for which a CYPADM form was completed Denominator 1.2 Number of all child and young person full resuscitation attempts Data source CPR records, for example cardiac arrest or resuscitation databases Exclusions Data collection will identify and exclude clinical situations where an easily reversible cause for the arrest has been identified * and where clinical judgement to attempt CPR may be appropriate despite the presence of a DNACPR form *Reversible cause for the arrest may include choking, anaphylaxis and general anaesthetics Numerator 1.3 Number of unsuccessful CPR attempts terminated within 10 minutes Denominator 1.3 Number of all unsuccessful CPR attempts Data source CPR records, for example cardiac arrest or resuscitation databases Exclusions Appropriateness of CPR attempt to be confirmed by review It is also recognised that not every inappropriate CPR attempt will be terminated within 10 minutes. This information is collected in cardiac arrest data. 6

9 Area of Improvement 2 Numerator 2.1 DNACPR indicator All recognised expected deaths i have the DNACPR/CYPADM decision documented in line with national policy Number of recognised expected deaths with a documented DNACPR decision or CYPADM form Denominator 2.1 Number of recognised expected deaths Data source Liverpool Care Pathway (or equivalent) audit, HSMR audit, Global Trigger Tool, Palliative Care DES, Palliative Care Expected Deaths audit Exclusions None Notes i These are patients that are recognised by the clinical teams as imminently dying (within the next few days). Data collection: sample approach. Area of Improvement 3 NHSScotland DNACPR or CYPADM form is completed correctly for every DNACPR decision Numerator 3.1 Number of correctly completed DNACPR/CYPADM forms Denominator 3.1 Number of DNACPR decisions Data source DNACPR/CYPADM audit, case note audit Exclusions None Notes A correctly completed DNACPR/CYPADM form will be legible and include the following information: patient demographic data, signature of appropriate senior clinician and review timeframe (actual or estimated and not indefinite ). Data collection: sample approach. Area of Improvement 4 Numerator 4.1 All advance/anticipatory care plan (ACP) templates must include a field about resuscitation status/dnacpr/cypadm decision Number of advance/anticipatory care plan templates including resuscitation status/dnacpr/cypadm decision Denominator 4.1 Number of advance/anticipatory care plan templates Data source Palliative care/long term condition leads Exclusions None Note This refers to the ACP template (such as would be shared with KIS) not the total number of ACPs in place. 7

10 5 References 1. The Scottish Government. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): integrated Adult Policy Decision making & communication [cited Oct]; Available from: 2. The Scottish Government. NHSScotland Resuscitation Planning Policy for Children and Young People (under 16years): Children and Young People Acute Deterioration Management (CYPADM) [cited Oct]; Available from: 3. NHSScotland. Electronic Palliative Care Summary (epcs) [online] [cited 2013 Jun 14]; Available from: 4. NHSScotland. Key Information Summary (KIS) [online] [cited 2013 Jun 14]; Available from: 5. Healthcare Improvement Scotland. Palliative and end of life care indicators. March 2013 [cited Jun]; Available from: _care/palliative_care_indicators.aspx 6. Scottish Government. Reshaping Care for Older People [online] [cited 2013 Jun 14]; Available from: Care/Support/Older-People/ReshapingCare 7. NHS National Services Scotland. Hospital Standardised Mortality Ratios (HSMR) [online] [cited 2013 Jun 14]; Available from: Topics/Quality-Indicators/HSMR/ 8. NHS Education for Scotland. Deteriorating Patient [online] [cited 2013 Jun 19]; Available from: 9. Spiller J, Murray C, Short S, Halliday C. NHS Lothian Do Not Attempt Resuscitation Policy NHSScotland. Decisions about cardiopulmonary resuscitation: Information for patients, their relatives and carers [cited Mar]; Available from: on.pdf 11. Carole Millar Research. Patient information about: cardiopulmonary resuscitation (CPR) and palliative care [cited Mar]; Available from: NHSScotland. Is resuscitation right for my child? [cited Mar]; Available from: Carole Millar Research. Patient information about: Resuscitation Planning for Children and Young People [cited Mar]; Available from: Resuscitation Council (UK). Resuscitation Guidelines [cited Jun]; Available from: 8

11 Appendix 1: NHS board DNACPR leads NHS board area/organisation Name Designation NHS Ayrshire & Arran Michael Canavan Lead Resuscitation Officer NHS Borders Rod McIntosh Resuscitation Training Officer NHS Dumfries & Galloway Lindsay Martin Palliative Care Consultant NHS Fife Jacqueline Beatson Resuscitation Training Officer NHS Forth Valley Elizabeth Millar Consultant in Ageing & Health NHS Grampian Sandra Mckandie Senior Resuscitation Officer NHS Greater Glasgow and Clyde John Dickson Associate Medical Director NHS Highland Grant Franklin Consultant in Acute Medicine NHS Lanarkshire Tracey Dunn Consultant Anaesthetist NHS Lothian Juliet Spiller Consultant in Palliative Medicine NHS Orkney Alan Bruce SPSP Programme Manager NHS Shetland Catriona Barr Consultant Anaesthetist NHS Tayside Ian McDougall Lead Resuscitation Officer NHS Western Isles NHS National Waiting Times Centre (Golden Jubilee Hospital) NHS 24 Scottish Ambulance Service Marion McLoone Calum Cassidy Fiona Pike Robin Lawrenson Interim Head of Clinical Governance and Risk Management Resuscitation Officer Associate Director of Nursing and Operations National Clinical Performance Manager 9

12 Appendix 2: NHS board executive leads for palliative and end of life care NHS board area/organisation Name Designation NHS Ayrshire & Arran Alison Graham Medical Director NHS Borders Sheena McDonald Medical Director NHS Dumfries & Galloway Lindsay Martin Palliative Care Consultant NHS Fife Anne Buchanan Director of Nursing NHS Forth Valley Peter Murdoch Interim Medical Director NHS Grampian Roelf Dijkhuizen Medical Director NHS Greater Glasgow and Clyde Marie Farrell Interim Director Rehabilitation & Assessment Directorate NHS Highland Heidi May Board Nurse Director NHS Lanarkshire Iain Wallace Medical Director NHS Lothian David Farquharson Medical Director NHS Orkney NHS Shetland NHS Tayside Derek Barron Kathleen Carolan Carrie Marr NHS Western Isles Nigel Hobson Nurse Director Interim Executive Nurse Director Director of Nursing, Midwifery & Allied Health Professionals Associate Director of Change and Innovation NHS 24 Sheena Wright Nursing Director NHS Education for Scotland NHS National Services Scotland National Waiting Times Centre Board (Golden Jubilee Hospital) Maggie Grundy Marion Bain Shona Chaib Programme Director Cancer Care Medical Director Nurse Director Scottish Ambulance Service George Crooks Medical Director 10

13 Appendix 3: Membership of the DNACPR implementation group Name Designation Deputy NHS board area/ organisation Catriona Barr Consultant Anaesthetist - NHS Shetland Jacqueline Beatson Resuscitation Training Officer Brenda Wilson NHS Fife Michael Canavan Lead Resuscitation Officer Jane Chestnut NHS Ayrshire & Arran Calum Cassidy Resuscitation Officer - John Dickson Associate Medical Director Maureen Boyd Rachael Dunk Directorate for Health and Healthcare Improvement NHS National Waiting Times Centre (Golden Jubilee Hospital) NHS Greater Glasgow and Clyde - Scottish Government Tracey Dunn Consultant Anaesthetist William Lannigan NHS Lanarkshire George Fernie Grant Franklin Senior Medico-Legal Adviser Consultant in Acute Medicine Mark Hazelwood Director - Robin Lawrenson Elaine MacLean National Clinical Performance Manager Professional Adviser, Palliative Care Angelique Mastihi Chrissie Lane - Graham Strang Medical Protection Society NHS Highland Scottish Partnership for Palliative Care Scottish Ambulance Service Care Inspectorate Ian McDougall Lead Resuscitation Officer Karen Smith NHS Tayside Rod McIntosh Sandra Mckandie Marion McLoone Resuscitation Training Officer Senior Resuscitation Officer Interim Head of Clinical Governance and Risk Management Lindsay Martin Palliative Care Consultant - Elizabeth Millar Consultant in Ageing and Health Dermot Murphy Consultant Paediatrician - Fiona Pike Associate Director of Nursing and Operations Tom Cripps NHS Borders - NHS Grampian - NHS Western Isles NHS Dumfries & Galloway - NHS Forth Valley - NHS 24 NHS Greater Glasgow and Clyde Aneta Sowinska Anaesthetist Alan Bruce NHS Orkney Juliet Spiller Consultant in Palliative Medicine Steven Short NHS Lothian Rosalie Wilkie Consultant Paediatrician - CATSCAN 11

14 Appendix 4: About Healthcare Improvement Scotland Healthcare Improvement Scotland was launched on 1 April This health body was created by the Public Services Reform (Scotland) Act 2010 and marks a change in the way the quality of healthcare across Scotland will be supported nationally. Our vision Our vision is to deliver excellence in improving the quality of the care and experience of every person in Scotland every time they access healthcare. Our purpose Our organisation has key responsibility to help NHSScotland and independent healthcare providers to: deliver high quality, evidence-based, safe, effective and person-centred care, and scrutinise services to provide public assurance about the quality and safety of that care. What we do We are building on work previously done by NHS Quality Improvement Scotland and the Care Commission, and our organisation includes: Healthcare Environment Inspectorate Scottish Health Council Scottish Health Technologies Group, and Scottish Intercollegiate Guidelines Network (SIGN). We also support the work of the Scottish Medicines Consortium and take a lead role in co-ordinating the work of the Scottish Patient Safety Programme. Our work programme supports Scottish Government priorities, in particular those arising from The Healthcare Quality Strategy for NHSScotland. Our work encompasses all three areas of the integrated cycle of improvement (see Figure 1) with patient focus and public involvement at the heart of all that we do. The integrated cycle of improvement involves: developing evidence-based advice, guidance and standards for effective clinical practice driving and supporting improvement of healthcare practice, and providing assurance about the quality and safety of healthcare through scrutiny and reporting on performance. 12

15 Figure 1: Integrated cycle of improvement Visit our website: for more information. 13

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