RESUSCITATION: Training & Standards Re Audit 2009/10 Amanda Clements ST4, Adult Psychiatry Brian Hockley Projects Manager, IGPE Sheffield Health and Social Care Foundation Trust
INTRODUCTION The Resuscitation Council (UK) in collaboration with The Royal College of Anaesthetists, The Royal College of Physicians and The Intensive Care Society published a set of standards for clinical practice and training with respect to Cardio-pulmonary resuscitation in October 2004. In December 2005 revised resuscitation protocols were released, based on research into Cardio-pulmonary arrest survival figures. These standards have been widely endorsed within the NHS. The Council state that all new members of staff should receive resuscitation training as part of their induction program and must have an annual update of their skills. The level of training should be appropriate to the individual s clinical responsibilities. Training should be provided through a locally appointed resuscitation officer but some aspects of training may be delegated. They also recommend training in an early warning scoring system to help staff identify patients who are critically ill and therefore at risk of cardiopulmonary arrest. They highlight the improved survival rates with appropriate early defibrillation and recommend defibrillation is available in any area that has experienced a cardiopulmonary arrest within the previous 5 years. Sheffield Health and Social Care Foundation Trust (SHSC FT) has a clear resuscitation policy which can be found on the trust intranet. The policy outlines the trust requirements for audit and training. Each clinical area has a nominated Local Resuscitation Trainer (LRT). The LRT along with the ward manager/team leader are responsible for maintaining skills and equipment in their area. Training should be updated annually and documented locally and centrally with the Risk Department. Training may be provided locally by the LRT or centrally by the Risk Department. The level of skill and equipment in each area is assessed annually and takes account of aspects such as staffing level and degree of clinical risk for the client group. In 2006/7 we conducted an audit of SHSC FT adherence to these standards. The same audit has been repeated in 2009/10.
METHODS In 2006/7 a two page audit tool was constructed. A senior House Officer distributed the tool to all junior doctors within Sheffield Care Trust achieving 9 coverage. In 2009/10, the same doctor has distributed the same audit tool with an equivalent group to that audited in 2006/7 but expanded to include consultant and middle grade staff. The audit tool was designed for electronic scanning and returned to the SHSCFT Clinical Effectiveness department in a pre-paid envelope. The forms were scanned and data analyzed proportionately. Differences in proportions in responses to analogous questions and staff groups between 2006/7 and 2009/10 have been analyzed using StatsDirect. Statistical differences are reported as probability values using appropriate tests.
RESULTS At the time of the first audit in 2006 there were 41 doctors working at Junior Grade within the then Sheffield Care Trust. They were a mixture of General Practice trainees (GPVTS), Foundation level trainees (F1-2) and rotational Psychiatry SHO s. In the repeat audit in 2009/10 there were 144 doctors with an approximately even split between inpatient and community settings: 45 Senior Grade (consultants), 37 Middle Grade (ST4-6/SpR s), and 62 Junior Grade (GPVTS, F1-2, ST1-3). A 62% overall response rate was achieved across all grades of doctor: 69% senior grade, 51% middle grade and 63% junior grade. Not all respondents answered all questions. Results are given as percentage values of responses received for any given question.
2009/10 RESPONSES TO INDIVIDUAL QUESTIONS Have you ever received Basic Life Support training? 10 9 2 1 No Yes When did you receive Basic Life Support training? 10 9 2 1 >2 Years 1-2 Years <1 Year
Who organised training? 10 9 2 1 Other SHSC Do you know the identity of your Local Resuscitation Trainer? 10 9 2 1 No Yes
Do you know the location of the resuscitation equipment bag? 10 9 2 1 No Yes Trained to use Automated External Defibrillator? 10 9 2 1 No Yes
Do you feel confident in your ability to administer Basic Life Support? 10 9 2 1 No Yes Do you feel confident in your ability to use the Automated External Defibrillator? 10 9 2 1 No Yes
Do you feel confident in your ability to insert an intra venous line? 10 9 2 1 No Yes Do you feel confident in your ability to administer intra venous adrenaline without nursing assistance? 10 9 2 1 No Yes
COMPARING THE 2006/7 AUDIT TO 2009/10 REAUDIT Received Basic Life Support training at some time? Received Basic Life Support training within 1 year? Training organised by SHSC FT? Knows the identity of Local Resuscitation Trainer? Knows the location of the resuscitation equipment bag? Trained to use Automated External Defibrillator? 10 9 2 1 2006 2009 BLS Trained Within 1 year By SHSC Know LRT Resus bag AED trained
Confident in ability to administer Basic Life Support? Confident in ability to use the Automated External Defibrillator? Confident in ability to insert an intra venous line? Confident in ability to administer intra venous adrenaline without nursing assistance? 10 9 2 1 2006 2009 BLS AED Cannulation IV Injection
SIGNIFICANCE OF THE CHANGES FROM 2006/7 to 2009/10 Junior Grades 2006/7 2009/10 Significant improvement? Trained in BLS* within 1 year Confident in BLS 34/37 39/39 P=0.002 19/37 29/39 P=0.035 Trained in AED** 20/37 32/39 P=0.004 Confident in AED 16/37 26/39 P=0.025 *Basic Life Support, ** Automated electronic defibrilator
2006/7 AUDIT RECOMMENDATIONS The first audit was presented at the Trust wide audit meeting in 2007 as part of the Risk Departments prompt and concerned response. It was proposed that the appropriate forum group develop and implement a system to train medical staff in resuscitation. Immediate recognition was given to the importance of the results; particularly in the light of this statement by the Resuscitation Council.. Failure to provide an effective (resuscitation training) service is a failure in duty of care that is a clinical risk, contravenes the principles of clinical governance, and has implications for clinical negligence premiums. It was highlighted that medical expertise was being eroded and that the Trust was losing a skill base that if retained would benefit patient care. Attention was given to the different role doctors have in a resuscitation attempt. It was suggested that doctors required a higher training level to other staff to reflect this. It was agreed Advanced Life Support (ALS) training is not indicated although it was strongly agreed that individuals should be able to access this level of training if they desired it. This is in line with the Resuscitation Council guidelines which state funding and time release should be provided for staff to attend higher training if requested. It was also suggested that some designated staff with particular interest in resuscitation should be trained to ALS level to facilitate and enhance ongoing training within the Trust. The consensus opinion was that training should be provided at the Immediate Life Support (ILS) level. This incorporates training in airway management (including use of airway adjuncts and bag and mask ventilator), effective chest compressions and appropriate early defibrillation. It also includes training in an Early Warning System which identifies patients at risk of cardio-pulmonary arrest to facilitate preventative measures. Junior doctor Induction every August was identified as an appropriate time to provide initial training. Several Consultants pointed out that they would also wish to attend both initial training and the annual updates. This implies a rolling program of training must also be established as there is no equivalent Induction which senior doctors attend. It was suggested that incorporating annual training into the Core Competencies for Junior Doctors would take the onus off the Risk Department and allow doctors to share responsibility for their own training as part of CME. It was suggested the audit be extended to all medical staff to identify training needs at more senior levels.
2009/10 AUDIT RECOMMENDATIONS The re audit results are only recently available and a period of dissemination and discussion with stake relevant professionals is required before recommendations can be formalized. The physical health of mental health service users is gaining a higher profile on the national health agenda. Increasingly, it is being placed at the heart of new mental health policy. Inadequacies in resuscitation training provision generate concern particularly in light of the Resuscitation Councils statement: "Failure to provide an effective (resuscitation training) service is a failure in duty of care that is a clinical risk, contravenes the principles of clinical governance, and has implications for clinical negligence premiums." Psychiatrists must now take the clinical lead and help trusts to focus on their responsibility to the physical, as well as the mental health of their patients. In Sheffield a business case for radical restructuring and investment in resuscitation training is currently being discussed. In addition this also demonstrates that trainee audit has the ability to cause structural change at the highest level within an organisation.
APPENDICES Resus_Training_General Comments CAMHS situation. uses 9999 to transfer to general hospital in the event of emergency My training came in July at the end of my rotation. It ought to be at the start. Fortunately it counts towards my current job but this was just coincidence. The SHSC training should be ILS not BLS they offer. I think the training should be offered every six months rather than every one - year. I think the first day of any 6 months posting should start with resuscitation training for half a day. Training should be multidisciplinary. Training should be centrally organised around induction. Trainees have to make their own arrangements at the moment and this is unsatisfactory. Availability is patchy. Please can I have some training soon! The basic training the Trust provides is awful - much too basic. When I received it - they were not able to offer the training for the automatic defib for some strange reason I can't remember! Resus Training to be made part of local induction. This would be helpful in keeping Doctors up to date. We need to have more clearer details on defibrillation. Unaware who the trainer in Sheffield is and where it is organised. Trust should organise it every 6/12 or 1 year. It should be part of SHO Training e.g. Conflict resolution training done annually so should be basic / hospital life support.
Resus_Training_General Comments Should probably be looked at on induction days and dates booked in at that point. I feel that BLS is not enough and in the event of something actually happening ILS would be more useful (especially on elderly wards). We don't receive paediatric BLS training even though we do 6 months of child & adolescent. It should be more available to junior doctors and easier to book. There is a requirement but is not user friendly to organise it. We don't know where to start looking for it in this Trust. Had no training since starting psychiatry. No idea what level of resus is expected on the ward. During this placement. It was very helpful to have the opportunity to do resus training in the induction; I think it will be very essential to have this training in induction pack. It was a relief to have decent training in Doncaster after many years in Sheffield with inadequate training. I feel much more confident now. None of my training has been by this Trust though have only been here 6 months. Should be a mandatory training session yearly that all staff sign up to. Can be brief eg. 2hrs but needs to be yearly. Have always known where resus equipment is when working on a ward. Having resus training in Bassetlaw on the training grid to book on, rather than just when organised by team would be much better (Notts NHS Trust). Or being able to book on Sheffield training despite working in Bassetlaw would be good.