Resuscitation and Related Medical Emergencies Policy CLP002 Page 1 of 38
Table of Contents Resuscitation and Related Medical Emergencies Policy CLP002... 1 Why we need this Policy... 4 What the Policy is trying to do... 4 Which stakeholders have been involved in the creation of this Policy... 4 Any required definitions/explanations... 4 Key duties... 5 Corporate Responsibility... 5 Director Responsibility... 5 Manager Responsibility... 6 Employee Responsibility... 6 Resuscitation Service Responsibility... 7 Policy detail... 7 Resuscitation Equipment Provision & Replenishment... 7 Preventing Deterioration and response to Medical Emergencies including Cardiac Arrest... 8 Post Resuscitation Care and Transfer... 10 Legal & Ethical Issues Pertaining to Resuscitation... 10 The Duty of Care... 10 The Standard of Care... 10 Insurance Liability... 11 Witnessed Resuscitation... 11 When to Stop Resuscitation... 11 Decisions Relating to Cardiopulmonary Resuscitation... 11 Manual Handling... 11 Cross Infection... 11 Training requirements associated with this Policy... 12 Mandatory Training... 12 Specific Training not covered by Mandatory Training... 12 How this Policy will be monitored for compliance and effectiveness... 12 For further information... 13 Equality considerations... 13 Page 2 of 38
Reference Guide... 14 Document control details... 15 Appendix 1 - Basic Life Support (BLS)... 16 Appendix 2 - Paediatric Basic Life Support (PBLS) (Paediatric inpatient areas only)... 17 Appendix 3 Sequence for a collapsed patient in hospital... 18 Appendix 4 - Advanced Life Support Algorithm... 18 Appendix 5 - Management of Choking... 20 Appendix 6 - Paediatric choking algorithm.21 Appendix 7 - Management of Anaphylaxis... 21 APPENDIX 8 - PERI-ARREST ALGORITHMS... 23 Appendix 9 - Management of tachycardia..24 APPENDIX 10 - SBAR/RSVP AND RECOGNIZING THE DETERIORATING PATIENT... 25 Appendix 11 - Anaphylaxis management and AED equipment lists... 32 Anaphylaxis Management Equipment (for certain physical health environments, community practitioners and similar)... 32 AED (Automated External Defibrillator) Equipment List... 32 AED and Oxygen Check Sheet... 33 Appendix 12 - Audit Form... 34 APPENDIX 13 nhft EQUALITY Analysis tool... 36 Appendix 14 - ACTION PLAN TEMPLATE... 38 Page 3 of 38
Why we need this Policy Northamptonshire Healthcare NHS Foundation Trust aims to provide the highest quality care to service users and to minimise risk in all the services it provides. The Trust is responsible for ensuring that all patient areas have immediate access to appropriate resuscitation equipment and appropriately trained personnel to manage victims (1) of medical emergency or cardiac arrest situations. What the Policy is trying to do The purpose of this policy is to ensure that the Trust complies with NHS Litigation Authority (NHSLA) Risk Management Standards (2012/13), HSC 2000/028, NPSA Rapid Response Report NPSA/2008/RRR010 and the recommendations of the Resuscitation Council (UK). Quality standards for cardiopulmonary resuscitation practice and training November 2013 This policy provides direction and guidance for the planning and implementation of a highquality and robust resuscitation service to the organisation. The policy outlines procedures and practices within the Trust with regard to the provision of emergency medical equipment and the expected response by staff to a medical emergency / cardiac arrest situation incorporating the current published guidelines for resuscitation (Resuscitation Council (UK), 2010). (Appendices 1 7). Services commissioned by the Trust should adhere to the principles of this Policy. Which stakeholders have been involved in the creation of this Policy Dr Alex O Neill-Kerr, Medical Director Michaela Cox, Chief Pharmacist; Janice Jones, Senior Pharmacist; Julie Shepherd, Director of Nursing, AHP s and Quality Lisa Gammon, Learning and Development Officer Clinical Any required definitions/explanations A medical emergency refers to any situation where an individual s physical health has deteriorated and requires urgent intervention to prevent further deterioration or cardiac arrest. Page 4 of 38
The state of cardiac arrest is defined as the absence of breathing and other signs of life in a collapsed person. Clinical Staff are those staff who have direct patient contact, including qualified and nonqualified staff. Non-clinical Staff are those staff who do not have direct patient contact. Basic Life Support will be referred to as BLS and PBLS for specific paediatric areas. The age of a paediatric is classed as 0 to puberty for resuscitation. Basic Life Support involves the assessment of the collapsed patient to diagnose cardiac arrest and the performance of external chest compressions and ventilations. The Resuscitation Council (UK) Immediate Life Support Course will be referred to as ILS. Skills taught on the ILS course include those of BLS as well as the use of basic airway adjuncts and drug administration for appropriate staff. ILS equipment is defined as the contents of the emergency trolley / grab bag, including an Automated External Defibrillator (AED) and oxygen. NHFT - Northamptonshire Healthcare NHS Foundation Trust Key duties Corporate Responsibility Healthcare organisations have an obligation to provide an effective resuscitation service to their patients and appropriate training to their staff. The Chief Executive, on behalf of the Trust Board, has overall responsibility for effective risk management within the Trust and a duty to ensure the Trust complies with its statutory obligations. The Trust Board has overall responsibility for ensuring that all staff have received appropriate training to enable them to effectively fulfil their role within the organisation and maintain the safety of service users. The Trust Board has responsibility to ensure adequate provision of suitable staffing and the provision and maintenance of necessary and appropriate equipment. It is the Trust s responsibility to ensure that appropriate training is available. Director Responsibility Medical Director, Director of Nursing, AHP s and Quality and Interim Director of Operations have responsibility for implementing and monitoring the effectiveness of this policy. Medical Director, Director of Nursing, AHP s and Quality and Interim Director of Operations are responsible for ensuring staff within their service areas comply with this policy. They must ensure all staff are supported and released to attend training. Page 5 of 38
Deputy Director of Operations is responsible for ensuring action plans to address areas of non-compliance with this policy are fully implemented. They are responsible for dealing with areas that consistently non-comply with the requirements of this policy. Manager Responsibility Managers are those individuals who have line management responsibility for other members of staff within the organisation. Managers are responsible for ensuring that all their staff are aware of this policy through local induction. They are also responsible for ensuring that familiarisation with the location of emergency medical equipment forms part of the local induction checklist. Managers should ensure that all staff are enabled to attend training appropriate for their role in accordance with the Statutory and Mandatory Training Policy. Clinical Managers / matrons must ensure that all emergency equipment is accessible and appropriately maintained in accordance with this policy. Clinical Managers / matrons are expected to ensure that appropriate documentation has been completed following a medical emergency / cardiac arrest event within their clinical area. Managers are responsible for ensuring appropriate actions are taken following the receipt of Resuscitation Service risk assessments. Line managers are accountable for promoting this Policy to their staff by bringing it to their attention and ensuring it is implemented, as well as ensuring appropriate documentation is completed following medical emergency / cardiac arrest occurrences within their area ensuring all staff have the necessary training to fulfil their specific roles within the organisation through clinical supervision and maintenance of a local training record ensuring appropriate actions are taken following receipt of Resuscitation Service risk assessments. Employee Responsibility All staff (permanent, temporary, locum and bank) directly employed by Northamptonshire Healthcare NHS Foundation Trust, sub-contracted or seconded to the organisation, must be aware of this policy and adhere to the procedures and practices herein. It is the responsibility of each staff member (as defined above) to maintain their competence in line with Resuscitation Training in accordance with the Statutory and Mandatory Training Policy. Each staff member is responsible for reporting any shortcoming in their knowledge or skills. Staff should only use equipment that they have been trained to use. Page 6 of 38
All staff (as defined above) have a responsibility to familiarise themselves with the emergency equipment within their clinical environment. It is their responsibility, to know the nearest location of emergency medical equipment in their work area(s). This should form part of the local induction process for staff. Staff must ensure that daily emergency equipment checks are completed and that the equipment is fit for use. Following any medical emergency / cardiac arrest, the staff members present must ensure appropriate documentation is completed and equipment replenished. Resuscitation Service Responsibility The Resuscitation Officer is: Accountable for developing, implementing and evaluating resuscitation training to Trust staff in conjunction with the Education Training and Development Department. Responsible for reviewing incidents involving medical emergencies / cardiac arrests. Responsible for maintaining medical emergency equipment and advising the Trust on matters pertinent to the replacement and purchasing of such equipment. Able to facilitate debriefing of staff following a medical emergency / cardiac arrest situation. Responsible for advising any Trust employee in all matters relating to Resuscitation. Responsible for maintaining and updating their own knowledge and skills. Policy detail Resuscitation Equipment Provision & Replenishment All areas where there is public access, including areas where patients are seen, within the Trust must have minimum Basic Life Support equipment of gloves and a pocket mask available. All staff who carry out home visits, or work in areas where resuscitation equipment is not normally available, must have a pocket mask individually provided. The following areas will have access to ILS equipment, including Automated External Defibrillators, and staff trained in their use, within three minutes of diagnosis of cardiac arrest. ILS training will be offered to all Doctors and Registered Nurses and specified Allied Healthcare Professionals working within these areas in accordance with the Statutory and Mandatory Training Policy. Mental Health - Adult, Child and Adolescent Mental Health Services (CAMHS,) Older Persons inpatient areas, areas of rapid tranquilisation ECT Treatment Centre Physical health Inpatient wards Podiatry & Dental Areas This list is not exhaustive and will include any other identified areas. Page 7 of 38
Automated External Defibrillators may be provided in other areas. These may include areas where an AED has historically been provided, and where ILS equipment would be inappropriate or in areas where there is a high risk of cardiac arrest but not a risk-assessed need for full ILS equipment. Such areas would include some drop-in or outpatient clinics. Resuscitation Council (UK) guidance currently suggests considering providing an AED where there is a likelihood or history of one cardiac arrest in 5 years. A working document detailing the specific levels of equipment provided in clinical and public areas will be maintained by the Resuscitation Officer in conjunction with the Chief Pharmacist, Medical Director and Director of Quality and Professional Development and Executive Nurse. Each emergency trolley / grab bag should be checked by a registered member of staff (e.g. registered nurse, registered dental nurse, registered ODP) at least once every 24 hours and immediately following an emergency event. The equipment should be laid out in the standard format set out in the emergency equipment daily check book (http://nww.nhft.northants.nhs.uk/content/clinical_services/ppett/clinical_skill S_MANDATORY_TRAINING/Resuscitation/index.jsp.) Supplementary emergency equipment provided at hospital reception areas will be checked on a monthly basis by the Resuscitation Service, not daily as in ward areas. Guidance on how to perform daily checks is found in the emergency equipment daily check book. Replenishment of any consumables used, and replacement of items found to be faulty or missing must be completed immediately after use or discovery of the fault. Items should be replenished from ward or hospital stock. Further supplies are obtainable from the Resuscitation Service or through NHS supplies. Emergency drug boxes should be replaced by contacting Pharmacy. Guidance on where to obtain particular items from is contained in the emergency equipment daily check book. Replacement must be carried out by staff who have discovered the defective equipment or have used the equipment at an incident. Resuscitation Service staff will perform checks of emergency equipment within ILS areas at least twice per quarter. Spot checks will be performed in areas where 90% compliance in emergency equipment daily checks is not achieved, and an incident form completed. This will be reported on a regular basis to the Safer Hospitals Group. Emergency equipment must be standardised throughout the Trust and therefore the proposed purchasing of new equipment must be discussed with the Resuscitation Officer. Preventing Deterioration and response to Medical Emergencies including Cardiac Arrest The National Early Warning Score (EWS, NEWS or CEWS) is used within the Trust to aid staff to identify critically unwell patients through the measuring of physiological observations, to enhance decision-making and care escalation. Training is provided to staff to ensure that they are capable of safely measuring observations, calculating EWS scores and acting on them. The frequency and type of training is documented in the Physical Health Observations Policy. Page 8 of 38
Staff must record a EWS every time physical health observations are recorded for a patient. All observations listed on the standardised observations chart (NEWS Chart) should be attempted at least once in every 24 hours. Blood glucose may be omitted from regular monitoring if it is not indicated. Domiciliary patients and those in palliative care areas should have observations performed at a frequency deemed appropriate for the individual. The observations and EWS are to be recorded on the NEWS Chart appended at Appendix VIII. Staff finding a patient with an EWS score other than 0 are required to take action as directed on the NEWS chart. Such actions are taken in order to prevent deterioration of physical health, and to prevent cardiac arrest. Any concerns discovered must be reported as a matter of urgency, and where appropriate a communication tool, such as RSVP/SBAR (Reason, Story, Vitals, Plan / Situation, Background, Assessment, Recommendation) as found in Appendix VIII. In the event that a patient requires the management of a medical emergency (other than cardiac arrest), e.g. seizure, suspected myocardial infarction, stroke, etc, or where rapid tranquilisation, physical intervention and / or seclusion has been implemented, then the relevant senior doctor should be contacted immediately. If no doctor is available, then Emergency Services should be contacted. In the event of a life threatening medical emergency / cardiac arrest, an immediate emergency call must be made. Emergency help will be summoned by triggering the emergency alarm (where appropriate), dialling (9 for an outside line if in trust property) 999 and giving Ambulance Control the exact incident location. The exception to the above is for the Department of GU (Genitro-urinary) Medicine at Northampton General Hospital and other staff working within an Acute General Hospital main building who will dial 2222 for the General Hospital Cardiac Arrest / Medical Emergency Team to respond. Through the emergency alarm being triggered in an inpatient Mental Health area, staff holding rapid response pagers will respond along with the Registered Nurse working in that patient area. If there is a doctor on site, they should also be alerted and called to attend through switchboard. The emergency medical equipment must be obtained and taken to the location of the collapsed person at the earliest opportunity to be used by trained personnel. Resuscitation of the collapsed patient must be commenced immediately following the current guidelines. Resuscitation Council (UK) guidelines for BLS can be found in Appendix I, PBLS Appendix II, ILS Appendix III and Advanced Life Support Appendix IV. Current guidance for the management of Choking can be found in Appendix V. Current Resuscitation Council (UK) guidelines for the management of Anaphylaxis can be found in Appendix VI and should be followed in all cases of suspected anaphylactic / anaphylactoid reactions. Page 9 of 38
In some areas, particularly the ECT Treatment Centre, drugs and monitoring equipment may be available for the management of peri-arrest arrhythmias. When a suitably qualified doctor is present, it may be appropriate to treat the patient according to the current peri-arrest algorithms (Appendix VII). Automated external defibrillators (AEDs) are designed to be used by members of the public, and are very effective at guiding the operator through the process of administering the shock. They are widely available, safe and easy to use, and will not allow a shock to be given to a victim who does not require one. If a member of staff feels competent to use an AED without prior training they should not be prevented from doing so. (Resuscitation Council (UK) 2010 guidelines). Post Resuscitation Care and Transfer Any person who has suffered a life threatening / cardiac arrest situation should be transferred by the Ambulance Service to an acute general trust facility as soon as possible. The immediate post resuscitation phase is typically characterised by high dependency and instability. If possible the condition of the patient should be stabilised prior to transfer, however this should not delay definitive management. The Trust Medical Emergency Audit Form (Appendix XI) must be completed by a member of staff involved and forwarded to the Resuscitation Officer as well as a Datix entry made. The person s next of kin should be informed at the earliest opportunity that they have been transferred and details of the location given. Legal & Ethical Issues Pertaining to Resuscitation The legal status of those who attempt Resuscitation The Duty of Care In order for a claim of negligence to succeed, a victim (1) would have to show that the rescuer owed him a duty of care, the standard of which was breached, thereby causing him harm. A person who witnesses a situation where resuscitation may be required is under no obligation to assist unless there is a contractual obligation. A contractual obligation normally exists where the relationship is that of professional and service user. If that person does choose to render assistance he will assume a duty of care. Intervening under a duty of care, a person who attempts resuscitation will only be legally liable if the intervention leaves a victim in a worse position than he would have been in had no action been taken at all. The Standard of Care Health care professionals who attempt resuscitation will be expected to employ the highest professional standard of care compatible with their position / specialty in the health service and with their level of training. For example, while it may be argued that both doctors and non-qualified staff Page 10 of 38
might be obliged to provide some assistance to a collapsed patient, the level of care and expertise employed by the medical staff would be expected to be of a different order. Insurance Liability Staff members are covered under the Trust vicarious liability provided they do not perform any action that they have not been trained to undertake. Witnessed Resuscitation It may be appropriate for relatives to be present during a resuscitation attempt. The Resuscitation Council (UK) guidance to help enable a balanced decision to be made may be found at http://www.resus.org.uk/pages/witness.pdf. When to Stop Resuscitation In the presence of a senior doctor, the decision may be made to terminate the resuscitation attempt following discussion with the team. No resuscitation attempt should stop before full assessments of the patient s details are taken into account. Senior doctors may make a clinical judgment on when to stop resuscitation advice on this can be found via Resuscitation Council (UK) website. NHS Ambulance Service personnel have strict protocols regarding the declaration of death in specific cardiac arrest settings. Decisions Relating to Cardiopulmonary Resuscitation It is essential in some situations to determine patients for whom cardiopulmonary arrest would be a terminal event and for whom cardiopulmonary resuscitation is inappropriate. Please refer to the Do Not Attempt Resuscitation Policy. Manual Handling In situations where the collapsed patient is on the floor, in a chair or in a restricted / confined space then the Trust s Moving and Handling Policy must be adhered to in order to minimise the risks of manual handling and related injuries to both staff and the patient. Please also refer to the Resuscitation Council (UK) document which can be found at http://www.resus.org.uk/pages/safehand.pdf. Cross Infection Whilst the risk of infection transmission from patient to rescuer during direct mouthto-mouth resuscitation is extremely rare, isolated cases have been reported. It is therefore advisable that direct mouth-to-mouth resuscitation be avoided in the following circumstances: all patients who are known to have or suspected of having an infectious disease; all undiagnosed patients entering the Trust through Outpatients or other admission source other persons where the medical history is unknown. All clinical areas should have immediate access to a pocket mask to eliminate the need for mouth-to-mouth ventilation. However, in situations where airway Page 11 of 38
protective devices are not immediately available, staff should start chest compressions whilst awaiting an airway device. If there are no contraindications, staff may consider giving mouth-to-mouth ventilations, but should not feel compelled to so do. Training requirements associated with this Policy Mandatory Training Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Statutory and Mandatory Training Policy Specific Training not covered by Mandatory Training Ad hoc training sessions based on an individual s training needs as defined within their annual appraisal or job description. How this Policy will be monitored for compliance and effectiveness The table below outlines the Trusts monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Duties Requirement for a documented plan for vital signs monitoring that identifies which variables need to be measured including the frequency of measurement Use of an Early Warning system within the organization to recognize patients at risk of deterioration Method of monitoring Individual responsible for the monitoring Monitoring frequency To be addressed by the monitoring activities below. Review of policy at each update to ensure this is included. Sample of 6 patient records reviewed to ensure observations being taken. Review carried out twice yearly from 3 randomly selected clinical areas. Sample of 6 patient records reviewed to ensure EWS recorded. Review carried out monthly. Trust Policy Board Ward managers as part of their quality schedule requirements Ward managers as part of their quality schedule requirements Upon review Monthly Monthly Group or committee who receive the findings or report Trust Policy Board Quality team (will share results with resus officers) Quality team (will share results with resus officers) Group or committee or individual responsible for completing any actions Resuscitation Officer Monthly submission to commissioning group Monthly submission to commissioning group Page 12 of 38
Resuscitation equipment is checked, stocked and fit for use. Actions to be taken to minimise or prevent further deterioration in patients All emergency trolleys in ward or clinical areas will be checked for stock levels and that daily checks are completed on at least 90%of relevant occasions. All incidents will be reported via incident reports to the Resuscitation Officer for assessment of the appropriateness of the response. Resuscitation Officer Resuscitation Officer Quarterly Every medical emergency or cardiac arrest Medical devices group Resus officers feedback to lead investigator or via Datix system Resuscitation Officer Risk management and improvement committee Staff have completed training associated with this policy in line with the TNA Training will be monitored in line with the Statutory and Mandatory Training Policy. Where a lack of compliance is found, the identified group, committee or individual will identify required actions, allocate responsible leads, target completion dates and ensure an assurance report is represented showing how any gaps have been addressed. For further information Please contact the Executive Nurse or Trust Policy Board The Trust s body of Policy can be found here: http://nww.nhft.northants.nhs.uk/content/policies_and_procedure/index.jsp No further references, bibliography or weblinks are provided for this Policy. Equality considerations The Trust has a duty under the Equality Act and the Public Sector Equality Duty to assess the impact of Policy changes for different groups within the community. In particular, the Trust is required to assess the impact (both positive and negative) for a number of protected characteristics including: Age; Disability; Gender reassignment; Page 13 of 38
Marriage and civil partnership; Race; Religion or belief; Sexual orientation; Pregnancy and maternity; and Other excluded groups and/or those with multiple and social deprivation (for example carers, transient communities, ex-offenders, asylum seekers, sex-workers and homeless people). The author has considered the impact on these groups of the adoption of this Policy see appendix 13. Reference Guide (1) https://www.resus.org.uk/resuscitation-guidelines/adult-basic-life-support-andautomated-external-defibrillation/ Resuscitation Council (UK) Standards for Clinical Practice and Training 2004 http://www.resus.org.uk/pages/standards.pdf Resuscitation Council (UK) Guidelines for Resuscitation 2015 https://www.resus.org.uk/resuscitation-guidelines/ NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Independent Sector Providers of NHS Care 2011/2012 http://www.nhsla.com/nr/rdonlyres/3a954c45-1178-4202-86af- 04FAD75471D7/0/NHSLAAcuteCommunityMHLDandIndependentSectorStandards201112.do c Clinical Guideline 25 Violence: the short-term management of disturbed / violent behaviour in psychiatric inpatient settings and emergency departments, National Institute for Clinical Excellence, February 2005, London Resuscitation Council (UK). The Emergency Treatment of Anaphylactic Reactions http://www.resus.org.uk/pages/reaction.pdf Decisions relating to Cardiopulmonary Resuscitation (3rd edition) Guidance from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing (previously known as the "Joint Statement") (2014) - https://www.resus.org.uk/pages/dnacpr.htm Resuscitation Council (UK). The Legal Status of Those who Attempt Resuscitation (2010) updated September 2015 http://www.resus.org.uk/pages/legal.htm Page 14 of 38
Resuscitation Council (UK) Quality Standards for cardiopulmonary resuscitation and training. http://www.resus.org.uk/pages/cpatpc.htm Resuscitation Council (UK). Guidance for Safer Handling during Resuscitation in Healthcare Settings (July 2015) https://www.resus.org.uk/publications/guidance-for-safer-handling-during-cpr-inhealthcare-settings/ National Patient Safety Agency Rapid Response Report NPSA/2008/RRR010: Resuscitation in Mental Health and Learning Disability Settings (November 2008) Document control details Author: Marc Kilby Resuscitation Officer Approved by and date: Executive Nurse, 13.01.15 Responsible Committee Quality Forum Any other linked Policies: CLP007 - Seclusion Policy, CLPr008 - Procedure for the Safe use of Ligature Cutters, Marsden Guidance Oxygen Therapy, CLP054 - Do Not Attempt Resuscitation (DNAR) Policy, CLP060 - Policy on Restrictive Interventions for Adults, CLP062 - Policy for the Prevention of Falls in NHFT, CRM002 - Incident Policy (covering near miss and serious incidents), HR025 Core Skills Policy, HSCg008 - First Aid Provision Guidelines, HSC010 - Moving and Handling Policy, Infection Control Policies, MMP011 - Rapid Tranquilisation Policy and Guidelines Policy number: CLP002 Version control: Version 3 Version No. Date Ratified/ Amended Date of Implementation Next Review Date Reason for Change (eg. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.) 2.0 12.4.16 12.4.16 12.4.19 New governance of trust policies template. 3.0 26.07.17 26.07.17 12.4.19 New NEWS Chart (Appendix 10) Page 15 of 38
APPENDIX 1 - BASIC LIFE SUPPORT (BLS) Paediatric modifiers: Compress to at least 1/3 the anterior posterior depth of the child s chest Use 1 or 2 hands for a child over 1 year and 2 fingers for a baby under one year Deliver 5 initial rescue breaths before first set of compressions If there is no-one to help and no means of calling for help immediately available, carry out CPR for 1 minute before going to get help. Page 16 of 38
APPENDIX 2 - PAEDIATRIC BASIC LIFE SUPPORT (PBLS) (PAEDIATRIC INPATIENT AREAS ONLY) Page 17 of 38
APPENDIX 3 - SEQUENCE FOR A COLLAPSED PATIENT IN HOSPITAL 18
APPENDIX 4 - ADVANCED LIFE SUPPORT ALGORITHM 19
APPENDIX 5 - MANAGEMENT OF CHOKING 20
Appendix 6 Paediatric Choking Algorithm 21
APPENDIX 7 - MANAGEMENT OF ANAPHYLAXIS **Where needed, advice on the administration of Hydrocortisone and Chlorphenamine, including dosing, may be found in the current edition of the British National Formulary or at www.resus.org.uk/reaction** 22
APPENDIX 8 - PERI-ARREST ALGORITHMS Management of Bradycardia 23
Appendix 9 Management of Tachycardia 24
APPENDIX 10 - SBAR/RSVP AND RECOGNIZING THE DETERIORATING PATIENT The National Early Warning Score (NEWS) is a standardised way of assessing if patients are deteriorating, and escalating their care if appropriate. NHFT acknowledge patients whose condition deteriorates should have this acted upon appropriately. Early detection of deterioration and a timely response is essential when caring for acutely ill patients. There are 2 ways in which NEWS is used: 1. To provide a continuous record of a patient s physiological status throughout the patients stay. 2. To provide a clear, national tool for the initial assessment of acute illness, with instructions of how and when to escalate. How to complete the form Instructions for filling in and responding to news chart and scores Respiratory rate: put a dot in the box. Oxygen saturations (SpO2): put a dot in the box. Inspired O2%: If on room air - leave box blank, if on supplemental oxygen, write flow rate or percentage of inspired oxygen in the box. Temperature: put a dot in the box or on the line as with current vital signs recording. Blood pressure: use a v and an inverted v joined by a line as currently used, but use only systolic blood pressure to calculate the score. Heart rate: put a dot in the box or on the line as with current vital signs recording. Where a dot is on the line between different coloured boxes, e.g. blood pressure of 220 systolic, allocate the higher score to this parameter. If the observation exceeds the range on the chart, the actual value should be recorded on the chart. Conscious level: put the letter (i.e. A, V, P or U) corresponding to the conscious level in the box. Blood Glucose: whilst not routinely measured if not indicated MUST be measured in a unwell/deteriorating patient. Total score: add up the score allotted to each observation and put the total in the box. Monitoring frequency: put in the number that corresponds to the frequency of observations, e.g. 1 for hourly obs. Escalation Plan: put Y or N in the box and document accordingly of plan in the notes. When the total score has been calculated, consult the Clinical Response to NEWS Triggers and where an elevated NEWS score is found, take the action indicated for the score. If it is decided to make a clinical judgement not to follow Clinical Response to NEWS Triggers, the reason and any alternative action plan MUST be clearly documented in the relevant patient notes. Any calls or handovers made to senior staff, doctors, out of hours services, ambulance service etc., in response to an elevated NEWS score MUST be clearly documented in the notes, together with an indication of what plan has been requested or agreed as per the SBAR Handover tool. Nothing within the NEWS scheme should prevent practitioners making an appropriate response based upon their clinical judgement. 25
Observation Chart for NEWS 26
NEWS Score and Escalation Status Care Plan 0 NONE 1 GREEN 2 GREEN 2 in one parameter AMBER 3 AMBER 3 In one parameter RED Minimum Frequency of Monitoring Routine Monitoring ( as per local minimum Intervals) BD (12hrly) TDS (8hrly) 4hourly ** Recheck obs sooner if clinical judgment dictates 4hourly ** Recheck obs sooner if clinical judgment dictates Increase frequency of observations to half hourly or as indicated by patient s condition If AVPU score 3 complete Neurological Observations (Glasgow Observation Chart) (in certain circumstances a score of 3 in a single parameter may not require 1/2hrly observations 1.e- some patients on oxygen and low sats - consider completion of Medical Variance) Alert Registered Nurse Registered Nurse Registered Nurse Registered Nurse Doctor Registered Nurse in Charge and On call doctor Response -Continue routine NEWS scoring with every set of physical health observations. -If concerned about the patient inform registered nurse for patient review. -Registered Nurse to review patient -Registered Nurse to review patient and determine frequency of observations and determine if doctor review required. -Ensure local actions considered and initiated. -Discuss raised NEWS at medical and nursing handovers. -Requirement for medical variance to be considered when has triggered for 72hours Registered Nurse to review patient and determine frequency of observations. -Evaluate triggers against Sepsis Screening Tool -Refer for doctor review. -Discuss raised NEWS and plan at medical and nursing handovers. -Requirement for Medical Variance to be considered when has triggered for 72hours -Registered Nurse to review patient and determine frequency of observations. -Evaluate triggers against Sepsis Screening Tool -Refer for doctor review. -Discuss raised news and plan at medical and nursing handovers. -Requirement for medical variance to be considered when has triggered for 72 hours -Registered Nurse in Charge to assess patient and escalate using SBAR handover tool to doctor and request immediate review. -Evaluate triggers against Sepsis Screening Tool -Consider (9) 999 call for ambulance assistance if doctor unable to assess within 30 minutes and concern remains over patient. -Discuss raised news and plan at medical and nursing handovers. 27
4-6 RED 7 or more RED 1 Hourly Registered Nurse in Charge ½ hourly plus continuous monitoring until emergency assistance arrived. and On call Doctor Registered Nurse in Charge and Immediate medical support/(9) 999 -Registered Nurse in charge to assess patient and escalate using SBAR handover tool to doctor and request immediate review. -Evaluate triggers against Sepsis Screening Tool -Consider (9) 999 call for ambulance assistance if doctor unable to assess within 30 minutes and concern remains over patient. -Consider continuous patient monitoring and transfer to higher level care. -Discuss raised news and plan at medical and nursing handovers. -Nurse in charge to assess patient and escalate using SBAR handover tool to doctor and request immediate review. -Evaluate Triggers against Sepsis Screening Too -(9) 999 call for ambulance assistance if doctor unable to assess immediately -continuous patient monitoring to be completed until transferred to higher level care. -Discuss raised news and plan at medical and nursing handovers Document all communication and management plans at each escalation point in patient s records. If a decision is made not to follow the clinical response guidance above this MUST be documented in the patients records and rationale for the decision. Nothing in this scheme should prevent a practitioner making an appropriate response based upon their clinical judgement. Where NEWs is used in areas where a Registered Nurse is not part of the staffing, another appropriate registered professional must initiate the appropriate response. Situation Background Assessment If Amber or RED Score Evaluate Triggers against the Community Nursing Sepsis Screening and Action Tool (UK SEPSIS TRUST) SBAR Medical Handover Template Identify yourself, ensure you have called the right person Identify the patient and their presenting problem Give reason for current referral Give background information on the patient Recommendation Trigger Respiratory rate above 20 Respiratory rate below 12 Give latest set of observations Give status of ABCDE (Airway, Breathing, Circulation, Disability, Exposure) and your concerns Give Early Warning Score State clearly what you want the person you are calling to do (e.g. to visit or to give advice about patient management) Consider Following Treatment Interventions Sit upright in bed - Check sats - Deep breathing exercise - Sit upright - Reassurance - ECG - If anxiety consider diversional activities 28
Oxygen sats below 95% Temperature above 37.5 C Temperature below 35.5 C Low systolic blood pressure below 90 Bradycardia (pulse below 50) Tachycardia (pulse above 90) AVPU Verbal Pain Unconscious - High % oxygen - ECG - Sit upright - Salbutamol neb if prescribed - Paracetamol 1g (If prescribed) - Cool drinks - Fan therapy/open window - Increase clothes/bed clothes - Warm drinks - Urinalysis if positive - MSU, if negative sputum specimen - Lie flat in bed (upright if breathless) - ECG - Rise feet - Encourage oral fluids - Sats 92-95 % - 2 litres via nasal specs/mask (If prescribed only) - Sats 91 % or less 15 litres oxygen via non rebreathe mask (can be administered non prescribed) - Urinalysis if + MSU, if negative sputum specimen - Carryout BM if above 7.7mmls?sepsis - Consider bloods including FBC, profile, CRP and ESR - Carryout BM if above 7.7mmls?sepsis - Consider bloods including FBC, profile, CRP and ESR - Lying and standing B/P check for postural drop - Check medications e.g. diuretics and antihypertensives lower B/P (consider omitting) - Consider bloods including FBC, profile, CRP and ESR - ECG - Check medications beta blockers lower pulse rates - Rest - Relaxation techniques - ECG - As for high temperature e.g. Urinalysis, BM s - Check observations treat as above - Bed rest? recovery position 29
Variances and Exceptions to NEWS Variances and Exceptions to NEWS may only be noted by a Registrar or Consultant. The doctor may amend the Clinical Response to NEWS Triggers, in terms of the escalation plan, monitoring frequency or trigger levels. S/he may not change any of the set levels on the observations chart, however. Most exceptions will be made in order to allow staff to increase the level of NEWS score before summoning help. A clear escalation and monitoring plan and trigger levels must be documented in the Variances and Exceptions section. Most commonly, variances will be made as a result of a pre-existing medical condition. The doctor may allow for the condition giving the patient abnormal observations, by increasing the level at which the scheme triggers if the patient has a high baseline NEWS score, and may also alter the response (escalation plan) at a given level. The amended response and level at which it triggers must be realistic, and never begin at more than 3 above the patient s normal baseline. The plan may be as detailed as the doctor feels appropriate. For example, a patient admitted with a history of COPD and a normal baseline of NEWS score 8 (RR26, SpO 2, 88% and on 2Lpm inspired oxygen over 24 hours) may have an escalation plan set: NEWS Score 9-11: Increase observations to hourly, observe for respiratory distress, call doctor if concerned with presentation of patient. If NEWS score further elevated above 11, call doctor, increase observations to at least half hourly, consider calling an ambulance. Or NEWS Score 9-11: recheck observations after nebuliser given, repeat nebuliser up to 3 times to keep oxygen Sats within range of 86-89%. If unsuccessful after 3 attempts, call doctor. NEWS Score 11-13: If breathless, give nebuliser as prescribed, if patient drowsy or having difficulty with breathing, call doctor, and consider calling ambulance. If Sats fall between 83-86%, increase oxygen therapy to 28% 4Lpm. If Sats fall below 83%, treat as a medical emergency. NEWS Score >13, call doctor, call ambulance, consider medical emergency treatment steps pending arrival of ambulance. Exceptions may also be placed on the NEWS temporarily, if the patient has a condition which will temporarily place their observations out of normal range. The new response and level at which it triggers must be realistic, and never more than 3 above the current score. Such exceptions should be reviewed at least every 24 hours. For example, a patient with a chest infection, scoring 9 on NEWS, but apparently stable and responding to treatment well should have the initial trigger to call the doctor set at no higher than 12. If the score were set at, for example, 18, this would fail to detect any subtle deterioration in the patient. Practitioners scoring NEWS should still act within their own professional judgement, and may summon assistance outside of a modified plan if their clinical judgement indicates that such help should be sought in the circumstance. 30
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APPENDIX 11 - ANAPHYLAXIS MANAGEMENT AND AED EQUIPMENT LISTS Resuscitation Equipment Lists Anaphylaxis Management Equipment (for certain physical health environments, community practitioners and similar) These packs will be supplied to practitioners administering injected medications for whom it is deemed appropriate to carry anaphylaxis equipment. 1 x Box 10 Vials 1:1000 Adrenaline (Epinephrine) 10 x Blue needles 10 x Green needles 10 x 1 ml Graduated syringes 1 x Sharps bin AED (Automated External Defibrillator) Equipment List Where an AED is provided, the pack the AED is stored in must contain the following items: 2 x Razors 1 x Guidance card 1 x Pair Tufcut shears (18cm) 2 x Sets of pads for the make and model of AED (1 pair and 1 spare) 1 x Pocket mask must also be available with the AED, although this will not normally fit in the AED pack. 1 x Daily check sheet 32
AED and Oxygen Check Sheet This check sheet is for use in areas where only an AED and/or oxygen is provided. Date Print Name & Sign AED & Pads Comments Oxygen Cylinder Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Name: Sign: Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? Working? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? How Full? 33
APPENDIX 12 - AUDIT FORM Affix Patient ID Label or record Name: NHS No: Hosp. No. D.O.B. / / Male Female Consultant: Ward: Date Time..Ward/Department.. Patient Staff member Gender M / F Age Ethnicity Visitor Contractor Disability Initial Condition of the patient at the time of 1 st healthcare professional Conscious Yes No Collapse Witnessed Yes No Breathing Yes No Patient monitored before call Yes No Pulse Yes No Time Doctor Called to Assess Patient Reason. Time of 999 call By whom... Pocket Mask available Yes No Pocket Mask used Yes No Bag-valve-mask available Yes No Used Yes No i-gel insertion Yes No By Whom..Time.. Intravenous access Yes No Defib pads applied Yes No By... 1st shock time. By Doctor Nurse Other Admission diagnosis.. Immediate precipitating factor (if known). Each line corresponds to one loop/cycle of advanced life support Time Rhythm AED Joulage if manual CPR (30:2 or continuous) Adrenaline Other drugs Fluids 34
Time of paramedics at patient side... Time Resuscitation discontinued. (Please state reason) Return of circulation Do Not Attempt Resuscitation Order Post arrest (please tick all that apply) No response to treatment Breathing Pulse Blood Pressure. / (please state) Neuro status: Alert Verbal response Response to pain Unresponsive Transferred to KGH NGH Other.. (please state) Time of transfer to other hospital Relatives informed Yes No By Whom... Time.. Consultant informed Yes No By Whom... Time Datix Entry completed Yes No By Whom.. Time.. Form completed by (please print).. Signature. Staff attending emergency Name Job Title Area of work Please return this form to: Resuscitation Officer Huxlow House St Mary s Hospital London Road Kettering Please photocopy & place in patient s notes Resuscitation Officer Comments 35
APPENDIX 13 NHFT EQUALITY ANALYSIS TOOL Title: Resuscitation and Related Medical Emergencies Policy What are the intended outcomes of this work? To provide a systematic approach to assessing and treating the patient in, or at risk of, cardiac arrest. To ensure suitable standardised emergency equipment is available to staff for use in a medical emergency. Who will be affected? All patients and those encountering healthcare professionals employed by NHFT, all NHFT employees. Evidence What evidence have you considered? Resuscitation Council (UK) Guidance: Guidelines for Resuscitation in Primary Care, the Resuscitation Guidelines 2010, Decisions relating to cardiopulmonary resuscitation 2014; NICE Guidelines Violence: CG25, RRR010 2008 Resuscitation in Mental Health and Learning Disability Settings. Disability No impact. Specific advice relating to planning emergency management of disabled patients is available from the Resuscitation Service. Sex No impact. Race No impact. Age No impact. Gender reassignment (including transgender) No impact. Sexual orientation No impact. Religion or belief No impact for refusal of resuscitation on grounds of belief, see the Do Not Attempt Resuscitation Policy. Pregnancy and maternity No impact. Advice relating to planning emergency management the pregnant patient is available from the Resuscitation Service. Other identified groups No impact. Engagement and involvement Internal consultation and ratification process. No testing required; review of current policy to ensure applicability across the organisation. 36
Summary of Analysis National guidance requires that resuscitation is provided to all patients in cardiac arrest unless they are subject to a DNACPR decision or have a valid Advance Decision in place. All patients should have condition management decisions based solely on the presentation of the condition, the practitioner s professional judgement, and the patient s expressed preferences. The policy and practice should ensure that equal treatment and management is available for all individuals, regardless of their characteristics. Eliminate discrimination, harassment and victimisation No evidence Advance equality of opportunity The policy ensures equality of opportunity and provision of care. Promote good relations between groups Not applicable What is the overall impact? There is no discriminatory impact within this Policy. Addressing the impact on equalities Not applicable. Action planning for improvement The Policy should be updated in light of any new Guidance issued or upon discovery of requirement to update based upon auditing of the Policy. Changes and amendments will be made to reflect any changes in law, national or regional guidance. Changes and amendments will be made based upon any findings from audits carried out. The Policy will be available to staff and public via the Internet. Information regarding resuscitation practice is available through the Trust and from the United Kingdom Resuscitation Council. For the record Name of person who carried out this assessment: Marc Kilby, Resuscitation Officer Date assessment completed: 30 th October 2014, reviewed with policy review March 2016 Name of responsible Director: Julie Shepherd, Executive Nurse Date assessment was signed: 30/04/2012 37
Appendix 14 ACTION PLAN TEMPLATE This part of the template is to help you develop your action plan. You might want to change the categories in the first column to reflect the actions needed for your policy. Category Actions Target date Person responsible and their Directorate Involvement and consultation Data collection and evidencing Analysis of evidence and assessment Monitoring, evaluating and reviewing Transparency (including publication) Page 38 of 38