SH CP 206 Checking, Restocking and Management of Medical Resus Bag Procedure Version: 2 Summary: Keywords: Target Audience: Procedure to the management of the Trust standardised Medical Resus bags including checking requirements and process for restocking. Resuscitation, medical emergency, AED, defibrillator, emergency equipment All staff with access to medical emergency equipment Next Review Date: Approved & Ratified by: Resuscitation Committee (Virtual) Date of meeting: March 2017 Date issued: March 2017 Author: Director: Hayley Stockford, Resuscitation Officer Sara Courtney, Interim Director of Nursing and AHPs 1
Version Control Change Record Date Author Version Page Reason for Change July 2017 Hayley Stockford 1 5,11 & 12 Removal of references to Openhouse fax number as this is now obsolete; Addition of blood glucose lancets to Order Form 9/4/18 Hayley Stockford 2 P4, P5 Minor amendments due to making it more operationally workable for staff, no further changes review date extended for further year to July 2019 Reviewers/contributors Name Position Version Reviewed & Date Hayley Stockford Kerry Lewis Helen Collins Tim Matthews Simon Johnson Jane Hazelgrove Carol Adcock Rachel Anderson Nicola Bennett Nicki Brown Alan Chambers Sara Courtney Tracey Eddy Uresh Fernandez Julie Francis Beverley George Tracy Hammond Paula Hull Kathy Jackson Julia Lake Jane Levers Helen Ludford Tracey McKenzie Steve Mennear Karen Osolo John Stagg Diane Statham Sophie Tomkins Gina Winterbates Raj Parekh Resuscitation Officer Resuscitation Officer Resuscitation Officer Resuscitation Officer Head of Essential Training & Delivery Director of Education Head of Nursing and Quality Clinical Lead, Lymington New Forest Hospital AD of Nursing and AHPs and Clinical Operations Manager, AMH Category Manager, Procurement Interim Director of Nursing and AHPs Consultant Psychiatrist, OPMH Speciality Doctor in Child and Adolescent Forensic Psychiatry School Health Nurse Practice Development Nurse Medical Devices Advisor Deputy Director of Nursing and Quality Head of Nursing - Inpatients AD of Nursing and AHPs Professional Lead for School Nursing Head of Quality Governance Head of Compliance, Assurance and Quality Senior Clinical Pharmacist Trust ECT lead Nurse AD for Nursing, AHPs and Quality (LD) Matron, Learning Disability Services Clinical Audit Facilitator Head of Nursing and AHPs Chief Pharmacist 2
Contents Section Title Page 1. Introduction 4 2. Storage, Replenishment and Maintenance 4 3. What to do in the event the a problem is identified during a daily check 6 4. What to do in the event the bag has been used 6 5. What to do when Openhouse arrive on site 6 6. Documentation 6 Appendix 1 Medical Resus Kit Daily Checklist 7 Appendix 2 Pictorial Contents List of Medical Resus Kit 8 Appendix 3 Southern Health Order Form 10 Appendix 4 AED Pro Quick Reference Guide 12 3
Procedure 1. Introduction The purpose of this appendix is to: 1.1 Provide guidance on the checking of the standardised resuscitation equipment across Southern Health NHS Foundation Trust. 1.2 Provide supportive documents to ensure the daily checking is documented and auditable. 1.3 Give guidance on what to do in the event the Medical Resus Bag has been used 2. Storage, Replenishment and Maintenance of the Medical Resus Bag 2.1 The replenishment and maintenance of the Medical Resus bags will be managed by an external company called Openhouse. If the bag is used, or if, during the daily check it is found the seal has been broken or replaced with a seal not matching the previously recorded tag number; Openhouse must be contacted who will then send an employee to check the bag and replace any missing items. 2.2 Daily Checking of the Medical Resus Bag 2.2.1 A registered nurse or mental health practitioner is ultimately responsible for the checking and recording the daily check of the Medical Resus bag. In the event a non-registered member of staff checks the bag i.e. in a health care support worker led clinic, the accountability remains with the registered member of staff they report to. 2.2.2 The daily check of the Medical Resus Bag does not require the seal to be broken and the bag opened. 2.2.3 The daily check will consist of: The bag is sealed with a numbered tag and the tag number corresponds to the checking list i.e. the same The status indicator of the AED is a green tick via a clear window on the front of the bag The oxygen cylinder is full via a clear window on the side of the bag 2.2.4 The daily check of the bag must be documented on the daily checklist which is in the external clear pouch of the bag. Once completed, the checklist must be kept in the external clear pouch. The checklists will be removed quarterly by Openhouse and returned to the Resuscitation Officers for audit purposes.. Electronic copies can be accessed with the electronic version of this procedure. 2.2.5 In the event the bag is located in an area where patients are not seen on a daily basis i.e. ECT suites, the bag must be checked on the days clinics are being run. This must be documented on the checklist for audit purposes. 2.3 Quarterly Checking of the Medical Resus Bag: Full Contents Check 2.3.1 There is a picking note each for consumables and drugs that are held within the bag in the clear external pouch. These lists document the batch numbers and expiry dates of each of the items held in the bag and are for staff information only THEY DO NOT NEED TO BE CHECKED ON 4
A DAILY BASIS. Each quarter, Openhouse will visit each site and check and audit the contents of the bag against these lists. The reports will be sent to the Resuscitation Officers and presented at the Resuscitation Committee. 2.3.2 Openhouse hold a central record of all the contents of all the bags, including batch numbers and expiry dates. When items approach expiry, Openhouse will contact the affected sites and facilitate the replacement of these items. 3. What To Do In The Event A Problem Is Identified During A Daily Check 3.1 In the event during a daily check the seal is broken, the seal number does not match the previous documented seal number, the oxygen cylinder is not full or the AED indicator is not a green tick, the Stock Replenishment form must be completed. There is a blank Stock Replenishment form in the external clear pouch attached to each bag. Alternatively, there is an electronic editable copy of the Stock Replenishment form that can be found on the Resuscitation Services intranet pages and also with the electronic version of this procedure on the intranet. When the form has been completed, it must be sent to Openhouse via email as follows: Scan the form and email a copy to southernhealth@openhouseproducts.com Complete an electronic form and email directly to: southernhealth@openhouseproducts.com 3.2 Any delay in completing the form and sending it to Openhouse will result in a delay in the bag being checked and replenished. 4. What To Do In The Event The Bag Has Been Used 4.1 In the event the bag has been used in any incident, the Stock Replenishment form must be completed. There is a blank Stock Replenishment form in the external clear pouch attached to each bag. Alternatively, there is an electronic editable copy of the Stock Replenishment form that can be found on the Resuscitation Services intranet pages and also with the electronic version of this procedure on the intranet. When the form has been completed, it must be sent to Openhouse via email as follows: Scan the form and email a copy to southernhealth@openhouseproducts.com Complete an electronic form and email directly to: southernhealth@openhouseproducts.com 4.2 Any delay in completing the form and sending it to Openhouse will result in a delay in the bag being checked and replenished. 4.3 If the AED has been used, the data stored on the AED will be downloaded by the Resuscitation Officers for event review, debrief and training purposes. 5. What To Do When Openhouse Arrive On Site For Openhouse staff to be able to access all Trust sites, they must have a contact name to meet on arrival. The person who shall meet Openhouse to facilitate the checking and restocking of the bag must be a registered member of staff. This is due to the drug contents within the bag. There are no exceptions to this requirement. 5
6. Documentation 6.1 The following documents will be in the external clear pouch: Medical Resus Bag Daily Checklist AED Pro Quick Reference Guide Southern Health Picking Note Southern Health Emergency Drugs Picking Note Pictorial contents list Location of next nearest available bag 6.2 The picking notes and completed checking lists must be in the clear pouch for 12 months. 6.3 The following documents will be located inside the bag: Medical Emergency and Resuscitation Bag Algorithms Southern Health Order Form Resuscitation Event Form 6.4 The Southern Health order form should be completed as explained in 4.1 6.5 The Resuscitation Event Form must be completed in ALL resuscitation attempts. Once completed, a copy must be sent confidentially to the Resuscitation Officers at LEaD, Tatchbury Mount. Please refer to Appendix 7 in the Medical Emergency and Resuscitation Policy. 6
Quarterly audit checks of the bag contents will be carried out by Openhouse who replace any expiring items. Openhouse log all batch numbers and expiry dates are for replacing expiring or recalled batch item. APPENDIX 1 MEDICAL RESUS KIT DAILY CHECKLIST LOCATION: BAG NUMBER: TAG NUMBER:.. MONTH:... The Medical Resus Kit must be checked DAILY. This DAILY check consists of the following: 1. The AED has the visible 2. The plastic seal for the bag is intact (not been broken) Document seal number each day in column 2 3. The oxygen cylinder is full DATE OF THE MONTH 1 2 3 PRINT NAME AND SIGN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 IN THE EVENT THAT a) the AED is showing X OR b) the plastic seal is missing, not intact or the tag number is different OR c) the oxygen cylinder is not full or after clinical use you must email Openhouse on: southernhealth@openhouseproducts.com 7
APPENDIX 2 8
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APPENDIX 3 Southern Health Order Form Hospital/Site Name: Address: Contact Name: Any special instructions that may help our driver find you on arrival: Telephone Number: Email Address: Fax Number: Once FULLY completed please return this form, either by email to SouthernHealth@openhouseproducts.com PRODUCT Bag Seal/Tag ONLY (No contents used) Oxygen Cylinder Refill Non-rebreath Oxygen Mask NaCL 500ml 0.9 Sodium Chloride Adrenaline 1:10,000 Prefilled Syringe Amiodarone 300mg Injection Box Chlorphenamine Ampoules Adrenaline Emerade Pen - 500mcg Adult Hydrocortisone Salbutamol Inhaler Salbutamol 5mg Nebuliser Solution Nebulizer Mask Ipratropium Bromide 500mcg Nebuliser Solution GTN Spray Box Furosemide Ampoules 20mg Box Aspirin 300mg Glucagon 1mg Box of Glucogel Flumazenil Amps (500mcg/5ml) Box Naloxone 400mcg/1ml Ampoules Disposable Tourniquet Intravenous Infusion Set Double Lumen IV Extension Set Saline Flush PFS Adhesive Tape - Micropore 2.5cm Roll Dressings Pads (Non stock sterile gauze) 2% Chlorhexidine Alcohol Wipes Ampoule Breakers IV Cannula Dressings Drawing Up Needle 5ML Syringe 2ML Syringe Gauze Swab Ligature Pack Stopwatch CPR Mask in Hard Case Disposable Gloves - Med/Large Safety Goggles Polythene Apron - White Adult Checking, BVM Restocking and Management of Medical Resus Bag QTY USED 10
PAGE 2 OF 2 Child BVM Zoll AED Pro Set Zoll CPR Pads 3 Lead ECG Cable Set ECG Dots Zoll AED Pro Battery Ready Pack in Clear Bag Algorithms Nasopharyngeal Airway Size 6,(and lubrication) Nasopharyngeal Airway Size 7 (and lubrication) Guedal Airway Size 2 (Green) Guedal Airway Size 3 (Orange) Guedal Airway Size 4 (Red) 1 x Magill forceps (8" Adult size) 1 x i-gel Airway (Size 3) 1 x i-gel Airway (Size 4) 1 x i-gel Airway (Size 5) 3 x Lube Sachet 1 x Portable Suction Unit 1 x Stethoscope - Dual Head 1 x Blood Glucose Testing Kit 1 x Pack Blood Glucose Testing Strips 1 x Pack of 3 Blood Glucose Lancets 1 x Pen Torch 1 x Pulse Oximeter - Fingertip 1 x Sphygmomanometer 1 x Manual Blood Pressure Cuff - Small 1 x Manual Blood Pressure Cuff - Medium 1 x Manual Blood Pressure Cuff - Large 1 x Manual Blood Pressure Cuff - X Large 1 x Sharps Bin - 1L 1 x Clinical Waste Bag (Single) 4 x 23 Gauge 1"1/4 Needle 1 x Aerochamber Plus Device 2 x 16G Grey IV Cannula 2 x 18G Green IV Cannula 2 x 20G Pink IV Cannula QTY USED Once FULLY completed please return this form, either by email to SouthernHealth@openhouseproducts.com 11
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