Cardiopulmonary Resuscitation Policy by nc4zemNm

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									                         Cardiopulmonary Resuscitation Policy
                       (Including Anaphylaxis and Defibrillation)




Version                                                12
Name of responsible (ratifying)
                                                       Resuscitation Committee
committee
Date ratified                                          23 January 2012

Document Manager (job title)                           Resuscitation Manager

Date issued                                            07 February 2012

Review date                                            31 January 2014

Electronic location                                    Clinical Policies
                                                       Do Not Attempt Cardiopulmonary Resuscitation Policy.
                                                       Neonatal Resuscitation Maternity Policy
                                                       Medical Devices Management Policy
Related Procedural Documents
                                                       First Aid At Work Policy
                                                       People Moving and Handling Policy
                                                       Management of the Deteriorating Patient
                                                       Cardiopulmonary; resuscitation; CPR; defibrillation;
Key Words (to aid with searching)                      anaphylaxis; heart arrest; cardio respiratory services;
                                                       bariatric patients
In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on
the document.

For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet




Cardiopulmonary Resuscitation         Issue 12 07 February 2012                                  Page 1 of 33
(Review date: January 2014 unless requirements change)
CONTENTS



QUICK REFERENCE GUIDE ............................................................................................................. 3

1.   INTRODUCTION.......................................................................................................................... 4

2.   PURPOSE ................................................................................................................................... 4

3.   SCOPE ........................................................................................................................................ 4

4.   DEFINITIONS .............................................................................................................................. 4

5.   DUTIES AND RESPONSIBILITIES ............................................................................................. 7

6.   PROCESS ................................................................................................................................... 8

7.   TRAINING REQUIREMENTS .................................................................................................... 14

8.   REFERENCES AND ASSOCIATED DOCUMENTATION ......................................................... 15

9.   EQUALITY IMPACT STATEMENT ............................................................................................ 16

10. MONITORING COMPLIANCE ................................................................................................... 17



APPENDIX 1: Resuscitation Training Needs Analysis for staff with frequent, regular contact with
patients…………………………………………………………………………………………………………18
APPENDIX 2: Anaphylaxis algorithm and investigations ….………………………………………….....20
APPENDIX 3: Cardiac Arrest/Medical Emergency Response Teams and equipment availability for
non-clinical areas on QAH site…………………………………………..…………………………………..22
APPENDIX 4: Minimum Personnel, Skills and Knowledge Levels for Queen Alexandra Hospital
Cardiac Arrest Teams (CAT)………………………………………………………………………………...25
APPENDIX 5: Cardiac arrest record forms…………………………………………………………………28
APPENDIX 6: Electrical equipment safety during defibrillation………………………………………..…32
APPENDIX 7: Defibrillation during renal replacement therapy using vascular access …………….....33
.




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QUICK REFERENCE GUIDE

This policy must be followed in full to ensure that a high-quality and robust resuscitation service is
available for patients, staff and visitors at all times.

For quick reference the guide below is a summary of actions required. This does not negate the need
for all staff to be aware of and follow the detail of this policy.

   1. All patients, staff and visitors will receive safe, early and appropriate Cardiopulmonary
      Resuscitation, including early defibrillation when required

   2. All staff with frequent, regular patient contact will attend annual resuscitation training relevant
      to their role. This training will include, as appropriate, anaphylaxis management, identification
      and response to the deteriorating patient, DNACPR and post resuscitation care;

   3. All in-patient vital signs will be recorded and an early warning score will be generated as per
      Management of the Deteriorating Patient policy (5). This will indicate whether escalation of
      care is required and ensure the appropriately skilled healthcare professional is called. This
      will aid identification and response to patients at risk from cardio-respiratory arrest;

   4. All patients having an anaphylactic reaction will be managed following the current
      Resuscitation Council (UK) guidance (6);

   5. All cardiac arrest equipment must be checked on a daily basis and after use by a registered
      healthcare practitioner to ensure continually availability in clinical areas;

   6. All staff using a defibrillator will attend training on an annual basis to demonstrate practical
      and theoretical competence in the safe use of a defibrillator;

   7. To enable the monitoring of compliance to this policy all respiratory and cardiac arrests will be
      recorded on the current PHT Cardiac Arrest Form.




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1. INTRODUCTION
  This Cardiopulmonary Resuscitation (CPR) policy is based on the recommendations for clinical
  practice and training in cardiopulmonary resuscitation published by the Resuscitation Council (UK)
  (2004, updated 2008). It has been developed to describe the process for managing and mitigating
  risks associated with resuscitation, as detailed in the current NHSLA Risk Management
  Standards, within Portsmouth Hospitals NHS Trust (the Trust).

  The Trust must provide a resuscitation service for patients, visitors and staff on its sites. The aim
  is that all health care staff who have direct patient contact must be able to provide CPR at levels
  appropriate to their role and healthcare environment in which they are working. As a minimum this
  is Basic Life Support (BLS). However, some staff e.g. doctors, nurses and technicians must
  provide elements of Advanced Life Support (ALS), including defibrillation.

  CPR is undertaken in an attempt to restore breathing (sometimes with support) and spontaneous
  circulation in a patient in cardiac and/or respiratory arrest. CPR is a relatively invasive medical
  therapy and it is therefore essential to identify patients for whom cardiac and/or respiratory arrest
  represents a terminal event in their illness. The Trust has a Do Not Attempt Cardiopulmonary
  Resuscitation (DNACPR) policy which should be read in conjunction with this policy to ensure that
  CPR is only initiated for patients when it is appropriate and in their best interests.


2. PURPOSE
  The purpose of this policy is to ensure that:
      prompt, safe, early and appropriate cardiopulmonary resuscitation and defibrillation occurs
        within the Trust;
      the management of anaphylaxis follows the Resuscitation Council (UK) guidelines (6) and
        appendix 2;

3. SCOPE
  This policy applies to all staff (including voluntary workers, students, locums and agency) of
  Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion, whilst acknowledging for
  staff other than those of the Trust the appropriate line management or chain of command will be
  followed.

  In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it
  may not be possible to adhere to all aspects of this document. In such circumstances, staff should
  take advice from their manager and all possible action must be taken to maintain ongoing patient
  and staff safety.

4. DEFINITIONS
  Adult Manual Defibrillation Pads
  Adhesive external pads which are attached to the patient to enable the delivery energy for external
  pacing, defibrillation or cardioversion purposes. Adult pads are used for all patients over 10kg.

  Advanced Life Support (ALS)
  The term ALS describes additional measures aimed at restoring ventilation and a perfusing
  cardiac rhythm: this is necessary to improve the chance of long term survival.

  Anaphylaxis is an acute life-threatening hypersensitivity reaction and should be considered when
  there is an acute onset, life threatening airway and/or breathing and/or circulation problems;
  especially if skin changes present (Appendix 2).

  Automated External Defibrillators (AED)
  The defibrillator itself analyses the cardiac rhythms, and advises whether a shock is indicated or
  not, and selects the appropriate energy levels according to the current Resuscitation Council (UK)
  Guidelines (3). AED’s allow staff such as nurses and physiotherapists to defibrillate prior to the
  arrival of more expert help. AED’s can be used on paediatric patients however attenuated pads

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  that reduce the energy delivered are used for children weighing less than 25kg. Where possible,
  AED’s should be avoided in the under one year old age group due to potential problems with
  rhythm recognition.

  Basic Life Support (BLS)
  The purpose of BLS is to maintain adequate oxygenation to the vital organs through maintenance
  of ventilation and circulation. This is continued until the respiratory/cardiac arrest is reversed,
  and/or the underlying cause treated, or the resuscitation attempt is stopped. It is therefore a
  "holding measure" until defibrillation and/or advanced life support is available. Failure of the
  circulation for three to four minutes (less if the victim is initially hypoxaemic) will lead to irreversible
  cerebral damage. Delay, even within that time, will lessen the eventual chances of a successful
  outcome. Emphasis must therefore be placed on prevention of cardiac arrest and early access to
  help then rapid institution of BLS by a rescuer if required.

  Basic Life Support with Airway Adjunct
  Basic life support implies that no equipment is employed. When a simple airway device or
  facemask is used to assist the delivery of ventilations, this is defined as "basic life support with
  airway adjunct".

  Cardiac Arrest
  Cardiac arrest is the sudden cessation of mechanical cardiac activity, confirmed by the absence of
  a detectable pulse, unresponsiveness, and apnoea or agonal, gasping respiration.

  Cardiac Arrest Team (CAT)
  A Cardiac Arrest Team is available on the Queen Alexandra Hospital site at all times and
  comprises staff trained in ALS. There are different teams for different patient groups as identified
  in Appendix 7. These teams must achieve a recommended level of training to achieve the required
  skill set (Appendix 8).

  Cardiac Rhythms
  Cardiac rhythms associated with cardiac arrest can be divided into two groups: ventricular
  fibrillation / pulseless ventricular tachycardia (VF/VT) and other rhythms (Non VF/VT). The latter
  includes asystole and pulseless electrical activity (PEA). The principle difference in the
  management of these two groups is the need for defibrillation in those patients with VF/VT.
  Subsequent actions, including chest compressions, airway management and ventilation, venous
  access, the administration of adrenaline, and the identification and correction of reversible causes,
  are common to both groups.

  Cardiopulmonary Resuscitation (CPR)
  Cardiopulmonary Resuscitation is a combination of artificial ventilation, chest compressions, drug
  therapy and defibrillation.

  Cardioversion
  This term will be taken to mean synchronised cardioversion i.e. the synchronised button is used to
  ensure that a DC shock is not delivered on the "T" wave, which in the susceptible heart can lead
  to VF or VT.

  Chain of Survival
  The interventions that contribute to a successful outcome after cardiac arrest can be
  conceptualised as a chain. The four links of the chain comprise of: early recognition and call for
  help (i.e. phone 2222), early CPR, early defibrillation and post resuscitation care

  Clinical Staff
  A member of trust staff whose job description includes direct patient care.

  Defibrillation
  Defibrillation is the definitive treatment for Ventricular Fibrillation (VF) and pulseless Ventricular
  Tachycardia (VT). It involves the delivery of a DC electric shock to the myocardium. The energy
  level to be administered is defined in the current ALS guidelines by the Resuscitation Council
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  (UK). For defibrillation to be effective, a critical mass of the myocardium needs to be depolarised
  to allow the heart’s own pacemakers to resume control.

  Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
  A DNACPR order indicates that in the event of a cardiac arrest, CPR will not be initiated.
  DNACPR decisions are the overall responsibility of the Consultant/General Practitioner in charge
  of the patient’s care. Attempts at CPR will not be commenced when it is felt that a patient would
  not survive or when it is not the patient’s wishes. It is emphasised that a DNACPR decision does
  not prevent other forms of treatment being provided. See current Trust DNACPR Policy for further
  detail.

  Early Warning Score and Escalation Protocols
  For adult in-patients the early warning system and escalation protocol is incorporated into
  VitalPAC. This is a tool for bedside evaluation of physiological parameters provides prompts to the
  clinical staff on when and who to call for additional help. There are adapted early warning systems
  and escalation protocols for Obstetric and Paediatric in-patients. Further information is in the Trust
  Management of the Deteriorating Patient Policy.

  Neonate
  For the purpose of this policy a neonate is any infant cared for within the Maternity Unit or
  Neonatal Intensive Care Unit (NICU) regardless of age. For other areas within the organisation the
  neonate is a baby below 29 days of age.

  Newborn Resuscitation Policy
  The newborn resuscitation policy outlines the management of the newborn/neonate infant whilst in
  Maternity and NICU.

  Non-clinical staff
  A member of the Trust staff whose job description does not include direct patient care. Some staff
  in this group need to attend annual resuscitation training, if their role includes patient contact
  without clinical staff immediately available, such as reception staff.

  Paediatric AED defibrillation pads
  Adhesive external pads used with an automated external defibrillator which itself analyses the
  cardiac rhythms. The pads are attached to the patient but reduce the energy before the delivery of
  current for defibrillation or cardioversion is delivered. These are used for paediatric patients under
  25kg.

  Paediatric Manual defibrillation pads
  Adhesive external pads used for infants under 10kg.

  Paediatric Resuscitation Guidelines
  The paediatric resuscitation BLS guidelines are related to size and used for the management of an
  infant, a baby under one year, and for a child between one year and puberty. The paediatric ALS
  guidelines are weight related and therefore apply to all babies and pre-puberty children.

  Patient Group Direction (PGD)
  Patient Group Directions (PGDs) are documents which make it legal for medicines to be given to
  groups of patients - for example in a vaccination programme - without individual prescriptions
  having to be written for each patient. They can also be used to empower staff other than doctors
  (for example paramedics and nurses) to legally give the medicine in question.

  Respiratory Arrest
  Respiratory arrest is the cessation of spontaneous breathing.

  2222 is the emergency number for the Cardiac Arrest Response at Queen Alexandra Hospital
  (QAH), St. Mary’s Community Hospital (SMH) and Gosport War Memorial Hospital (GWMH).



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5. DUTIES AND RESPONSIBILITIES

  Resuscitation Manager and the Resuscitation Training Team
  The Resuscitation Manager and the Team are responsible for ensuring that:
         Resuscitation Training delivered to Trust staff adheres to the current Resuscitation
           Council (UK) guidelines and incorporates training on the current early warning system
           used by the Trust for the identification of patients at risk, including the systems for
           summoning help, and DNACPR decision making;
         The delivery of annual resuscitation training updates including the requirement for
           attendees to be aware of the need to read and implement this policy and the DNACPR
           policy;
         All ‘2222’ calls relating to medical emergencies and cardiac arrests are reviewed and
           relevant data is collected Monday to Friday by a Resuscitation Officer (RO) and entered
           on the database.
         A Resuscitation Officer will:
               o Review all returned audit sections of the DNACPR form and ensure key data is
                   entered onto the database;
               o Lead on collecting data on resuscitation
         A rolling annual audit of the Cardiac Arrest equipment is undertaken in the Trust clinical
           areas located on the Queen Alexandra Hospital, St Mary’s Community Hospital,
           Petersfield Community Hospital and Gosport War Memorial Hospital sites;
        There are equipment and daily check lists available for the clinical staff to ensure the
           cardiac arrest equipment is in a state of readiness at all times.

  The Resuscitation Link Network
  The Network, which meets quarterly, consists of resuscitation link champions from each clinical
  area and the three Resuscitation Officers, each of whom chair the Network on a rolling basis. The
  Network is utilised to cascade information to and from the clinical areas, to support organisational
  learning and feedback

  Line Managers
  Line Managers are responsible for:
         Ensuring the daily checks are completed on the cardiac arrest equipment to ensure it is
           in a state of readiness at all times;
         Taking any unresolvable queries to the link champions or Resuscitation Manager who
           will take it to the appropriate forum for resolution;
         Releasing their staff to attend Resuscitation Training, in accordance with the
           requirements identified in Appendix 1, and monitoring attendance using the monthly
           reports from Learning and Development.

  All Clinical Staff
  All staff are responsible for ensuring that they:
           Immediately alerting the appropriate response team in the event of a cardiac/obstetric or
              neonatal emergency (see section 6.2.2);
           Practice within the current Resuscitation Council (UK) Guidelines and their own Codes
              of Professional Conduct;
           Attend the appropriate resuscitation training annually, as in Appendix 1. This will be
              monitored by the Line Managers and the Clinical Service Centre (CSC) Governance
              Steering group using the monthly reports from Learning and Development;
           Participate in the daily checking of cardiac arrest equipment to make sure the
              equipment is in a state of readiness at all times;
           Are familiar with the processes to follow if any cardiac arrest equipment fails or is found
              to be faulty during the daily operational check or when being used.




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  Governance and Quality Committee
  The Committee is responsible, through the receipt of annual reports from the Resuscitation
  Committee, there is continuous and measurable improvement in the quality of the services
  provided.

  The Trust Resuscitation Committee
  The Committee is responsible for ensuring that:
         This procedural document is up to date, technically accurate, is in line with evidence-
           based best practice and has been produced following consultation with stakeholders
         The processes to enable audits of compliance and monitoring of trust standards, as
           detailed in this policy, are in place and the actions identified as a result of those audits
           are implemented.;
         Through the Chair, assurance on the effectiveness of this policy and the Trust’s
           procedures for CPR, is provided through an annual report to the Governance and
           Quality Committee, including any necessary recommendations to address identified
           deficits;

  Cardiac Arrest Teams
  The Teams consist of four members: a team leader; an airway technician; a circulation technician;
  and an assistant. Members of the team must respond at the earliest opportunity to any cardiac
  arrest bleep, including the test call, which is tested at random each day. The members of each
  team are outlined in Appendix 3.

  Clinical Engineering Team
  The Team is responsible for:
         Responding to reports of any faults with defibrillators and for making arrangements to
            repair or replace the equipment (24 hour cover via the Queen Alexandra switchboard).

6. PROCESS

    6.1 Identification of patients at risk of cardio-respiratory arrest.
        There is a Trust Management of the Deteriorating Patient Policy (5) developed in response
        to the key recommendations of the NICE Clinical Guideline 50. The policy describes in full
        the process for managing and mitigating risks relating to all aspects of the treatment and
        care of adults who are acutely ill or at risk of physical deterioration and cardio-respiratory
        arrest.

    6.2 Cardiac Arrest Response
        6.2.1 CPR should be commenced for all patients/visitors/staff who suffer a cardiac arrest,
               unless there is a valid DNACPR decision in place.

        6.2.2 Queen Alexandra Hospital Site

              It is the responsibility of the clinical staff to ensure that patients, visitors and staff
              suffering a respiratory or cardiopulmonary arrest, receive the appropriate treatment as
              described in current guidelines by the Resuscitation Council (UK) and as per the
              appropriate site response.

              The appropriate emergency response/team will be summoned by using the universal
              number 2222. The precise location of the patient must be communicated promptly and
              clearly to the switchboard operator

                   Adult patients state Adult Cardiac Arrest Team

                   Obstetric patients state Maternal Crisis and Adult Cardiac Arrest Team


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                   Paediatric patients state Paediatric Cardiac Arrest Team

                   Neonates state Flat Baby (Neonatal Emergency Team)

              All cardiac arrest bleeps are alerted simultaneously by the Queen Alexandra Hospital
              switchboard operator via a speech channel. Each member of the emergency team
              that has been called must attend the specified location immediately. ALS will be
              provided by the responding team. The composition and skills of the teams above are
              detailed in Appendix 3 and 4.

              Note: The speech channel is tested at random each day, to ensure that the system
              and individual bleeps are in working order. All bleep holders must respond to this test
              call.

        6.2.3 St Mary’s Community Hospital and Gosport War Memorial Hospital sites.

              The response on these sites is BLS, AED and Ambulance. These hospital sites have
              a switchboard system so use the universal number 2222. This enables switchboard to
              activate the medical emergency response bleeps and then call the ambulance service.
              The member of staff should return to the victim to commence BLS.

              BLS and AED response as per Resuscitation Council (UK) guidelines will be provided
              by the healthcare staff present and Advanced Life Support will be provided by the
              ambulance service.

              All medical emergency response bleeps will be alerted simultaneously by the relevant
              site switchboard operator via a speech channel. Each member of the site response
              team must respond at their earliest opportunity. The speech channel will be tested at
              random each day, to ensure that the system and individual bleeps are in working
              order, all bleep holders must respond to this test call.

        6.2.4 Petersfield Community Hospital and other Community sites such as Health
              Centres
              The response on these sites includes BLS, AED and Ambulance. As there is no
              switchboard facilities at these sites the Trust healthcare staff present should be aware
              of the site response procedures to enable the ambulance response to be summoned
              promptly.
              BLS and AED (if available) response as per Resuscitation Council (UK) guidelines will
              be provided by the healthcare staff present and Advanced Life Support will be
              provided by the ambulance service

        6.2.5 Resuscitation in non-clinical areas within main buildings

              The nearest member of staff to the incident must summon help as per site response.
              If there is a nearby clinical area then they could be contacted to provide clinical
              expertise and equipment to patients, visitors and staff. The member of staff at the
              incident will facilitate the transfer of the victim to a “Place of Safety”.

              Some non-clinical areas/departments will have a designated person responsible for
              first aid who should also be summoned. See the Trust’s First Aid at Work Policy for
              further details.

              See Appendix 6 for details of Cardiac Arrest Equipment cover for non-clinical areas.

        6.2.6 Resuscitation in areas outside of the main buildings (e.g. grounds, car parks)

              If the victim has collapsed outside of the main hospital buildings staff should dial the
              normal emergency number for the site using the nearest internal telephone and
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               switchboard will call an ambulance for transfer to a place of safety.

               If access to an internal phone is not possible, for example the victim is in an isolated
               place, then staff should call an ambulance directly as they would in the community
               setting.


        6.2.7 Staff Illness
              For members of staff who have a life-threatening emergency at work the procedures
              outlined above should be followed.


  6.3   Documentation
        6.3.1 Cardiorespiratory arrests in Queen Alexandra Hospital
              All cardiorespiratory arrests in Queen Alexandra Hospital must be recorded on the
              Cardiac Arrest Record Form (Appendix 5).

               The inner copy of the Form must be detached and returned to the Trust Resuscitation
               Department, by the member of staff who completed the form.

        6.3.2 Cardiorespiratory arrests in community sites
              All cardiorespiratory arrests in community sites must be recorded on the Community
              Sites Audit Form (Appendix 5) and returned to the Resuscitation Department, by the
              member of staff who completed the form.

  6.4   Post resuscitation care.
        The healthcare staff responsible for the patient’s care, such as Cardiac Arrest Team Leader
        or Nurse in Charge, must ensure safe continuity of care and where necessary, safe transfer
        following resuscitation. This may involve one or more of the following steps:

              Referral to a specialist;

              Full and complete documentation and hand-over of care;

              Preparation of equipment, oxygen, drugs and monitoring systems;

              Intra-hospital or inter-hospital transfer;

              Liaison with the Ambulance Service;

              Liaison with staff experienced in patient retrieval and transfer;

              Informing relatives;

              Completion of an Adverse Incident Reporting Form if indicated and in accordance with
               Trust Policy (13).

  6.5   Ensuring continual availability of cardiac arrest equipment
        6.5.1 All cardiac arrest equipment must be maintained in a state of readiness at all times
              and must be checked by a registered healthcare practitioner every day of
              ward/departments clinical activity and immediately following conclusion of a cardiac
              arrest event. The defibrillator must be operationally checked in accordance with the
              instructions issued by the Clinical Engineering Department. Daily check lists must be
              kept within the clinical areas for the life of the defibrillator and suction machine (which
              will be on average ten years) plus one year for audit purposes.

        6.5.2 If any cardiac arrest equipment fails or is faulty during the daily operational check or
              when being used, the ward/department based clinical staff must be familiar with the
              local procedure for this scenario (i.e. the clinical staff would go to the next nearest
              clinical area and arrange appropriate cover). Defibrillator faults must be reported
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                immediately to the Clinical Engineering Department (24hr cover via Queen Alexandra
                Hospital switchboard) so arrangements can be made for repair or replacement as
                soon as possible. Additional information can be found in the Trust Policy and
                Protocol for Management of Medical Devices (10).

        6.5.3 The cardiac arrest equipment held must be stocked in accordance with a standardised
               list issued by the Resuscitation Committee (8). The current list can be found on the
               Resuscitation Department intranet page.

        6.5.4 Disposable items should be replenished at the earliest opportunity as indicated on the
              Trust’s ALS equipment lists (8). Non-disposable items should be de-contaminated
              and/or cleaned in accordance with both the manufacturers’ guidance and the Trust-
              wide infection control guidance and re-instated to the trolley as soon as is practical.
              Further information can be obtained on the Resuscitation Department intranet page.

          6.5.5 On the Queen Alexandra Hospital site the Cardiac Arrest Drug boxes are replaced
                from pharmacy during normal working hours and outside of this time they are
                replaced from the Emergency Drug Cupboards (14). The locations of the Emergency
                Drug cupboards are detailed on the Trust Pharmacy intranet page.

  6.6     Manual Handling
          In situations where the collapsed patient is on the floor, in a chair or in a restricted/
          confined space the organisational guidelines for the movement of the patient must be
          followed to minimise the risks of manual handling and related injuries to both staff and the
          patient (15). Further information is also available from the Resuscitation Council (UK) who
          have issued Guidance for Safer Handling During Resuscitation in healthcare settings (Nov
          2009) (16).

  6.7     Cross Infection
          6.7.1 Whilst the risk of infection transmission from patient to rescuer during direct mouth-
                to-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 Emergency Department, Outpatients or
                     other admission source;
                    Other persons where the medical history is unknown.


          6.7.2 All clinical areas must have immediate access to a pocket mask, which must be
                strategically located, to minimise the need for mouth-to-mouth ventilation. However,
                in situations where airway protective devices are not immediately available, start
                chest compression only CPR whilst awaiting an airway/ventilation device.

  6.8     Anaphylaxis management
          6.8.1 The management of suspected anaphylactic reactions must be conducted in
                accordance with the current Resuscitation Council (UK) Guidelines for the
                Management of Anaphylaxis (6). See Appendix 2 for the current treatment algorithm.

          6.8.2 All healthcare professionals administering medication will attend mandatory annual
                Basic Life Support and Anaphylaxis training as a minimum standard.

          6.8.3 For governance purposes non-prescribing healthcare professionals should use the
                Portsmouth Combined NHS Trusts Patient Group Direction for the use of Adrenaline
                in the Treatment of Anaphylaxis (17). In addition they must complete and maintain
                the relevant anaphylaxis competency by attendance at annual training (18). Evidence

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                of competency is held on the ward/department in the individual’s personal
                development records.

          6.8.4 To aid diagnosis the post event the investigations detailed in Appendix 2 must be
                completed.
  6.9     Defibrillation
          6.9.1 Defibrillators must only be operated by persons specifically trained in their use. The
                training will be in accordance with the current Resuscitation Council (UK) Guidelines
                (3). Staff authorised to manually defibrillate or use AED must have demonstrated
                practical and theoretical competence to the Trust Resuscitation Department or have
                attended a course recognised by the Trust’s Resuscitation Department such as
                RC(UK) Advanced Life Support Course. For further recognised courses please call
                Ext: 6110.

          6.9.2 The member of staff must continue to update practical and theoretical competence
                annually. However for flexibility and to minimise the impact on the clinical areas and
                patients there is a permitted period of 2 months whereby staff can urgently arrange
                an update should their certificate have expired.

          6.9.3 If a patient who has had an emergency thoracotomy requires defibrillation then the
                chest should be closed and external defibrillation should be delivered as per current
                ALS guidelines.

          6.9.4 For further information on electrical equipment safety during defibrillation see
                Appendix 7.

          6.9.5 For further for information on defibrillation during haemodialysis see Appendix 8.

  6.10    Procurement
          For all resuscitation equipment purchasing the Medical Devices Management policy must
          be followed (10). All resuscitation equipment purchased must be agreed by the
          Resuscitation Department prior to ordering.

  6.11    Cardiopulmonary Resuscitation for Bariatric Patients
          Standard Resuscitation Council (UK) Basic Life Support and Advanced Life Support
          guidelines should be followed with additional consideration given to the following issues:

          Airway and Breathing

               Potential Problems
                    Likely to be more difficult to manage airway
                    Increased risk of regurgitation
                    May be more difficult to achieve good seal with pocket mask/Bag Valve Mask

                Actions
                     Two person technique when using Bag Valve Mask device
                     Early use of airway adjuncts e.g. Oropharyngeal airway
                     Consider early intubation

          Circulation

               Potential Problems
                    Intravenous access likely to be more difficult to achieve
                    Intra-osseous may also be more difficult to achieve

               Actions
                    If unable to achieve access, consider performing cut-down


Cardiopulmonary Resuscitation         Issue 12 07 February 2012              Page 12 of 33
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          Chest compressions

                Potential Problems
                  More difficult for chest compression provider to achieve correct hand/arm
                     position (shoulders directly above hands)
                    More difficult to compress adequate depth (5-6 cms)

                Actions
                  Position bed height to facilitate effective chest compressions. This is likely to be
                      with the bed at or near it’s lowest position
                     Compressions provider to use foot stool if available
                  Consider the height of the person performing chest compressions and if a taller
                      member of staff is available changing the compression person should be
                      considered as the taller person may find it easier to achieve adequate
                      compressions

          Defibrillation

                Potential Problem
                  May be more difficult to place pads in correct position
                  The patients body mass may increase transthoracic impedance

                Actions
                   Use standard defibrillator pad position. Avoid breast tissue if possible.
                   Use Standard defibrillator energy, 150 Joules, escalating to 200 Joules after
                      first shock

  6.12    Cardiopulmonary Resuscitation for patients with an Implantable Cardioverter
          Defibrillator (ICD)

           6.12.1 Deactivation of an ICD with a magnet is normally indicated when the ICD is
                  providing inappropriate shock therapy or the patient is undergoing emergency
                  surgery out of hours requiring diathermy. In these situations the decision to
                  deactivate the ICD should be advised by appropriately trained SpR or Consultant
                  with Advanced Life Support training. If an ICD has been deactivated the patient
                  should be closely monitored for treatable arrhythmias and an external defibrillator
                  should be attached to patient. A member of staff trained in external defibrillation
                  should remain in attendance.

           6.12.2 In event of Cardiac Arrest the effectiveness of ICD should be monitored. If the ICD
                  provides an appropriate shock, that is not successful in correcting VT/VF, ALS
                  should not be delayed. A magnet can be applied during CPR (19) and should
                  remain in situ. Special attention must be given to the person delivering chest
                  compressions following a case report (20) where electrical injury to the rescuers
                  hand was sustained. If any risk to the rescuers is suspected then the ICD should
                  be deactivated with a magnet immediately and standard ALS protocols followed.
                  External pads should be placed 8cm away from the device site preferably use
                  antero- posterior position. The Cardiology SpR or Consultant should be contacted,
                  as soon as possible, for further advice.

           6.12.3 The magnets are stored on the cardiac arrest trolleys and should be placed over
                  the ICD using adhesive tape. The ICD site is indicated by scar; usually left infra
                  clavicular or rarely right infra claviclular region. Very rarely ICD may be in
                  abdomen or groin.

           6.12.4 Post CPR if there is return of spontaneous circulation leave the magnet in situ until
                  ICD is reprogrammed by a Cardiac Physiologist. If the patient dies then advise


Cardiopulmonary Resuscitation         Issue 12 07 February 2012              Page 13 of 33
(Review date: January 2014 unless requirements change)
                   mortuary technicians to remove magnet and inform Cardiac Physiologists of
                   patient’s location.

           6.12.4 Some ICD devices cannot be deactivated with a magnet. This is rare and if it
                  occurs the patient should be made comfortable with sedation. If it is necessary to
                  identify the device manufacturer the patients are advised to carry information
                  regarding their device at all times.

  6.13    Urgent Blood Gas Analysis in Cardiac Arrest And Peri-Arrest Situations on the QAH
          site

              For urgent arterial blood gas (ABG) analysis (including potassium) at a cardiac arrest
               or peri-arrest situation in the East Ward Block (Old Hospital) the blood gas
               sample can be taken to the Emergency Department for testing.

              For urgent blood gas analysis (including potassium) at a cardiac arrest or peri-arrest
               situation in the South Ward Block (New Hospital) the blood gas sample can be
               taken to the Department of Critical Care (E5) for testing.

              All non-urgent ABG's should be taken to the Pathology Laboratory (Path Lab)
               having ensured the samples and forms are fully and correctly labelled at the bedside.
               The blood gas machine in the Path Lab cannot provide a potassium result and
               therefore a serum potassium sample should also be taken if required.

              To save time in emergency situations, there are blank biochemistry/haematology
               request forms on all the cardiac arrest trolleys.

              The blood gas syringes compatible with all analyzing machines is the Radiometer
               PICO70 syringes.

              All non-urgent blood gases should continue to be sent to the Path Lab in the usual
               way.

7. TRAINING REQUIREMENTS

  7.1     The strategy for resuscitation training embodies the statements and guidelines published
          by the Resuscitation Council (UK) and the European Resuscitation Council, incorporating
          the most recent updates to these guidelines. This explicitly incorporates current Do Not
          Attempt Cardiopulmonary Resuscitation (DNACPR) policy, the identification of patients at
          risk from cardiac arrest and a strategic approach to implement preventative measures such
          as Early Warning Systems/ Patient at Risk Systems.

          The Trust will provide sufficient and appropriate resuscitation training for all clinical staff to
          attend annually. Profession specific resuscitation training will be directed by their
          respective functional role and the guidelines and directives issued by their professional
          bodies (e.g. The Royal College of Anaesthetists).

           All clinical staff are trained in the identification of the deteriorating and critically ill patients
           and the use of physiological observation charts to enhance decision making and care
           escalation. This is included in annual resuscitation training updates to a level relevant to
           the staff role.

           The profession specific guidelines for resuscitation training are detailed in the Training
           Needs Analysis (Appendix 1). The uptake of training monitored monthly through the
           reports from Learning and Development Department to all Clinical Service Centres
           (CSC’s).



Cardiopulmonary Resuscitation         Issue 12 07 February 2012                    Page 14 of 33
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           Clinical Staff
           All doctors, nurses, midwives and Allied Health Professionals must be trained annually in
           cardiopulmonary resuscitation to a level appropriate to their clinical roles and
           responsibilities. The level of that training is determined by their respective professional
           bodies (e.g. General Medical Council) and/or the duties that those staff would be expected
           to undertake when in attendance at a cardiac arrest/medical/obstetric/neonatal
           emergency. This is detailed in the Training Needs Analysis (Appendix 1).

           Non-Clinical Staff
           All hospital staff with frequent, regular unsupervised (by clinical staff) contact with patients
           should be trained in basic life support (BLS).

   8. REFERENCES AND ASSOCIATED DOCUMENTATION
     1. Resuscitation Council (UK) (2004. Updated June 2008) CPR Standards for Clinical Practice
         and Training. http://www.resus.org.uk/pages/standard.htm
     2. NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or
         Mental Health & Learning Disability Services and Independent Sector Providers of NHS
         Care 2011/12. Standard 4. Criterion 7. Levels 1-3. http://www.nhsla.com/RiskManagement/
     3. Resuscitation Guidelines (UK) 2010. http://www.resus.org.uk/pages/guide.htm
     4. PHT Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy. Located on the
         intranet under clinical policies. http://pht/PoliciesGuidelines/ClinicalPolicies/default.aspx
     5. PHT Management of the Deteriorating Patient Policy. Located on the intranet under clinical
         policies. http://pht/PoliciesGuidelines/ClinicalPolicies/default.aspx
     6. Resuscitation Council (UK) (2008) Emergency treatment of anaphylactic reactions.
         Guidelines for healthcare providers. Resuscitation Council (UK): London
         http://www.resus.org.uk/pages/mediMain.htm
     7. PHT Neonatal Resuscitation Maternity Policy. Located on the intranet. Departments –
         Maternity – Maternity Services Guidelines Neonatal Resuscitation Maternity Services Policy
     8. Current PHT Resuscitation BLS & ALS equipment Recommendations and daily checklists
         are located on PHT Resuscitation intranet site. Departments – Resuscitation. Resuscitation
         Equipment Lists and Forms
     9. Procedural Documents Development And Management Policy. Located on the intranet
         under management policies. http://pht/PoliciesGuidelines/ManagementPolicies/default.aspx
     10. PHT Medical Devices Management Policy. Located on the intranet under management
         policies. http://pht/PoliciesGuidelines/ManagementPolicies/default.aspx
     11. NICE Clinical Guideline 50. Acutely ill patients in hospital. Recognition of and response to
         acute illness in adults in hospital. July 2007. http://guidance.nice.org.uk/CG50
     12. PHT First Aid at Work Policy. Located on the intranet under health and safety policies.
         http://pht/PoliciesGuidelines/HealthandSafetyPolicies/default.aspx?PageView=Shared
     13. PHT Adverse Incident and Near Misses Management policy. Located on the intranet under
         management policies. http://pht/PoliciesGuidelines/ManagementPolicies/default.aspx
     14. Emergency Drug Cupboard List is located on PHT intranet – Departments – Pharmacy - Out
         of hours. http://pharmweb/Closed/emergencydrugcupboards.asp
     15. PHT People Moving and Handling policy. Located on the intranet under clinical policies.
         http://pht/PoliciesGuidelines/ClinicalPolicies/default.aspx
     16. Resuscitation Council (UK) (2009) Guidance for Safer Handling during Resuscitation in
         healthcare settings. http://www.resus.org.uk/pages/mediMain.htm
     17. Portsmouth Hospitals Trust. Patient Group Directions for Adrenaline (Epinephrine) Injection
         BP 1:1000 PGD Ref No: RSS 003. Current version is located on the intranet – Departments
         – Pharmacy – PGD’s http://pharmweb/FMG/PGD/Database/
     18. PHT Competency Statements on Adult and Paediatric Anaphylaxis. PHT intranet. Learning
         and Development Zone, Nursing and Midwifery. Generic Nursing and Midwifery
         Competency Framework
     19. Nolan JP et al. Part 1: Executive summary: 2010 International Consensus on
         Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
         Treatment Recommendations. Resuscitation 2010;81:e1-e25.
     20. Stockwell B., Bellis G., Morton G., Chung K., Merton W. L., Andrews N. P., Smith G. B.
Cardiopulmonary Resuscitation         Issue 12 07 February 2012                 Page 15 of 33
(Review date: January 2014 unless requirements change)
         Case report. Electrical injury during “hands on” defibrillation—A potential risk of internal
         cardioverter defibrillators? Resuscitation 2009;80;832-4


9.   EQUALITY IMPACT STATEMENT
     Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
     practicable, the way we provide services to the public and the way we treat our staff reflects
     their individual needs and does not discriminate against individuals or groups on any grounds.

     This policy has been assessed accordingly




Cardiopulmonary Resuscitation         Issue 12 07 February 2012               Page 16 of 33
(Review date: January 2014 unless requirements change)
   10. MONITORING COMPLIANCE
       As a minimum, the following elements will be monitored.

        Minimum requirement to              Lead                   Tool              Frequency of       Reporting arrangements        Lead(s) for acting on
             be monitored                                                            Reporting of                                      recommendations
                                                                                     Compliance
        100% of Cardiac Arrest           Resuscitation     PHT Cardiac Arrest          Annually        Policy Audit Report            Resuscitation Manager
        Record Forms are completed         Manager       Record Form based on                              Resuscitation Committee
        appropriately                                     the Utstein Template
                                                                                                           Governance and Quality
                                                              (Appendix 5)                                  Committee
        Continual availability of        Resuscitation   Current Resuscitation         Annually        Policy Audit Report to         Resuscitation Manager
        resuscitation equipment:           Manager       Equipment Standards                               Resuscitation Committee
        equipment will be available at                            (8)
                                                                                                        
        all times
        85% of staff will attend Basic   Learning and    Audit of Electronic Staff     Annually        Policy Audit Report            CSC Heads of Nursing /
        Life Support training annually   Development              Record                                   Resuscitation Committee     Chiefs of Service
        as set out in training needs       Business
        analysis                           Manager




Cardiopulmonary Resuscitation         Issue 12 07 February 2012                        Page 17 of 33
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                                     Resuscitation Training Needs Analysis for staff with frequent, regular contact with patients                                             Appendix 1
Minimum standard for all clinical staff and non-clinical staff with frequent, regular contact with patients
       As a minimum standard all clinical staff with direct Adult patient contact must attend Adult Basic Life Support (BLS) annually.
       As a minimum standard all clinical staff with direct Paediatric patient contact must attend Paediatric Basic Life Support (BLS) annually.
       As a minimum standard all clinical staff with direct Newborn patient contact must attend Newborn Life Support annually.
       As a minimum standard all clinical staff with direct Maternal patient contact must attend Maternal Basic Life Support (BLS) annually.

Annual Resuscitation Training for Registered Nursing/Midwifery/AHP’s with Direct Patient Contact

                           PHT       PHT      PHT         PHT         Anaphylaxis      RC (UK)      RC (UK)    EPLS/      RC (UK)     RC (UK)     PHT NICU        PHT Maternal    PHT
                           Adult     Paed     CSSD        Adult       Training if      ALS          ILS        APLS       pILS        Newborn     Resuscitation   BLS and         Newborn
                           BLS       BLS                  BLS &       administering    Provider     Course     Course     Course      Life        Training        anaphylaxis     Life
                                                          AED         medicines        Course                                         Support     Programme                       Support
                                                                                                                                      Course                                      Update
     Registered Staff in       M                    D                          M            D          D
     Adult Critical Care                         Every 2
     Areas                                        years
     Registered Staff in       M                    D                          M                       D
     Acute Adult Ward                            Every 2
     Areas                                        years
     Registered Staff in       M                              M                M
     Community
     Hospitals
     Registered Staff in       M                                               M
     Adult non-ward
     clinical areas
     Registered Staff in       M          M                                    M                                   D             D
     Paediatric Areas
     Registered Staff in       M                                               M                                                          D             M                              M
     Newborn Areas
     Registered staff in       M                                               M                                                                                        M              M
     Maternity Areas
                    BLS = Basic Life Support             CSSD = Critical Skills Study Day               AED = Automated External Defibrillation       ALS = Advanced Life Support
                    ILS = Immediate Life Support         EPLS = European Paediatric Life Support        APLS = Advanced Paediatric Life Support       pILS= Paediatric Immediate Life Support
                    NICU = Neonatal Intensive Care Unit M = Mandatory on an annual basis                D = Desirable                                 Blank = Not Applicable




Cardiopulmonary Resuscitation         Issue 12 07 February 2012                                    Page 18 of 33
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                                                                                                                                                                                      Appendix 1 cont.
Annual Resuscitation Training for Medical Staff with Direct Patient Contact


                                 Adult     Paed     PHT       Anaphylaxis      RC (UK)        PHT Adult         EPLS/       RC (UK)     PHT Paed             RC (UK)        NICU            Maternal
                                 BLS       BLS      Adult     Training if      ALS            Manual/AED        APLS        pILS        Manual               Newborn Life   Resuscitation   BLS
                                                    ALS       administering    Provider       Defibrillation    Course      Course      Defibrillation and   Support        Training
                                                              medicines        Course                                                   Anaphylaxis          Course         Programme

Medical Staff On Adult              M                  M            M             M                                                                                                            M
Cardiac Arrest Team                                                             FY1(D)
All Other Medical Staff with        M                               M              D                 D                                                                                         D
direct adult patient contact
Anaesthetists                       M         M                     M              D                M               D             D                                                            D

Medical Staff On Paediatric         M         M                     M                                               M                          D
Cardiac Arrest Team
All Other Medical Staff with        M         M                     M                                               D             D             D
direct paed patient contact
Medical Staff On Neonatal           M                               M                                                                                             M               M
Emergency Response Team
All Other Medical Staff with        M                               M
direct Neonatal patient
contact
Medical Staff On Maternal           M                               M                               M                                                                                          M
Emergency Response Team
All Other Medical Staff with        M                               M                                D                                                                                         M
direct Maternal patient
contact
                               M = Mandatory on an annual basis               D = Desirable                    Blank = Not Applicable




Cardiopulmonary Resuscitation         Issue 12 07 February 2012                                          Page 19 of 33
(Review date: January 2014 unless requirements change)
                                                                                    Appendix 2
                    Resuscitation Council (UK) Anaphylaxis Treatment Algorithm




Cardiopulmonary Resuscitation         Issue 12 07 February 2012     Page 20 of 33
(Review date: January 2014 unless requirements change)
                                                                                     Appendix 2 cont

                       Investigations post anaphylactic/severe allergic reaction

     When a patient experiences an adverse event that is thought to be a possible anaphylactic or
     anaphylactoid reaction, ensure that the following basic samples are obtained:

     An EDTA plasma (purple top) or serum sample (red or yellow top) for tryptase estimation
     (one bottle will suffice)
             Sample            As soon as possible after, or within one hour of, onset of the reaction.
             1

              Sample          3 hours post-reaction
              2

              Sample          24 hours post-reaction (required to act as a baseline to exclude
              3               mastocytosis).


     Sample transport
     These samples can be transported at room temperature to the laboratory where they will be
     stored until the series is received.


     Interpretation of results
                Peak              Systolic BP
                tryptase          (mmHg)
                level

                >50ug/L           Unrecordable          Type I Hypersensitivity (drug history required
                                                        for allergen specific IgE studies).

                20-               20-80                 Non-immune anaphylactoid reaction either
                50ug/L                                  (i) direct release by pharmacologically active
                                                        drugs or (ii) complement activation.

                2-20ug/L          100-120               Probable bronchospasm


       NB: There will be occasions when this protocol is unworkable and a single blood sample
       taken post mortem for example, may still be of value in the investigation of underlying
       causative pathology.




Cardiopulmonary Resuscitation         Issue 12 07 February 2012              Page 21 of 33
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                                                                                         Appendix 3
                        Cardiac Arrest and Emergency Response Teams

Table 1. ADULT Cardiac Arrest Team at Queen Alexandra Hospital

     Team                           Resuscitation Committee recommended        Emergency
                                    minimum training standard                  Number
Medical SpR/ST3 and above           ALS & PHT ALS                              2222
                                                                               State Cardiac
Medical SHO/FY2/ST1 & 2             ALS & PHT ALS                              Arrest Team
                                                                               and location
Medical FY1/FY2                     PHT ALS (ALS desirable)

Doctor from DCCQ                    PHT ALS

Department Nurse / AHP              BLS/CSSD/ILS

Specialty Nurse Bleep Holder        CSSD/ILS


Table 2. PAEDIATRIC Cardiac Arrest Team at Queen Alexandra Hospital

     Team                           Resuscitation Committee recommended        Emergency
                                    minimum training standard                  Number
Paediatric SpR/ST3 and above        APLS/EPLS                                  2222
                                                                               State Paediatric
Paediatric SHO/ ST1&2               pILS/EPLS                                  Cardiac Arrest
                                                                               Team and
SpR from DCCQ                       EPLS/APLS                                  location

Paediatric Nurse Bleep Holder       pILS

Department Nurse / PAM              Adult & Paed BLS/CSSD/ILS



Table 3: NEONATAL Emergency Response Team at Queen Alexandra Hospital

     Team                           Resuscitation Committee recommended        Emergency
                                    minimum training standard                  Number
                                                                               2222
Neonatal Consultant                 NLS                                        State “Flat
                                                                               Baby”
Neonatal SpR/ST3 and above          NLS                                        (Neonatal
                                                                               Emergency
Neonatal SHO/FY2/ST1&2              NLS                                        Response
                                    NLS or NICU Resuscitation Training         Team) and
Department Nurse                    programme                                  location
                                    NLS or NICU Resuscitation Training
Nurse in Charge of each Shift
                                    programme & Adult BLS




Cardiopulmonary Resuscitation         Issue 12 07 February 2012          Page 22 of 33
(Review date: January 2014 unless requirements change)
Table 4: Response to Maternal Cardiac Arrests at Queen Alexandra Hospital


      Team                          Resuscitation Committee recommended       Emergency
                                    minimum training standard                 Number
Adult Cardiac Arrest Team

Medical SpR/ST3 and above           ALS & PHT ALS                             2222
                                                                              State Maternal
Medical SHO/FY2/ST1 & 2             ALS & PHT ALS                             Crisis and
                                                                              Cardiac Arrest
Medical FY1                         PHT ALS (ALS desirable)                   Team and
                                                                              location
Doctor from DCCQ                    PHT ALS

Maternity Crisis Team

Department Midwife/AHP              Maternal BLS

Maternity Bleep Holder              Maternal BLS

Maternity Anaesthetist              ALS & PHT ALS

Gynaecology SpR                     BLS & Defib

If requested the Neonatal
Emergency Response Team

Neonatal Consultant                 NLS

Neonatal SpR/ST3 and above          NLS

Neonatal SHO/FY2/ST1&2              NLS

ALS = Resuscitation Council (UK) Advanced Life Support Course Provider
PHT ALS= PHT Advanced Life Support for the Cardiac Arrest Team
CSSD= PHT Critical Skills Study Day
ILS= Resuscitation Council (UK) Immediate Life Support Course
APLS = Advanced Paediatric Life Support Course Provider
EPLS= Resuscitation Council (UK) European Paediatric Life Support Course Provider
pILS = Resuscitation Council (UK) Paediatric Immediate Life Support Course
NLS = Resuscitation Council (UK) Newborn Life Support Course
NICU = PHT Neonatal Intensive Care Unit

Table 5: Emergency Response in PHT Community sites

                         Resuscitation Committee recommended minimum          Emergency
Team
                         training standard                                    Number

Clinical areas               BLS & AED                                        Site specific


Non-clinical areas           BLS                                              Site specific




Cardiopulmonary Resuscitation         Issue 12 07 February 2012        Page 23 of 33
(Review date: January 2014 unless requirements change)
Table 6: Availability of Cardiac Arrest equipment to non-clinical areas on the Queen Alexandra
Hospital Site.

     Equipment Provided By:                        Place of Safety
 For A, B & C Level corridors in the East
 Ward Block (‘Old Hospital’) the
                                              Emergency Department (ED)
 Emergency Department (ED) staff will
 respond with cardiac arrest equipment
 For D, E, F & G Level corridors in the
                                              The nearest clinical area. The clinical staff and cardiac
 East Ward Block (‘Old Hospital’) the
                                              arrest team would then arrange the continuing care and
 nearest clinical area will provide the
                                              carry out safe transfer if required.
 equipment
 For A, B, C, D, E, F and G Level
                                              The nearest clinical area. The clinical staff and cardiac
 corridors in the South Ward Block (‘New
                                              arrest team would then arrange the continuing care and
 Hospital’) the nearest clinical area will
                                              carry out safe transfer if required.
 provide the equipment
                                              Adult BLS equipment including an AED & oxygen have
                                              been placed behind Main Reception. A Cardiac Arrest
 Main Entrance, Retail Shop and Coffee
                                              trolley can be obtained from Paediatric Department. The
 Shop, A Level
                                              cardiac arrest team would then arrange the continuing
                                              care and carry out safe transfer if required.
                                              Adult BLS equipment including an AED & oxygen are in
                                              Medical OPD. A Cardiac Arrest trolley can be obtained
 North Entrance, C Level                      from Orthopaedic Outpatients. The cardiac arrest team
                                              would then arrange the continuing care and carry out
                                              safe transfer if required.
                                              Adult BLS equipment including an AED is held at the
                                              Education Centre reception. A Cardiac Arrest trolley can
 Education Centre, E Level                    be obtained from E8 Ward. The cardiac arrest team
                                              would then arrange the continuing care and carry out
                                              safe transfer if required.




Cardiopulmonary Resuscitation         Issue 12 07 February 2012             Page 24 of 33
(Review date: January 2014 unless requirements change)
                                                                                          Appendix 4

        Minimum Personnel, Skills and Knowledge Levels for Queen Alexandra Hospital
                                Cardiac Arrest Teams (CAT)

     The CAT should consist of 4 members – a team leader, airway technician, circulation
     technician and one assistant (1).

     Team Leader: must
     • Possess a current Resuscitation Council (UK) Advanced Life Support course certificate
     • Be able to recognise cardiac arrest
     • Be able to provide basic life support
     • Possess a thorough understanding of the current RC (UK) guidelines for the treatment of
        cardiac arrest
     • Possess basic and advanced airway management skills to include use of:
          o Use of simple airway opening manoeuvres
          o Use of oral and nasopharyngeal airway adjuncts
          o Use of laryngeal mask airway
          o Tracheal intubation (preferred)
          o Suction of the upper and lower airway
     • Possess following skills relating to breathing:
          o Use of pocket mask
          o Use of bag /valve / mask devices (manual resuscitators)
          o Use of oxygen therapy in emergency care
     • Possess following skills relating to the circulation:
          o Peripheral intravenous (IV) cannulation
          o Central vein cannulation (preferred)
          o Defibrillation and synchronised cardioversion
     • Possess an understanding of current drug therapy for cardiac arrest
     • Possess an understanding of current treatments for peri-arrest arrhythmias
     • Be able to organise and co-ordinate the efforts of the cardiac arrest team
     • Understand the ethics of resuscitation, including “Do not attempt cardiopulmonary
        resuscitation” and “treatment limitation” decisions
     • Know and understand current Portsmouth Hospitals Trust policies relating to resuscitation:
          o Cardiopulmonary Resuscitation policy
          o Do not attempt cardiopulmonary resuscitation policy
     • Must possess good communication skills permitting the transfer of information to staff, the
        relatives of cardiac arrest victims and, where appropriate, the victims themselves.
     • Must complete a Cardiac Arrest Record Form for each cardiac arrest event
     • Must lead the organisation of the following
          o Post arrest investigations
          o Post arrest transfer to coronary care unit and critical care
          o Inter hospital transfer

     Team member (Airway & Breathing technician)
     • Must be able to recognise cardiac arrest
     • Must be able to provide basic life support
     • Must possess an understanding of the current RC (UK) guidelines for the treatment of
        cardiac arrest
     • Must possess basic and advanced airway management skills to include use of:
          o Simple airway opening manoeuvres
          o Oral and nasopharyngeal airway adjuncts
          o Laryngeal mask airway
          o Tracheal intubation, including the use of intravenous sedative and paralysing drugs
          o Suction of the upper and lower airway
     • Must possess following skills relating to breathing:
          o Use of pocket mask
          o Use of bag /valve / mask devices (manual resuscitators)
Cardiopulmonary Resuscitation         Issue 12 07 February 2012           Page 25 of 33
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           o Use of oxygen therapy in emergency care
     •   Must understand the ethics of resuscitation, including “Do not attempt cardiopulmonary
         resuscitation” and “treatment limitation” decisions
     •   Must know and understand current Portsmouth Hospitals Trust policies relating to
         resuscitation:
           o Cardiopulmonary Resuscitation policy
           o Do not attempt cardiopulmonary resuscitation policy
     •   Must possess good communication skills permitting the transfer of information to staff, the
         relatives of cardiac arrest victims and, where appropriate, the victims themselves.
     •   Must participate in the completion a Cardiac Arrest Record Form for each cardiac arrest
         event
     •   Must participate in the organisation of the following
           o Post arrest investigations
           o Post arrest transfer to coronary care unit and critical care
           o Inter hospital transfer

     Team member (Circulation technician)
     • Must be able to recognise cardiac arrest
     • Must be able to provide basic life support
     • Must possess an understanding of the current RC (UK) guidelines for the treatment of
        cardiac arrest
     • Must possess basic airway management skills to include use of:
          o Use of simple airway opening manoeuvres
          o Use of oral and nasopharyngeal airway adjuncts
          o Suction of the upper and lower airway
     • Must possess following skills relating to breathing:
          o Use of pocket mask
          o Use of bag /valve / mask devices (manual resuscitators)
          o Use of oxygen therapy in emergency care
     • Must possess following skills relating to the circulation:
          o Peripheral intravenous (IV) cannulation
          o Central vein cannulation (preferred)
          o Defibrillation and synchronised cardioversion
     • Must understand the ethics of resuscitation, including “Do not attempt cardiopulmonary
        resuscitation” and “treatment limitation” decisions
     • Must know and understand current Portsmouth Hospitals Trust policies relating to
        resuscitation:
          o Cardiopulmonary Resuscitation policy
          o Do not attempt cardiopulmonary resuscitation policy
     • Must possess good communication skills permitting the transfer of information to staff, the
        relatives of cardiac arrest victims and, where appropriate, the victims themselves.
     • Must participate in the completion a Cardiac Arrest Record Form for each cardiac arrest
        event
     • Must participate in the organisation of the following
          o Post arrest investigations
          o Post arrest transfer to coronary care unit and critical care
          o Inter hospital transfer

     1 other Team Member (assistant)
     • Must be able to recognise cardiac arrest
     • Must be able to provide basic life support
     • Must possess an understanding of the current RC (UK) guidelines for the treatment of
        cardiac arrest
     • Must possess basic and advanced airway management skills to include use of:
          o Use of simple airway opening manoeuvres
          o Use of oral and nasopharyngeal airway adjuncts
          o Suction of the upper and lower airway
     • Must possess ability to assist airway technician (see above)
     • Must possess following skills relating to breathing:
Cardiopulmonary Resuscitation         Issue 12 07 February 2012             Page 26 of 33
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           o Use of pocket mask
           o Use of bag /valve / mask devices (manual resuscitators)
           o Use of oxygen therapy in emergency care
     •   Must possess ability to assist circulation technician (see above)
     •   Must possess an understanding of current drug therapy for cardiac arrest
     •   Must understand the ethics of resuscitation, including “Do not attempt cardiopulmonary
         resuscitation” and “treatment limitation” decisions
     •   Must know and understand current Portsmouth Hospitals Trust policies relating to
         resuscitation:
           o Cardiopulmonary Resuscitation policy
           o Do not attempt cardiopulmonary resuscitation policy
     •   Must possess good communication skills permitting the transfer of information to staff, the
         relatives of cardiac arrest victims and, where appropriate, the victims themselves.
     •   Must participate in the completion of a Cardiac Arrest Record Form for each cardiac arrest
         event




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                                                                                  Appendix 5
     Queen Alexandra Site Cardiac Arrest Record Form




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                                                                                  Appendix 5 cont




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                                                                           Appendix 5 cont
                             Community Sites Cardiac Arrest Record Form




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                                                                           Appendix 5 cont

                       Community Sites Cardiac Arrest Record Form cont




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                                                                                               Appendix 6

                            Electrical equipment safety during defibrillation

     Electrical equipment safety during defibrillation is important for its effectiveness, the rescuers

     safety and to avoid potential damage to machinery.


     Electrical current predominantly takes the path of least resistance. During defibrillation the
     intended destination of the current is from one pad, through the thorax and the myocardium to
     the other pad. If another route is available, i.e. there is equipment attached to the patient, the
     current may follow that route. In addition, the intended current pathway can be disturbed by the
     presence of other devices connected to the patient.

     If aberrant pathways are taken this may lead to insufficient depolarisation of the myocardium
     and as a consequence defibrillation may not be successful.

     It is recommended that all equipment (For example ECG machines, IV pumps, haemodialysis
     machines etc) is disconnected from the patient receiving defibrillation, but this must not delay
     the shock being given.

     Medical equipment that has some degree of protection from defibrillation is marked with either
     of the bottom two symbols however it is still recommended that this equipment be detached for
     the reasons identified above.




     If medical equipment has been attached to the patient during defibrillation and you are

     concerned about it’s function, contact the Clinical Engineering Department for advice.




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                                                                                     Appendix 7
                 Defibrillation during renal replacement therapy using vascular access

       This guidance outlines the specialty specific actions to be taken by Health Care Professionals,
       should a patient have a cardiopulmonary arrest during haemodialysis (RRT) or any other renal
       replacement therapy using vascular access (RRT).
       This should be used in conjunction with the PHT Cardiopulmonary Resuscitation Policy (1), the
       Wessex Renal Transplant Service (WRTS) Access management for Haemodialysis (packs 1
       and 2) (2) and DCCQ Dialysis Catheter Care Guideline (3)

       RRT therapy and defibrillation treatment plan
       Immediately stop the fluid loss on the RRT machine and disconnect patient (2&3).
       Defibrillation must not be delayed by attempting to return the blood held in the extra corporeal
        circuit

       If the patient does not require defibrillation:
        Immediately stop the fluid loss on the RRT machine.
        Discontinue the RRT as soon as possible (2&3)

       Rationale
       1. Disconnection from RRT machine removes risk of aberrant current pathways & associated
       risks to staff, patient and machinery.
       2. Blood held in the extra corporeal circuit can be returned back to the patient (2&3).This
       process must not delay defibrillation.
       3. If blood is not returned, the patient may be affected by hypovolaemia. However this can be
       managed with fluid replacement therapy during the cardiac arrest.

       Care of Vascular access
       During the cardiac arrest maintain vascular access patency (2&3).
       Leave one lumen of the central venous catheter free for immediate use or leave a fistula
        needle in situ if no other iv access can be obtained.
       Ensure the lumen to be used is flushed with normal saline, clamped, and the end closed
        between uses.
       The lumen of the central venous catheter that is not used needs to be flushed and locked as
        per the Renal Standard Operating Procedure for the Medical Device Duralock – c (Trisodium
        citrate) Renal PGD’s .
       Ensure the fistula needle to be used is flushed and kept patent as per the Renal Patient
        Group Direction for Sodium Chloride Injection B 0.9% for flushing Renal PGD’s , then
        clamped and closed with a cap.

    Community Haemodialysis (HD)
    If the fistula needle is left in situ or the HD line lumen is being used as access, this must be
     handed over to the paramedic staff.
    A care sheet should be sent to the hospital to inform the staff looking after the patient.

       Continuing Care
       Continue Care as per Portsmouth Hospitals NHS Trust Cardiopulmonary Resuscitation Policy
        (including Anaphylaxis and Defibrillation) (1).

       References
       1. Current PHT Cardiopulmonary Resuscitation
       2. Wessex Renal Transplant Service (WRTS) Access management for Haemodialysis (packs 1
       and 2). Authors Sarah Kattenhorn & Siobhan Gladding (contact PHT Renal Unit).
       3. Current PHT DCCQ Dialysis Catheter Care Guideline DCCQ Dialysis Catheter Care
       Guideline.



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