document title resuscitation policy… · 10/6/2020 · cntw(c)01 cumbria northumberland, tyne and...

Document Title Resuscitation Policy

Reference Number CNTW(C)01

Lead Officer Medical Director

Author(s) (name and designation)

Kevin Crompton Physical Health Projects and Skills Advisor Dennis Davison Associate Director Dorothy Matthews Macmillan Clinical Nurse Specialist Palliative Care

Ratified by Business Delivery Group

Date ratified October 2020

Implementation Date

October 2020

Date of full implementation

October 2020

Review date October 2023

Version Number V06

Review and Amendment Log

Version Type of change

Date Description of change

This policy supersedes the following policy which must now be destroyed:

Reference Number Title

CNTW(C)01 – V05.3 Resuscitation Policy

CNTW(C)01

Cumbria Northumberland, Tyne and Wear, NHS Foundation Trust CNTW(C)01 – Resuscitation Policy – V06-Oct 2020

2

Resuscitation Policy

Section Resuscitation Policy Contents Page No:

1 Introduction 4

2 Purpose 4

3 Duties and Responsibilities 5

4 Abbreviations used within this Policy 6

5 Clinical cross-reference 7

6 Standardisation of equipment and standards 7

7 Frequency of checks 9

8 Equipment safety 10

9 Emergency drugs 10

10 ECT departments 12

11 Infection Prevention and Control 12

12 Moving and handling 13

13 Escalation of care 13

14 Training 14

15 Conveyance policies 17

16 References 18

17 Decision Making 19

18 Decisions relating to resuscitation 20

19 Decision Making Process 21

20 Communication with Service User 22

21 Information provided to Service Users 22

22 Responsibility for Decision Making 23

23 Involving Relatives 23

24 Confirmation by Consultant 24

25 Documentation of decision not to attempt resuscitation (DNACPR)

24

26 Time limitations of the decision not to attempt resuscitation (DNACPR)

25

27 Changing Circumstances 25

28 Communication to the Professionals 25

29 Transportation of service user with DNACPR decision form 26

30 Identification of Stakeholders 26

31 Equality and Diversity Impact Assessment 26

32 Implementation 27

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33 Monitoring Compliance – Please see Appendix C 27

34 Fair Blame 27

35 Associated Documents 27

36 Decision Making References 28

Standard Appendices attached to policy

A Equality Analysis Screening Tool 30

B Communication and Training Needs Information 32

C Monitoring and Audit Tool 34

D Policy Notification Record Sheet - click here

Appendices – listed separately to policy

Appendix No: Description

Appendix 1 Framework for decision making process

Appendix 2 DNACPR-Fillable Form

Appendix 3 Resuscitation record form

Appendix 4 DNACPR North East Ambulance Service Conveyance Policy

Appendix 4a North West Ambulance Service Conveyance Allocation and Utilisation of Resources Policy

Appendix 4b North West Ambulance Service Regional – Mental Health – Transportation – Protocol

Appendices 5a to 5h

Resuscitation Equipment CHECK LISTS

Appendix 5 a Resuscitation Equipment Standard Monitoring Tool-Action Sheet

Appendix 5 b Resuscitation Equipment Std Monitoring Tool Action Sheet

Appendix 5 c Automated External Defibrillator (AED) Daily checks

Appendix 5 d Suction Unit – Daily checks

Appendix 5 e Pulse Oximeter – Daily checks

Appendix 5 f Dinamap Vital Signs Monitor: Daily Checks

Appendix 5 g Cardiopulmonary Resuscitation Equipment List

Appendix 5h Naloxone Record Form

Appendix 6 Personal Protective Equipment (PPE) Guidance

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

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1 Introduction 1.1 The purpose of this policy is to provide clear guidance and standardisation of

approach for medical emergency response for all staff within Cumbria Northumberland, Tyne and Wear NHS Foundation Trust.

2 Purpose 2.1 This policy will ensure that all staff are trained and regularly updated to achieve a

level of clinical skills relating to resuscitation relevant to role and job description. The policy is designed to ensure a robust infrastructure across the Trust in response to medical emergencies and as such has implications with respect to Duty of Care, Training, Standards of Care, Risk Assessment and Clinical Governance.

2.2 Resuscitation Council UK’s (RCUK) guidelines guarantee that health and care

professionals across the UK share the same knowledge base surrounding teamwork and practice. However the RCUK allows for ‘local’ decision making as regards health organisation appreciation. It also recognises the infrastructure, training, equipment, clinical settings and ‘acute medical emergency experience’ may differ between different specialist NHS providers.

2.3 CNTW reflect the RCUK Guidelines 2015 and Quality Standards: Mental Health

Inpatient Care equipment and drug lists. Originally published May 2014. Last updated May 2020.

2.4 NICE has accredited the process used by Resuscitation Council UK to produce its Guidelines development Process Manual. Accreditation is valid for 5 years from March 2015. More information on accreditation can be viewed at https://www.nice.org.uk/about/what-we-do/accreditation. Accessed 27.10.2020

2.5 CNTW Trust aims to reflect the Resuscitation Council UK ‘Future Journey for 2020

and Beyond’, in establishing CPR and ‘Heart-start, first –responder and ‘Restart a Heart Events’ approach across the Trust’s many services within our shared community. ‘The Chain of Survival starts with bystander intervention. We need to share our passion for resuscitation with the public so that when they witness an emergency, they feel confident that they can help. We need to raise awareness of defibrillators in local communities, and ensure that people feel confident enough to use them. We need the UK - from the rural hamlets to the biggest cities - to come together and spread the word about why CPR education and emergency care planning can change lives. We also want to enhance the quality of care received by those who experience a cardiac arrest. They deserve physical and mental health treatment that matches the magnitude of what they’ve been through. Likewise, rescuers should receive better support after their attempts at saving a life’.

RCUK 01/01/2020

https://www.nice.org.uk/about/what-we-do/accreditation

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2.6 CNTW have already embarked on this ‘journey’ by incorporating AED Defibrillation in CPR and First Aid Training. Even where staff have no immediate access to an AED unit it is recognised they are part of the community in respect of their roles within CNTW and also as citizens in everyday life. They could be the one that accesses the community AED to help save a life.

2.7 CNTW also recognises any initiative that helps identify deteriorating health status

that could indicate life-threatening presentation is vitally important. As such, CNTW has implemented National initiative and developments in regards to clinical assessment tools such as Sepsis Assessment Tool, Communication Tools for escalation of care and the Nation Early Warning Score (NEWS-2). Further, CNTW has adapted the clinical response in order to reflect the specialist nature of our clinical care provision and promote robust clinical implementation.

3 Duties and responsibilities 3.1 CNTW Trust has a designated Resuscitation and Medical Emergencies Group

which in turn links directly to the Trust Business Development Group. This provides the duties of resuscitation services into their governance and clinical structures and reflects the following RCUK Standards:

CNTW has an identified Resuscitation service structure that has clearly defined terms of reference

Reflecting the duties on the Chief Executive as outlined in the Health Services Circular 2000/028, CNTW has non-executive clinical advisors to the board: Physical Projects and Skills Advisor though CNTW and Physical Skills Lead Trainer within CNTW Academy

The Resuscitation service structure has an associated authority’s management structure for clinical governance, clinical risk, quality improvement, education service, Policies and PGN’s

The Resuscitation service structure must also be responsible for implementing operational policies that govern prevention of cardiac arrest, including recognition of patients who are deteriorating before they arrest

The Resuscitation service structure must determine the level of resuscitation training required by staff members

Frequent meetings structure and ‘learning lessons’ 3.2 Healthcare organisations such as Cumbria, Northumberland, Tyne and Wear NHS

Foundation Trust have an obligation to provide a high-quality resuscitation service, and to ensure that staff are trained and updated regularly to a level of proficiency appropriate to each person’s expected role. This Resuscitation Policy is driven by the following documents:

Cardiopulmonary Resuscitation: standards for clinical practice and training (2016 / 2017 / 2018). https://www.resus.org.uk/search?search=training+standards accessed 27.10.2020

NHS Executive Health Services Circular 2000/028 Resuscitation Policy, Guidance for Mental health Trusts. Prevention of cardiac arrest and decisions about cardiopulmonary resuscitation. Resuscitation Guidelines 2015, Resuscitation Council (UK). http://www.resus.org.uk/resuscitation-guidelines/ accessed 27.10.2020

https://www.resus.org.uk/search?search=training+standardshttp://www.resus.org.uk/resuscitation-guidelines/

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3.3 The Chief Executive on behalf of the Trust retains ultimate accountability for the

health, safety and welfare of all service users, carers, staff and visitors; however key tasks and responsibilities will be delegated to individuals in accordance with the content of this policy.

3.4 Medical Director and Executive Director of Nursing and Operations are required

to:-

Ensure that all Medical and Nursing staff are aware of this policy and other policies and guidance which relate to this policy

Ensure that adequate training is given to allow medical and nursing staff to implement this policy safely

To inform Senior Management if the policy is not being implemented or adhered to in service areas / within the Trust

3.5 All staff are required to:-

Ensure that they are aware of the content of this policy and supporting policies

Ensure that they attend the appropriate level of training for their staff group on a yearly basis

Ensure that they abide by their governing bodies professional code of practice at all times

4 Abbreviations used in the policy

Basic Life Support (BLS)

Immediate Life Support (ILS)

Resuscitation and Medical Emergencies Group (RMEG)

Medical Devices Safety Management Group (MDAM)

The Medicines Optimisation Committee (MOC)

Physical Health and Wellbeing Group (PHW)

Prevention and Management of Violence and Aggression (PMVA)

Resuscitation Council UK (RCUK)

Automated External Defibrillators (AED)

Electro Convulsive Therapy (ECT)

Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)

Deciding Right (DR)

North East Ambulance Service (NEAS)

North West Ambulance Service (NWAS)

Public Health England (PHE)

Infection Prevention and Control (IPC)

Practice guidance Note (PGN)

National Early Warning System (NEWS-2)

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5 Clinical cross-reference 5.1 The Resuscitation Policy must be read in conjunction with and clinical use of the

following documents:

NEWS-2 National Early Warning Score (NEWS 2) AMPH-PGN-03 Part of CNTW(C)29 – Trust standard for the assessment and management of physical health policy

CNTW Communication Tool ‘SBAR’ Situation, Background, Assessment and Recommendation

Sepsis Assessment Tool – V02-Dr04 Sepsis AMPH-PGN-05 - part of NTW(C)29 – Trust standard for the assessment and management of physical health policy

Anaphylaxis Acute Management of Anaphylaxis – V01 RES- PGN–01 Part of CNTW(C)01- Resuscitation Policy

6 Standardisation of Equipment and standards

6.1 All resuscitation equipment will reflect Resuscitation Council UK 2015/2020 Guidelines

Quality standards for cardiopulmonary resuscitation practice and training. Within the document: CNTW reflect all guidance and recommendations as outlined in the RCUK document ‘Mental health - Inpatient care - equipment and drug lists’

6.2 The choice of all emergency equipment will be decided upon by the RMEG that must identify the clinical need and provide the clinical governance for implementation. The RMEG will link with Medical Devices Safety Management Group (MDAM) to establish clinical requirements and effective objective equipment choice.

6.3 It is the task of these groups to weigh up any clinical data, specifications sheets or

undertake equipment review and if required provide clinical evaluation papers for BDG consideration.

6.4 All Immediate Life Support (ILS) emergency resuscitation equipment will be

located within a red ‘grab bag’.

6.5 All Grab Bags should contain the following equipment: Oropharyngeal Airways size 2,3 & 4, CD Oxygen Cylinder, Non-re-breathe Oxygen Mask, Bag- valve-mask with Small, Medium and Large Airways.

6.6 CNTW standard states all areas that have grab-bag with CD oxygen cylinder, must have two extra ‘back-up’ cylinders available in the corresponding designated clinical area.

6.7 All Grab-bags will contain PPE: FFP3 Masks, Gloves, Aprons and Eye Protection, reflecting PHE and CNTW IPC Guidance, refer to Appendix 6 PPE Guidance

6.8 Suction unit will be located in the same designated location as the Grab-Bag.

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6.9 Additional supportive equipment: Pulse Oximeter, ECG Unit and Dinamap will be

clearly located at designated areas to enable effective and timely response to support physical health assessment.

6.10 All inpatient wards and any identified clinical care settings will have access to

CNTW approved Ligature Cutter. 6.11 The use of an AED should be attempted by all Trust staff but may be used with

minimal or no training. Further the RCUK advises that NHS Trusts should ensure that no restriction is placed on the use of an AED by an untrained NHS employee confronted with a patient in cardiac arrest when no more highly trained individual is present. The administration of a defibrillator shock should not be delayed whilst waiting for more highly trained personnel to arrive.

6.12 The AED’s will have standardised generic features that include: -

Ease of use

Automated functions

Voice prompted actions

Biphasic shock administration

Shock sequence in line with Resuscitation Guidance 2015

6.13 The following AED support equipment: scissors, razor, spare electrodes pads, spare battery (refer to local site arrangements) and manual will also be checked on a daily basis.

6.14 There should be immediate access to Stethoscope and Sharps Box at all designated locations.

6.15 All ILS equipment must be in good working order, have a valid expiry date where

indicated, therefore all items must be checked as indicated and immediately replenished following an incident / use.

6.16 Both Ward 31a and Yewdale Ward will retain the Crash Trolley with extended

resuscitation equipment: cardiac drugs, advanced airways, fluids/access, manual/AED and suction.

6.17 The Crash trolleys on both sites are the responsibility of the Acute Hospitals. 6.18 Both Ward 31a and Yewdale Ward will maintain daily and weekly checks as

identified through the respective acute hospital, through use of pictorial reference material and identified recording documentation.

6.19 Any trolley familiarisation or information must be accessed through the acute

hospital clinical education department and Resuscitation officer. 6.20 Local arrangements for re-stocking crash trolleys will continue. 6.21 Both 31a and Yewdale Wards will have independent access CNTW standard

Immediate Life Support Equipment.

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6.22 The Ward Manager or designated person is responsible for ensuring checks are

undertaken and the appropriate documentation is complete. 6.23 The Ward Manager or delegated other will also ensure that all staff have a clear

understanding of the equipment contained within the grab bag and how to use it. 6.24 Further equipment and drugs may be needed to manage other types of

emergencies that are likely to be encountered in a particular setting; this may include: monitoring equipment (e.g. blood pressure, pulse oximetry, temperature, 12-lead ECG recorder and near-patient tests (e.g. blood glucose).

6.25 Resuscitation equipment should be single-patient-use and latex-free, whenever

possible and appropriate. Where non-disposable equipment is used, a clear policy for decontamination after each use must be available and must be followed.

6.26 All equipment choices will be mediated through the RME, PHW and MDAM groups,

which will also identify and prioritise the location of Automated External Defibrillators (AED) Trust-wide, taking into consideration: -

Specialist treatment departments such as Electro Convulsive Therapy (ECT)

Inpatient services where there is a potential for physical interventions or rapid tranquillisation and seclusion

Locally identified medical risk factors

Area of high volumes of ‘throughput’ of people

6.27 The medical devices department will have a central record of where AED are located within the Trust.

6.28 All nursing and medical staff must have local induction medical emergency equipment location.

6.29 Medical emergency Equipment and response infrastructure will be identified in Junior Doctors medical education induction and ward-based ‘Local Induction’ using the medical mentor induction checklist.

7. Frequency of Checks 7.1 It is the responsibility of the Ward or unit Manager to ensure that the location of

equipment is clearly displayed, all staff are familiar with the location of equipment and that it is accessible at all times.

7.2 Equipment such as AED units, suction pulse oximeter and dinamaps, will be

checked daily as per Appendix 5 a to 5 f. 7.3 Grab-bag contents will be checked on weekly basis or following use. 7.4 Registered nurse or medic will be responsible for undertaking the checks but this

must be seen as an opportunity for all staff to facilitate familiarisation of grab-bag contents and support equipment.

7.5 All check must be rotated between shift day, night patterns and rotation of staff.

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8. Equipment Safety 8.1 All electrical equipment will be checked prior to distribution as recommended by

the Trust wide Resuscitation and Medical Emergencies Group and as per requirements of the Trust policies, CNTW(O)20 - Health and Safety and CNTW(C)21 – Medical Devices Specified within the Medical Devices Policy.

8.2 If staff notice equipment is damaged or has not been PAT tested they should liaise

with the Estates manager and remove the item from use until it is safe to use. 9 Emergency Drugs 9.1.1 Grab-bags will include:

Adrenaline (Epinephrine) 1:1000 1mg/1ml X Two ampoules with safety needles (23G 0.6 mm x 25 mm) in kit form. Syringe calibration will allow for accurate dose delivery from 150 mcg to 500 mcg.

Naloxone 2 milligrams/2 ml pre-filled syringe with one five safety needles in kit-form (For children’s services see point 9.3 below).

9.2 Adrenaline

9.2.1 Dose

CNTW Trust will reflect RCUK standards in dose identification (see appendix 1, 2

and 4).

18 years) – 500 micrograms

In specialised clinical settings the availability of dose range may vary but this must

be clinically led, an example is the specialist eating disorder unit which has both

300 mcg and 500 mcg to reflect low BMI presentation.

9.2.2 Adrenaline availability

If Adrenaline is used in any clinical setting it must be replaced as soon as

possible. It can be obtained by ordering from the Pharmacy Dept (in working

hours) or is available in emergency drugs cupboard (out of hours). If unsure

where stock is held, the Emergency Duty Pharmacist can be contacted via

switchboard.

CNTW have experienced difficulties with Emerade Auto-injector availability,

therefore Adrenaline ampoules have been provided as a temporary alternative

option.

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Refer to ‘Resuscitation Equipment Standard Monitoring Tool Appendix 5a’ and

PGN-01 Acute Management of Anaphylaxis

9.3 Naloxone

One pre-filled syringe will provide the potential of up to five doses of 400

micrograms for reversal of opiate overdose presentation.

Within Children’s services Naloxone will be available within secured locked

cabinets, due to special considerations in relation to opiate overdose

recognition, dose, potential side-effects and monitoring.

Currently intranasal naloxone is not available in CNTW emergency grab bags.

This is currently under review.

9.4 Emergency medications not contained in emergency grab bags

9.4.1 Glucagon

GlucaGen Hypokit (Glucagon) 1mg for the treatment of hypoglycaemia is

available to all wards as ward stock and in emergency drug cupboards across

the Trust.

Refer to PPT-PGN 06 Guidelines for the Safe Prescribing, Administration and

Monitoring of Insulin and oral anti-diabetic drugs for information on its usage.

9.4.2 Flumazenil

In the context of Rapid tranquilisation during COVID-19 – The National Association

of Psychiatric Intensive Care and Low Secure Units (NAPICU)

https://napicu.org.uk/wp-content/uploads/2020/04/NAPICU-

Guidance_rev3_10_Apr.pdf accessed 28.10.2020

Recommends that Flumazenil should be immediately available where

benzodiazepines are used, especially if used via the IM route. It has been

clinically identified that patients with COVID-19 will be more susceptible to

respiratory depression and are liable to become more acutely unwell quicker.

accessed 30-09-2020

12 Due to COVID-19 there may be an associated need for palliative care

medication, such as subcutaneous (SC) Midazolam. To enable effective SC

administration Midazolam is routinely supplied in its high strength formulation

(10 mg/2 ml). In 2008, a National Patient Safety Agency (NPSA) alert was

circulated about the possible risks of over sedation through miss-selection of

the higher-strength product over the lower-strength injection. One of the

mitigations recommended was that Flumazenil be available where Midazolam

is used and its use is regularly audited as a marker of excessive dosing.

This forms the basis of an NHS Never Event.

(https://improvement.nhs.uk/resources/never-events-policy-and-framework/)

accessed 27.10.2020

https://napicu.org.uk/wp-content/uploads/2020/04/NAPICU-Guidance_rev3_10_Apr.pdfhttps://napicu.org.uk/wp-content/uploads/2020/04/NAPICU-Guidance_rev3_10_Apr.pdfhttps://improvement.nhs.uk/resources/never-events-policy-and-framework/

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Therefore CNTW has made a temporary change the availability of Flumazenil

during the COVID-19 pandemic. Flumazenil will now be available all localities

that correspondingly stock high-strength Midazolam in the context of end-of-

life care. The locations will be identified by the Medicines Optimisation

Committee (MOC).

Following administration of Flumazenil, the patient should be monitored for an

adequate period of time based on the dose and duration of effect of the

benzodiazepine. This will include level of response, Electrocardiogram (ECG),

Pulse Oximetry, Heart Rate, Respiratory Rate and Blood Pressure.

The NEWS-2 observation tool will be used in all cases and Flumazenil should

only be used by staff competent in both its use and in the monitoring and care

of the patient following administration. CNTW Pharmacy will provide a

supportive information sheet, approved by MOC.

The RMEG and MOC will review all critical incidents where Flumazenil is used.

9.4.3 All other medication previously identified as emergency drugs will be kept as

standard ward stock and managed in the usual manner (see CNTW(C)17 -

Medicines Policy).

10. ECT Departments 10.1 ECT provision is provide through a Service Level Agreement and all practice will

reflect the National Electro-convulsive Therapy Accreditation Standards (ECTAS). 10.2 ECT Departments will have access to extended resuscitation equipment: cardiac

and anaesthetic drugs, advanced airways, fluids/access, manual/AED and suction. 10.3 Anaesthetists and ALS trained Doctors will be the only designated staff to operate

manual defibrillators situated within ECT Departments.

10.4 All CNTW staff involved in ECT will be trained to ILS level equipment and have access to supportive ILS standard equipment.

10.5 ECT nursing staff will complete ‘Recovery Training’ reflecting ECTAS Standards. 10.6 ECT Departments are the only areas within CNTW that will hold a stock of

Flumazenil for benzodiazepine reversal. This is only for use under the direction of an Anaesthetist.

11. Infection Prevention and Control 11.1 In all cases CNTW IPC guidance will be adhered to, reflecting the latest

Governmental and Public Health England Guidance on COVID-19, in relation to safe care delivery and use of personal protective equipment (PPE) refer to Appendix 6.

11.2 PPE equipment will be located with all medical emergency grab-bags as per

RCUK, PHE, Governmental and IPC guidance.

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11.3 Specific PPE guidance will be identified within Appendix 5 g and 6. 11.4 IPC and CNTW Academy will dynamically update clinical areas on any clinical

guidance changes independently of this policy. 11.5 It is mandatory training for all CNTW staff to attend and keep updated on all IPC

and PPE guidance. 12 Moving and Handling 12.1 CNTW will reflect external guidance from RCUK ‘Guidance for safer handling

during cardiopulmonary resuscitation in healthcare settings’ July 2015 (review 2020).

12.2 CNTW will reflect internal guidance from Health and Safety HS-PGN-02 Moving

and Handling. 13. Escalation of Care 13.1 CNTW has well established principles of early identification of deteriorating patient

with supported tools such which is cross-referenced with other clinical tools such as Sepsis Assessment.

13.2 As directed in appendix 4 and 4a escalation of care could be through General

Practitioner, which would include out of hours GP services. 13.3 Within HM Haverigg Prison this would include on-site GP provision during working

hours and Cumbria Health on Call (CHOC) Services out of hours. 13.4 Within in-patient hospital settings on call Doctor will be used. 13.5 If unable to contact GP services, on-Call Services or significant concern in

regarding deteriorating health, the 999 ambulance service will be used and response triaged.

13.6 Both the North West Ambulance Service (NWAS) and North East Ambulance

Service (NEAS) follow the NHS Ambulance Response Categorisation which is reflected in their respective conveyance and response documentation, which is located within Appendix 4 a and 4 b.

NHS Ambulance Response Categorisation:

Category four: Less urgent calls. In some instances you may be given advice over the telephone or referred to another service. Responded to at least 9/10 times

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Category one: Life-threatening injuries and illnesses. These will be responded to in an average time of 7 minutes

For further ambulance conveyance guidance, refer to;

North East Ambulance Service (NEAS) refer to CNTW(C)01 Appendix 4a Conveyance Policy

North West Ambulance Service (NWAS) refer to: CNTW(C)01 Appendix 4b Allocation and Utilisation of Resources and NWAS Regional Mental Health-Transportation-Protocol

13.7 Ward 31a Royal Victoria Infirmary Hospital Newcastle and Yewdale Ward, North

West Cumbria, Hospital Whitehaven, will utilise the on-call services and retain the 2222 medical emergency ‘Crash Team Response’ as agreed through local acute site service provision.

14 Training 14.1 The Trust will ensure that all staff have access to appropriate levels of training

compatible with their roles and responsibilities, it is the responsibility of each Group Director to ensure staff attend. Levels of training are identified in the training needs analysis available on the Trust Intranet page under the Training link. Training needs should be identified during annual Joint Development and Review (JDR): refer to the Trust’s policy CNTW(HR)09 – Staff Appraisal (non-medical) which includes Practice Guidance Notes (PGNs).

14.2 CNTW Trust make no distinction between registered and non-registered nursing

staff in terms of identified level of CPR training, which is only directed by clinical practice setting and associated role.

14.3 All training will be ratified through the RME group. 14.4 The RME group will provide lead advice and support. 14.5 All training provision through the CNTW Academy will reflect the

Resuscitation Council UK 2015 guidelines, update 2020 and include annual CPR training updates.

14.6 All staff are directed to maintain on-going awareness of emergency

equipment location and familiarisation. 14.7 Through the Prevention and Management of Violence and Aggression (PMVA)

programme (CPR delivery), all PMVA trainers will be recognised as ‘local’ support and advice in order for wards and department to maintain medical emergency response awareness. This also applies to stand alone CPR cascade trainers.

14.8 The following resuscitation training structure will be available within CNTW training

programme:

Medical emergency response awareness through Trust/local induction

Basic Life Support (BLS) Adult

Basic Life Support (BLS) Infant/Child

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Immediate Life Support (ILS) Adult

Paediatric Immediate Life Support (PILS)

14.9 There will also be unit/service user specific sessions available that combine the above such as Adult ILS with Infant/Child components.

14.10 CNTW recognise externally accredited Advanced Life Support (ALS) four year

qualification delivered by recognised Resuscitation Council UK training centre. 14.11 CNTW will reflect RCUK guidance and provide all junior Doctors with and ILS

awareness training session in order to provide familiarisation of: Medical Emergency Response (MER), infrastructure, ME Equipment and expected roles.

14.12 All medics on rotation into CNTW Trust will have the medical emergency response

covered within their induction process and clinical mentor check-list. 14.13 Although CNTW does recognise prior learning of medics within RCUK

resuscitation training programme, it is mandatory for them to attend an ILS update session to familiarise them with CNTW equipment and medical emergency response.

14.14 Basic Life Support (BLS) and Immediate Life Support (ILS) training requires annual

updates 14.15 It is mandatory for all medical staff to attend yearly CPR at ILS level. 14.16 The RCUK identifies that it is mandatory for all nursing staff to attend BLS training

as a minimum on an annual basis. The use of an AED should be attempted by all Trust staff, ideally following attendance at a face to face resuscitation course, however, may be used with minimal or no training. The Trust acknowledges the following statement from the Resuscitation Council (UK):

“The Resuscitation Council (UK) advises that NHS Trusts should ensure that no restriction is placed on the use of an AED by an untrained NHS employee confronted with a patient in cardiac arrest when no more highly trained individual is present. The administration of a defibrillator shock should not be delayed whilst waiting for more highly trained personnel to arrive. The same principle should apply to individuals whose period of qualification has expired. The COVID-19 Pandemic has impacted on all NHS training programmes and CNTW recognises concerns in relation to frequency and extended time periods for CPR updates and offers both support and reassurance. CNTW Training Academy offer non-classroom support through:

NHS and Health Education England e-learning training programmes in conjunction with National health Bodies

E-learning to ‘extended critical care skills’ in relation to potential Nightingale ward use: e-LfH is a Health Education England Programme

Online CNTW intranet resource material

NEWS-2 National Certificated Training and in-house Academy training programme

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Where classroom based training is delivered, this will reflect all PHE, National Governmental and CNTW IPC Guidance

Clinical support from all CPR Cascade Trainers 14.17 All nursing staff working within inpatient services where physical intervention, rapid

tranquillisation and seclusion could potentially be used must be trained to ILS level as part of their PMVA training. This will also include dangers of physical intervention/positional asphyxia and medical risk factors such as: Compartment Syndrome, Sickle Cell Anaemia, Pregnancy and relevant underlying medical conditions and drug use. PMVA training will also include use of pulse oximetry.

14.18 All nursing staff involved with Electro-Convulsive Therapy (ECT) will be trained in

ILS on a 6 monthly basis. The Trust will at all times aim to reflect the National Electro-convulsive therapy accreditation standards (ECTAS) CNTW(C)51-ECT-PGN-01 and 02.

14.19 All nursing staff working in areas that have known; associated or potential medical

risk factors will access training at ILS level. 14.20 Naloxone information that includes location details, dose and administration

protocol will be signposted in all Junior Doctors Induction and all CPR at Immediate Life Support Level.

14.21 Opiate overdose recognition and use of Naloxone awareness for Registered

Nurses will be provided through CNTW central resource material on ‘SharePoint’ as self-directed learning. It would also be expected that Registered Nurses will access local clinical information and self-directed literature and research on Opiate Overdose and appreciation of Naloxone as directed by NMC. Specific ‘in-house’ Information and guidance on opiate overdose and use of Naloxone will be provided within specialist addictions/drug and alcohol services.

14.22 Anaphylaxis is now available through e-learning in the form of two modules: Module 1 National ESR e-learning and assessment Module 2 CNTW ESR e-learning (following completion of module 1) 14.23 Anaphylaxis training is mandatory for all Registered Nurses and is updated three

yearly as a general awareness, yearly for ECT nurses, specialist treatment services and for staff administering vaccinations.

However individual staff can complete the e-learning programme as frequently as required in order to maintain on-going awareness.

14.24 All qualified staff involved in the potential use of rapid tranquillisation will adhere to

the Trust policy, CNTW(C)02 - Management of Rapid Tranquillisation and receive appropriate training.

14.25 The medical emergency number and procedures will be outlined during all the Resuscitation training sessions. 14.26 The medical emergency procedure and equipment location will be outlined in all

local ward or department induction.

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14.27 All flu vaccinators will receive annual updates in CPR (ILS), Anaphylaxis and specific vaccination training. Related to the area of practice all inpatient areas- Immediate life support level (ILS), Community specialist support such as pharmacy Basic Life support (BLS) Administration of Influenza Vaccine CNTW PGD 14.

14.28 Training records will be kept using both hard copy and computer based formats.

Paper based records will include:

Course attendance

Contents

Standards

Outcomes

Assessment

Evaluation (electronic)

14.29 Staff can identify training details by using the training matrix located on the Trust intranet on the Training link below.

14.30 Levels of training are identified in the CNTW training needs analysis and are included within the Training Guide.

15 Conveyance Policies 15.1 CNTW have worked collectively with North East Ambulance Service and North

West Ambulance Service in order to promote organisation appreciation and shared practice standards.

15.2 Both NEAS and NWAS are openly invited as core members of CNTW RMEG with

the aim of sharing good practice and ‘shared standards’. 15.3 Through the RMEG and PHWG any relevant cross-over developments or initiative

will be communicated to the NEAS and NWAS. 15.4 The NEAS and NWAS Conveyance Policies will be used in the respective Cumbria

and North East geographical locations and service provision (see appendices 4a & 4b).

15.5 Both organisations adhere to National NHS frameworks in relation to service

standards and ambulance response categorisation. 15.6 CNTW must be aware of geographical location and access to acute services

across the organisations and factor this into the respective service provision reflecting:

- Medical emergency response identification - 24/7 arrangements - Level of CPR training - Equipment access - Specific clinical risk factors

16. References

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National Early Warning Score (NEWS) 2 ‘Standardising the Assessment of Acute-illness Severity in the NHS’ December 2017

National Early Warning Score (NEWS) 2- ‘Update Report/Executive Summary and Recommendations December 2017

Resuscitation Council UK (RCUK) 2020 www.resus.org.uk accessed 27.10.2020

https://improvement.nhs.uk accessed 27.10.2020

Pharmacological PGN: Oxygen Use in Adults PGN NTW(C) m38 PPT-PGN-23

Rapid Tranquillisation Policy NTW(C) 02 and RT appendix 2 Monitoring Chart

National Electro-convulsive therapy accreditation standards (NECTAS) CNTW(C)51-ECT-PGN-01 and 02.

National e-learning training programme on NEWS-2:

https://news.ocbmedia.com/ accessed 27.10.2020

Cardiopulmonary Resuscitation: standards for clinical practice and training (2016 / 2017 / 2018). https://www.resus.org.uk/library/quality-standards-cpr/mental-health-inpatient-care accessed 27.10.2020

Assessment and Management of Physical Health Policy NTW (C) 29

NTW’s Sepsis Assessment Tool (PGN-05-NTW (C) 29

PPT-PGN- NTW 15 Appendix 4 Fluid Balance Chart

PGN–PPT-23, part of NTW(C)38 Pharmacological Therapy Policy Pharmacological Therapy Policy, Oxygen use in Adult

https://www.youtube.com/watch?v=ujHhqTbS1xg – accessed 27.10.2020

NHS Improvement, July 2016. Patient Safety Alert: Supporting safer care where patients are deteriorating (adults and children)

https://napicu.org.uk - accessed 27.10.2020

(https://improvement.nhs.uk/resources/never-events-policy-and-framework/) – accessed 27.10.2020

Royal College of Physicians, December 2017. National Early Warning Score (NEWS) 2 https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 - accessed 27.10.2020

NHS Improvement, July 2016. Resources for the detection and management of deterioration in adult patients

http://www.resus.org.uk/https://improvement.nhs.uk/https://news.ocbmedia.com/https://www.resus.org.uk/library/quality-standards-cpr/mental-health-inpatient-carehttps://www.resus.org.uk/library/quality-standards-cpr/mental-health-inpatient-carehttps://www.youtube.com/watch?v=ujHhqTbS1xghttps://napicu.org.uk/https://improvement.nhs.uk/resources/never-events-policy-and-framework/https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

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https://improvement.nhs.uk/resources/detection-and-management-deterioration-adult-patients/ - accessed 27.10.2020

Patient Safety Collaborative https://improvement.nhs.uk/resources/patient-safety-collaboratives/ -accessed 27.10.2020

www.survivingsepsis.org -accessed 27.10.2020

https://sepsistrust.org – accessed 27.10.2020

https://www.nice.org.uk – accessed 27.10.2020

https://www.nice.org.uk/about/what-we-do/accreditation accessed 27.10.2020

https://www.gov.uk – accessed 27.10.2020

https://www.rcplondon.ac.uk/news/news2-and-deterioration-covid-19 accessed 27.10.2020

Health and Safety HS-PGN-02 Moving and Handling

17 Decision Making

17.1 The Department of Health states:

“It is a general legal and ethical principle that valid consent must be obtained before starting treatment, physical investigation or providing personal care” This principle reflects the right of patients to determine what happens to their own bodies, and is a fundamental part of good practice (DOH).

17.2 All patients/clients have a right to receive accurate information about their condition and intended treatment. It is the responsibility of individual practitioner proposing to carry out the treatment to ensure that the patient/client understands what is proposed (NMC 2015 and Updated 10 October 2018).

17.3 This policy also reflects principles under the Human Rights Act 1998 with particular

reference to:

Article 5: The right to liberty and security of person

Article 8: The right to privacy

Article 10: Confidentiality

17.4 The term “consent” refers to the service user’s agreement for a health professional to provide care, or agreement to participate in education or research. Service users may indicate consent non-verbally, orally or in writing. Consent will need to be gained for the procedure, research and any educational/supervisory purpose.

17.5 For the consent to be valid the service user must have capacity to make that particular decision. The Mental Capacity Act 2005 details assessment of capacity and best interest decisions. The service user should firstly be assumed as having

https://improvement.nhs.uk/resources/detection-and-management-deterioration-adult-patients/https://improvement.nhs.uk/resources/detection-and-management-deterioration-adult-patients/https://improvement.nhs.uk/resources/patient-safety-collaboratives/http://www.survivingsepsis.org/https://sepsistrust.org/https://www.nice.org.uk/https://www.nice.org.uk/about/what-we-do/accreditationhttps://www.gov.uk/https://www.rcplondon.ac.uk/news/news2-and-deterioration-covid-19

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capacity to make decisions if the person’s capacity is in question an assessment must be carried out and documented. A person is unable to make a decision for themselves if they are unable to:

Understand the information relevant to the decision

Retain that information

Use or weigh that information as part of the process of making the decision

Communicate their decision (Either verbally, using sign language or by any other means)

17.6 If a person does not have the capacity to consent to this procedure a ‘best interests’ decision must be made by the person carrying out the procedure. This must consider any advanced decision or advanced statement made by the person. Any decision must be in the best interests of the service user and follow the principles of the least restrictive option possible. Best interest decision must also be documented. For further advice on consent/capacity please consult the Trust policy, CNTW(C) 05 - Consent to Examination or Treatment.

18. Decisions relating to resuscitation

The Trust will adopt the principles of the 2016 guidelines from the British Medical Association, Resuscitation Council and Royal College of Nursing: October 2014

18.1 Decisions about CPR must be made on the basis of an individual assessment of

each patient’s case and documented evidence of best interests / DNACPR must be available, in the absence of any DNACPR documents the patient must receive CPR to preserve life as outlined in Professional Governing Bodies Guidance.

It is not the sole decision of the responder either not to commence CPR or to end

CPR they must commence and continue CPR until guidance / support is received from emergency services.

18.2 Advance care planning, including making decisions about CPR, is an important

part of good clinical care for those at risk of cardiorespiratory arrest.

18.3 Communication and the provision of information are essential parts of good quality & informed care.

18.4 It is not necessary to initiate discussion about CPR with patients if there is no reason to believe that a patient is likely to suffer a cardiorespiratory arrest.

18.5 Where no explicit decision has been made in advance there should be an initial

presumption in favour of CPR.

18.6 Where the expected benefit of attempted CPR may be outweighed by the burdens, the patient’s informed views are of paramount importance. If the patient lacks capacity those close to the patient should be involved in discussions to explore the patient’s wishes, feelings, beliefs and values using the Best Interests process of the Mental Capacity Act.

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18.7 If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and applicable advance decision refusing CPR, this should be respected.

18.8 A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision does not override clinical judgement in the unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged.

18.9 DNACPR decisions apply only to CPR and not to any other aspects of treatment. 19 Decision making process

Making a CPR decision v60 Adapted from: 2014 BMA/RC/RCN Joint Statement on CPR; Clinical Medicine, 2005; 5: 354-60; and A Guide to Symptom Relief in Palliative Care, 6th edition Radcliffe Medical Press, 2010.

"All DNACPR forms can be accessed via the following link; the original version

should be used as photocopies cannot be accepted by the conveying ambulance service for example the North East Ambulance services (NEAS)"

www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/ - accessed 27.10.2020

19.1 Consequences of the guidelines:

A professional’s decision about future CPR should not be influenced by poorly informed or unfounded assumptions about the impact of a disability, advanced age or the patients presumed quality of life.

Teams or departments should not be routinely assessing CPR status in all patients

The only patients who should be asked to consent for CPR are those who have the capacity for this decision and in whom a cardiac or respiratory arrest is anticipated and in whom CPR could be successful

In the absence of a CPR decision, there is an initial presumption in favour of CPR.

A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) does not override clinical judgement if the health professional believes the arrest is from reversible causes. However, for this to work, the circumstances of the anticipated arrest must be clearly documented

A bedside assessment of the circumstances is essential, even if a CPR decision is in place and regardless of whether it is for CPR or DNACPR. Putting CPR decisions in place to avoid such an assessment is no longer appropriate

If an arrest is anticipated and CPR could be successful the patient must be asked for consent regarding CPR. If the patient wants this, CPR must be given in the event of an arrest even if the clinical team believe the burdens will outweigh the benefits

http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/

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19.2 Decisions Relating to CPR Issues for Consideration: Children and Young People

The advice on CPR decisions in Section 9 applies to children and adults. In addition:

In England, Wales and Northern Ireland, consent to from a person with parental responsibility or a court may override a competent young service user’s decision

Where there is serious disagreement between the family and health team, legal advice should be sought.

20 Communication with the service user 20.1 Obtaining consent about CPR is a very intricate process and requires effective

communication and discussions need to be planned and considered. Only a small minority of Trust patients will have consented for CPR but all should receive effective communication, which may include a sensitive discussion about CPR if this is what they wish.

This may arise as part of the general discussion regarding service user’s care,

however, information should not be forced on an unwilling recipient or if they indicate that they do not wish to discuss such an issue

20.2 Discussions regarding the advisability or otherwise of attempting CPR are highly sensitive, individualised and complex and should be undertaken by senior, experienced members of the medical team, supported by the senior member of the nursing team.

21 Information provided to service users 21.1 Written information regarding resuscitation policies should be included in general

literature provided within healthcare establishments. The purpose is to demystify the process by which decisions are made and should be seen as part of advance care planning.

Such information should reassure the service user of their part in the decision

making process and should make it clear that for most service users, the question may not arise. Such information must be handled sensitively with an appreciation of the individual’s health status and capacity to understand.

21.2 The Trust will adopt the principles of the Planning for Your Future Care - A Guide

NHS Improving Quality (2014). This outlines “What is Advance Care Planning”. It will be the responsibility of the senior nurse or lead practitioner to order and

locate this information within their respective areas. 21.3 The views of all members of the medical and nursing team including those involved

in the service user’s primary care and people close to the service user are valuable in forming the decision. In all cases, there must be due regard to service user confidentiality. Once made, all decisions must be communicated effectively to the relevant professional.

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21.4 Involving the individual with capacity is the default when making CPR decisions. This applies even if CPR cannot work. However, this information must be delivered as part of a shared dialogue over time. For individuals who lack capacity for this decision, their opinion and that of any parent, partner or family are key to the Mental Capacity Act best interest process.

22 Responsibility for decision making 22.1 In an adult without capacity for CPR decisions, the overall responsibility for

decision-making in relation to CPR and DNACPR orders rests with the Responsible Clinician in charge of the service user’s care. He or she should be prepared always to discuss the decisions for an individual with other healthcare professionals involved in the service user’s care.

The importance of teamwork and good communication is paramount at all times

and must reflect the service user’s wishes. Where care is shared such as between hospital and general practice, the doctors involved should discuss the issue with each other, and with other members of the healthcare team.

22.2 Healthcare professionals must use their best judgement bearing in mind the

clinical condition of the individual service user. Such decisions must be based on reliable up-to-date clinical guidelines.

22.3 Any decision must be made on an individual service user basis and reflect the

Human Rights Act and guidance within governing bodies codes of conduct. 23 Involving relatives 23.1 Subject to the wishes of the service user who has the right to confidentiality,

medical staff will take reasonable steps to inform partners or relatives when decisions to not resuscitate are contemplated or have been made. In the case of children, the parents would be part of the decision-making process.

23.2 Doctors have the authority to act in their service user’s best interest where consent

is unavailable. Unless to do so would be contrary to the service user’s interest, people close to the service user should be kept informed about the service user’s health and be involved in the decision making in order to reflect the service user’s views and preferences.

It should be made clear that their role is not to make decisions on behalf of the

service user. Relatives and others close to the service user should be assured that their views on what the service user would want will be taken into account in the decision-making, but they cannot insist on treatment or non-treatment. Further guidance can be found within the National Council for Palliative Care and Dying Matters Good Decision Making document (2017)

23.3 The Mental Capacity Act requires a specific process to decide a person’s best

interests: - MCA2 Record of actions taken to make a best interest decision http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-

forms / -accessed 27.10.2020

Appoint a decision maker (usually after an interdisciplinary team discussion) who should consider the following as a minimum:

http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms%20/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms%20/

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Is an IMCA needed for a person aged 16yrs or more? If there is no one who knows the individual well, you must consider instructing an Independent Mental Capacity Advocate (IMCA) and receive a report from an IMCA. However this must not delay urgent treatment

Have you avoided making assumptions merely on the basis of the individual’s age, appearance, condition or behaviour?

Have you identified all the things the individual would have taken into account when making the decisions for them? Consider that the individual may have a ADRT or Advance Care Plan made when they had capacity

Have you considered if the individual is likely to have capacity at some date in the future and if the decision can be delayed until that time?

Have you done whatever is possible to permit and encourage the individual to take part in making the decision?

Where the decision relates to life sustaining treatment, have you ensured that the decision has not been motivated in any way by a desire to bring about their death?

Has consideration been given to the least restrictive options for the individuals including restricting their rights?

Consult others (within the limits of confidentiality) this may include an LPA, IMCA or Court Appointed Deputy as well as factors such as emotional bonds, family obligations that the person would be likely to consider if they were making the decision?

Having considered all the relevant circumstances, weigh up all factors in order to inform the decision/action to be taken in the best interests of the individual

24 Confirmation by consultant 24.1 The decision to not attempt resuscitation will be discussed at the next available

opportunity with the Responsible Clinician in charge of the service user’s care, those Involved in the discussions will also include the service user (if possible), the service user’s family, MDT and any other relevant persons. Once again, the aim is to make decisions in advance and where this has not occurred, there will be an initial presumption in favour of resuscitation

25 Documentation of decision not to attempt resuscitation (DNACPR) 25.1 This will be recorded on the DNACPR form developed within the Deciding Right

regional guidance which has been adopted by CNTW. 25.2 NEAS can apply a flag to a patient record indicating an advanced care decision is

in place via the Special Patient Note Form which must be completed electronically and sent by email to [email protected]

Paramedic crews will be informed by the control centre of the decision. 25.3 The forms within the link:

http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-

forms/ cannot be photocopied and the original document must always stay with the patient irrespective of their care setting. Accessed 27.10.2020

mailto:[email protected]://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/

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25.4 In the North West the Electronic Referral Information Sharing System (ERISS) is available for all health & social care professionals. The facility to add an alert regarding care plans or medical conditions of patients including palliative / end of life care information is available at: https://www.nwas.nhs.uk/ accessed 27.10.2020

25.5 In addition to completing the DNACPR decision document, the details of the proposed plan in the event of a cardiac arrest will be written within service user’s notes (paper or electronic record) along with reasons that led to the decision. In addition, a record of contact with and the explanation given to relatives will also be made within the notes. The nurses must be kept informed of all decisions and ensure that the decisions made are recorded accordingly.

26 Time limitations of the decision not to attempt resuscitation (DNACPR) 26.1 The DNACPR decision will usually only apply for a specific period and must be

reviewed:

If the individual requests a review of the decision

To reflect change in the individual’s condition

Any change in care setting

Within 12 months if not reviewed earlier

Review of the decision will not be needed when death is seen as inevitable

27 Changing circumstances 27.1 A significant change in a service user’s condition will prompt a review of the

planned use of CPR. Also, other circumstances i.e. invasive procedures, anaesthesia or surgery may require that treatment, including CPR can be given. Any changes to status or within the decision-making process may require a review of the CPR decision –

See http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms - accessed 27.10.2020-

28 Communication to professionals 28.1 It is very important that once a CPR decision has been made that this is effectively

communicated to the relevant professionals involved in the individuals care. 28.2 The Responsible Clinician in charge of the service user’s care making the decision

will verbally inform the Nurse in Charge of the decision and make reference to the service user’s notes where the treatment plan is recorded and the status form completed.

28.3 The Nurse in Charge will be responsible for ensuring that all nurses caring for the

service user are made aware of the decision and of any documents in place regarding this. This could be communicated at handover time(s) with a suitable entry being made in the service user’s notes accordingly.

.

https://www.nwas.nhs.uk/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-formshttp://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms

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If there is no DNACPR form or no evidence regarding a CPR decision the service user concerned will be resuscitated.

29 Transportation of service user with DNACPR decision form

29.1 Staff organising transportation of those service users with a DNACPR order must follow the policy of the North East Ambulance Service (NEAS) on transportation (Appendix 4 – North East Ambulance Service NHS Trust - Do Not Attempt Resuscitation (NEAS) Conveyance Policy. See link below for ‘Referral form’, which is linked to Northern England Strategic Clinical Networks – scroll down to NEAS and click on ‘NEAS-Deciding right flag referral’- Special patient note form (SPN Form): http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/ accessed 27.10.2020

30 Identification of stakeholders

30.1 This is an existing policy which has undergone an early review due to major changes that relate to operational and / or clinical practice and has therefore been circulated to the following for a two week consultation period

North Locality Care Group

Central Locality Care Group

South Locality Care Group

Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

CNTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

Health Safety Security and Resilience

31 Equality and diversity impact assessment 31.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has

undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. (See Appendix A)

32 Implementation

32.1 This will be implemented immediately and monitored by the SSMDRG for quality and safety during the review process. If at any stage there is an indication that the

http://www.nescn.nhs.uk/wp-content/uploads/2014/06/NEAS-Deciding-Right-Flag-Referral-v1-3.pdfhttp://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/

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target date cannot be met, then the SSMDRG will consider the implementation of an action plan.

33 Monitoring compliance – Please see Appendix C 33.1 The Resuscitation Council guidance states that each hospital will have a

Resuscitation Committee that meets on a regular basis. The Trust wide RME will take on this role within this Trust. The person taking the lead for resuscitation on behalf of the group will be the identified lead trainer for Cardio-pulmonary Resuscitation (CPR) who will provide advice as required.

33.2 The RME will provide the Quality and Performance Committee with assurances in the following areas: -

Developing and maintaining standards

Ensuring policies and procedures are in place and communicated to the relevant people

Establishing clear lines of accountability in the procurement and maintenance of equipment

Ensuring an appropriate programme of training is in place for relevant staff

Monitoring the implementation of relevant NICE guidelines

Ensuring appropriate actions occur in response to alerts

Reviewing significant incidents reported via the CNTW(O)05 – Incident Policy and ensuring appropriate action is taken

Decontamination of Medical Devices

33.3 The SSMDRG membership will include representation from the Board of Directors as Chair of the group and will include as well as medical, nursing, pharmacy, practice development, training, clinical risk, patient safety/health and safety representatives as well as Trust wide representation that reflect specialist fields.

33.4 Monitoring and reviewing of training will be done in line with the Resuscitation

Council National Guidelines. 34 Fair blame

34.1 The Trust is committed to developing an open learning culture. It has endorsed

the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

35 Associated documentation CNTW(C)02 Management of Rapid Tranquillisation Policy

CNTW(C)10 Seclusion Policy

CNTW(C)16 Recognition, Prevention and Management of Aggression and

Violence Policy

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CNTW(C)17 Medicine Management Policy

CNTW(C)21 Medical Devices Policy and Practice Guidance Notes

CNTW(C)23 Infection, Prevention and Control Policy; Practice Guidance Notes

CNTW(C)38 Pharmacological Therapy Policy, practice guidance note

PPT-PGN-13 – Acute Management of Anaphylaxis

CNTW (C)49 Care of the Dying – End of Life Policy

CNTW (C)40 Dignity in Care V3 Policy

CNTW(O)01 Development and Management of Procedural Documents Policy

CNTW(O)05 Incident Reporting Policy

CNTW(O)20 Health and Safety Policy, Practice Guidance Notes

CNTW(HR)09 Staff Appraisal Policy

36 References

British Medical Association. The Impact of the Human Rights Act (1998) on Medical Decision-Making: London BMA October 2000

British Medical Association Medical Ethics Department: https://www.bma.org.uk/advice-and-support/ethics - accessed 27.10.2020 Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing (previously known as the ‘Joint Statement’) Decisions relating to cardiopulmonary resuscitation 3rd edition (1st revision) 2016

MCA2 Record of actions taken to make a best interest decision http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional- forms/ accessed 27.10.2020

NHS Improving quality: Planning for your future care - A Guide: September 2014 https://www.nhs.uk/Livewell/Endoflifecare/Documents/Planning_your_future_care%5B1%5D.pdf accessed 27.10.2020

NHS Executive. Resuscitation Policy (HSC 2000/028). London: Department of Health, September 2000. Scottish Executive Health Department Resuscitation Policy (HDL 2000) 22: Edinburgh: Scottish Executive: November 2000.

NHS North East Deciding Right An integrated approach to shared decision making in children, young people and adults. (2012) http://www.northerncanceralliance.nhs.uk/deciding-right/ - accessed 27.10.2020

North of England Strategic Clinical Networks – Regional Forms http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/ accessed 27.10.2020

Making a CPR decision v60 Adapted from: 2013 BMA/RC/RCN Joint Statement on CPR; Clinical Medicine, 2005; 5: 354-60; and A Guide to Symptom Relief in Palliative Care, 6th ed Radcliffe Medical Press, 2010.

Resuscitation Council (UK). Standards for Clinical Practice and Training, updated version: Updated May 2020. https://www.resus.org.uk/library/quality-standards-cpr/mental-health-inpatient-care accessed 27.10.2020

Royal College of Nursing. www.rcn.org.uk accessed 27.10.2020

The National Council for Palliative Care and Dying Matters: Good Decision Making, What you need to know about the Mental Capacity Act and end of life

care. Second edition (2017)

https://www.bma.org.uk/advice-and-support/ethicshttp://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-%20%20%20forms/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-%20%20%20forms/https://www.nhs.uk/Livewell/Endoflifecare/Documents/Planning_your_future_care%5B1%5D.pdfhttps://www.nhs.uk/Livewell/Endoflifecare/Documents/Planning_your_future_care%5B1%5D.pdfhttp://www.northerncanceralliance.nhs.uk/deciding-right/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/http://www.northerncanceralliance.nhs.uk/deciding-right/deciding-right-regional-forms/https://www.resus.org.uk/library/quality-standards-cpr/mental-health-inpatient-carehttps://www.resus.org.uk/library/quality-standards-cpr/mental-health-inpatient-carehttp://www.rcn.org.uk/

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Christopher Rowlands October 2020 October 2023 Trust wide

Policy to be analysed Is this policy new or existing?

Policy or Service to be Assessed Resuscitation – V06

Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

The purpose of this policy is to provide clear guidance on emergency response for all staff.

Who will be affected? Staff, service users, carers, wider public.

Staff, Service Users, carers and wider public

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability NA

Sex NA

Race NA

Age NA

Gender reassignment

(including transgender)

NA

Sexual orientation. NA

Religion or belief NA

Marriage and Civil Partnership

NA

Pregnancy and maternity

NA

Carers NA

Other identified groups NA

How have you engaged stakeholders in gathering evidence or testing the evidence available?

NA

How have you engaged stakeholders in testing the policy or programme proposals?

NA

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For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

NA

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

NA

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

NA

Advance equality of opportunity NA

Promote good relations between groups NA

What is the overall impact?

NA

Addressing the impact on equalities NA

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Chris Rowlands Date: October 2020

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing Policy update

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

Yes (please see section 14 Training)

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Solutions etc.

Please identify the risks if training does not occur

National Guidance linked to Immediate Life Support

Resuscitation Council UK Guidance

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

As per Training Needs Analysis

Is there a staff group that should be prioritised for this training / awareness?

As per Training Needs Analysis

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Face to Face by specialist clinical trainers (Please see section 14 Training)

Please identify a link person who will liaise with the CNTW Academy to arrange details for the Trust Training Prospectus, Administration needs etc.

Kevin Crompton/Marc House

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group Type of training

Duration of

Training

Frequency of Training

Nursing, Medical, allied professionals and has implications for all CNTW employees

Targeted through training needs analysis

Depending on role and level of identified training.

E-learning

Interactive Resuscitation Council UK (RCUK) Training

CNTW Intranet training and support material

Cascade clinical support

Practical Assessment Training

Initial and update mandatory training (depending on clinical or non-clinical role and respective training needs analysis)

On-going with self –direction and through clinical supervision

Practical 1.5-3 hours

6-12 months

Reflecting current COVID-19 pandemic Public Health England guidance

RCUK Guidance

CNTW Infection Prevention and Control guidance on training delivery

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Appendix C

Monitoring Tool Statement

The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(C)01 – Resuscitation Policy - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1 Ward/department/unit can demonstrate that staff access Cardio-Pulmonary Resuscitation (CPR) training and this is compatible with the training level for their area as outlined in the Resuscitation Policy.

In line with individual JDR requirements, Team Managers will check Dashboards to ensure staff that they have responsibility for are appropriately trained

The resuscitation and medical devices group will annually review dashboard data to ensure compliance.

Individual Supervision and Performance Management as per Trust Policy – CNTW(HR)04 – Disciplinary.

Gaps in compliance will be reported to core group quality and performance groups for development of action plan which will be monitored via the quality and performance core groups and the resuscitation and medical devices group.

2 Equipment is compatible with expected roles and this equates with the level identified in the Resuscitation Policy for their area.

Weekly checklist (App5a) completed by nominated qualified nurse via the Ward Manager

Any concerns would be immediately managed and escalated through line management, if appropriate via Risk Register

3 All policy documentation is utilised, including: DNAR and resuscitation record forms in decisions relating to resuscitation

As required via a review of the clinical record by the Clinical Nurse manager

Monitored via individual supervision and Group Quality and Performance Committees

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.