resuscitation policy version: status: guideline … policy... · september 2014 . last review date...

RESUSCITATION POLICY

Guideline Reference: SCH Serco CP35 Version: 2.1 Status: Approved Type: Clinical Guideline applies to : All services within SCH Guideline applies to (Staff Groups): All staff

Required compliance: This policy must be complied with fully at all times by the appropriate staff. Where it is found that this policy cannot be complied with fully, this must be notified immediately to the owner through the waiver process

Guideline owner: Director of Nursing, Therapies and Governance Guideline authors: SCH Resuscitation Committee Other contact:

Clinical Quality & Safety Assurance Group

Date this version adopted September 2014 Last review date July 2014 Next review date September 2017 Location of electronic master SCH Intranet AGREED GUIDELINE REVIEW / RATIFICATION / ADOPTION PATH: Level 1: Agreed by: Resuscitation Committee Date: 8/7/14

Level 2: Agreed by: Clinical Policy Group Date: 29/7/14

Level 3: Agreed by: Clinical Quality & Safety Assurance Group Date: 23/9/14

S/Internal/ResuscitationPolicy/Sept14/V2.1

Contents

1. Introduction 1

2. Purpose of this Clinical Policy 1

3. Policy Agreement Path 1

4. Ethical and Legal Issues 1

5. Resuscitation Guidelines 1

6. Definitions 2

7. Defibrillation 2

8. Anaphylaxis 3

9. Paediatric Resuscitation 4

10. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order 4

11. Pacemakers and Implantable Cardioverter Defibrillators (ICDs) 4

12. Equipment Requirements and Maintenance 5

13. Training and Education 6

14. Reporting Resuscitation Episodes/ Documentation and Audit 6

15. Post-resuscitation Care 6

16. Manual Handling 7

17. Infection Control 7

18. Emergency Numbers 7

19. Glossary of terms 7

20. Cross Reference to related SCH and other Polices/ Guidelines 7

APPENDIX 1: UK Resuscitation Council Guidelines Algorithms: 8

1a: Chain of Survival Flowchart 8

1b: Adult Basic Life Support Flowchart 9

1c: Adult AED Algorithm 10

1d: Adult Choking Treatment Algorithm 11

1e: Paediatric Basic Life Support Algorithm 12

1f: In-hospital Resuscitation Algorithm 13

1g: Anaphylaxis Algorhithm 14

APPENDIX 2: Medical Emergency Report Form 17

APPENDIX 3: Standard Resuscitation Trolley/ Grab Bag Contents 19

APPENDIX 4: Required Levels of Life Support Training for SCH staff and availability of equipment 21

APPENDIX 5: Resuscitation Trolley Drugs and Equipment Audit Tool 22

APPENDIX 6: DNACPR Summary Decision Making Framework 24

S/Internal/ResuscitationPolicy/Sept14/V2.1

RESUSCITATION POLICY

STATEMENT OF OVERARCHING PRINCIPLES All Policies, Policy and Guidelines of Suffolk Community Healthcare are formulated to comply with the overarching requirements of legislation, policies or other standards relating to quality and diversity.

1. Introduction

1.1. The Resuscitation Policy fully supports the recommendations for clinical practice and training in cardiopulmonary resuscitation (CPR) published by the Resuscitation Council UK (RCUK) Guidelines (2010).

2. Purpose of this Clinical Policy

2.1. The purpose of this policy is to provide direction, guidance and information for staff about resuscitation within Suffolk Community Healthcare (SCH) premises and in patient’s homes. This will consequently ensure that in all circumstances of deterioration/ collapse of a patient, visitor or staff member the response is rapid and competent.

3. Policy Agreement Path

3.1. Refer to front sheet for policy agreement path.

4. Ethical and Legal Issues

4.1. Cardiopulmonary resuscitation (CPR) should ideally be targeted at those individuals who are likely to benefit. If a health care professional accepts duty of care for a patient, within their normal duty to work, then the patient has a right to expect a reasonable standard of resuscitation should the need arise.

4.2. Health care professionals within their official capacity have an obligation to initiate and perform CPR when indicated, in the absence of a DNACPR order.

4.3. The Resuscitation Council (UK) has standard guidelines which are evidence based. All SCH staff are required to administer resuscitation, to the level they are trained at, on SCH premises/ land and patients’ homes. They are required to administer resuscitation outside of work should their professional membership expect them to do so, e.g. The NMC.

4.4. In order to avoid resuscitating inappropriate patients (i.e. those who will have no chance of surviving or where it is futile), CPR status should be identified for all patients on admission to the community hospitals and when onto the caseload in the community

5. Resuscitation Guidelines

5.1. All resuscitation attempts should follow the current UK Resuscitation Council Protocols (shown as Appendices 1a – 1e)

5.2. Glossary of terms and abbreviations used in guidelines (see Appendix 1a)

S/Internal/ResuscitationPolicy/July14/V2.0 1

6. Definitions

6.1. Cardiac Arrest - cardiac arrest may be defined as the abrupt cessation of cardiac function that is potentially reversible

6.2. Basic Life Support - external chest compressions and ventilation which may include the use of oral pharyngeal airways, face masks, bag-valve-mask systems, oxygen and in AED.

6.3. Immediate Life Support - use of all basic life support techniques, extended airway techniques and adjuncts, understanding the A, B, C, D, E approach to resuscitation and the safe early use of defibrillation, are the skills needed as a core member of a cardiac arrest team

6.4. Advanced Life Support - use of all basic life support techniques with added intervention of drugs, defibrillation and other mechanical devices acting on the patient’s cardiac rhythm and output. Team leadership within a resuscitation event should also be included.

6.5. Defibrillation – the termination of ventricular fibrillation by the passing of an electrical current across the myocardium to depolarise a critical mass of the cardiac muscle simultaneously to allow the natural pacemaking tissue to resume control

6.6. Implantable Cardioverter Defibrillators (ICDs) – device able to give the heart electrical shocks, similar to a pacemaker, works by constantly monitoring and then correcting abnormal heart rhythms

7. Defibrillation

7.1. The Resuscitation Council (UK) recommends the use of AEDs. Automated external defibrillators (AED): AEDs are sophisticated, reliable, safe, computerised devices that deliver electric shocks to victims of cardiac arrest when the ECG rhythm is one that is likely to respond to a shock. Simplicity of operation is a key feature: controls are kept to a minimum, voice and visual prompts guide rescuers. AED training is provided as part of BLS/ILS/ALS. All AEDs analyse the victim’s ECG rhythm and determine the need for a shock. AEDs are suitable for use by both lay rescuers and healthcare professionals.

7.2. Automated External Defibrillators (AED) are located within SCH where there is a greater risk of cardiac arrest. Community staff in all other clinical areas have no access to AEDs in their clinical workplace, however may come across them in public areas such as shopping centres, railway stations and airports. Currently the following locations hold and maintain AEDs.

a) Bluebird Lodge; 100 Mansbrook Boulevard, Ipswich IP3 9GJ b) Aldeburgh CH; Park Rd, Aldeburgh, IP15 5ES c) Felixstowe CH; Constable Rd, IP11 7HJ d) Newmarket CH; 56 Exning Rd, Newmarket, CB8 7JG e) Cardiac Rehab; 3 at Allington Clinic, 1 at Sudbury (transported to outreach clinics as required)

7.3. AED training should be included as part of BLS, ILS and ALS. Staff should also ensure they practice the skill of defibrillation regularly to improve familiarity and confidence with using the machines via the use of mock resuscitation scenarios.

7.4. Following the onset of pulseless ventricular fibrillation / ventricular tachycardia (VF/VT), cardiac output ceases and cerebral hypoxia starts within three minutes. If complete neurological recovery is to be achieved, successful defibrillation must be accomplished rapidly. The keys to improving morbidity and mortality rates in sudden adult collapse are directly related to early chest compressions and early defibrillation.


7.5. Use and Maintenance:

a) All AEDs must be used correctly and safely, ensuring that all safety procedures and precautions are adhered to at all times.

b) All AEDs within SCH (Zoll / Cardiac Science) are self testing; staff need to inspect them daily alongside other resuscitation equipment checks.

c) All AEDs must be operated with the correct compatible pads for the particular machine. AED pads have a limited shelf life (generally about 21 – 24 months but can be up to 5 years) so should be regularly checked and replaced if necessary.

d) AEDs come with batteries and the machine will inform the user when the batteries need to be replaced but it is best practice to replace them according to manufacturer’s recommendations.

8. Anaphylaxis

8.1. Anaphylaxis is a rapidly progressing, life-threatening allergic reaction. Rapid assessment, diagnosis and treatment are necessary to avoid death of the victim.

8.2. Anaphylaxis training is included as part of part of, ILS and ALS, and standalone sessions are also available to staff who require this training and do not attend ILS or ALS. The level of life support training staff are required to attend varies within SCH (see Appendix 7)

8.3. Patients experiencing anaphylactic symptoms must be assessed using a full Airway, Breathing, Circulation, Disability and Exposure (ABCDE assessment and treated as emergencies. If a patient is suspected of developing an anaphylactic reaction staff should treat in accordance with the UK Resuscitation Council Emergency Treatment of Anaphylactic Reactions Guidelines (2008) (see Initial Treatment and Algorithm Protocols appendices 3 & 4)

8.4. Techniques for assessment and treatment of anaphylaxis should be instigated if necessary including the administration the patient’s own auto-injector if available. Use of an Auto-Injector is included within standalone anaphylaxis training.

8.5. If the reaction is becoming severe and if a resuscitation trolley is available it should be taken to the patient so that emergency anaphylaxis drugs and equipment are at hand (including oxygen if available) as early Immediate /Advanced Life Support is essential.

8.6. Community nurses who carry anaphylaxis kits should have these available with them at all times. Expiry dates should be monitored and new kits should be ordered within 30 days of expiry. All community nurses who administer vaccinations must attend anaphylaxis training annually.

8.7. Patients who have had a suspected anaphylactic reaction (i.e. an airway, breathing or circulation (ABC) problem) should be admitted to the local A & E department and treated/ observed for at least 6 hours in a clinical area with facilities for treating life-threatening ABC problems; they should then be reviewed by a senior clinician and a decision made about the need for further treatment or a longer period of observation.

8.8. NB. Adrenaline, chlorphenamine and hydrocortisone injection can be administered in an emergency situation without the need for a doctor’s prescription or PGD as the administration is exempt from Medicines Act restrictions as follows. Regulation 238 of the Human Medicines Regulations 2012 (Schedule 19) allows the following prescription only medicines to be administered by anyone for the purpose of saving life in an emergency:-

i) Adrenaline 1:1000 up to 1mg for intramuscular use in anaphylaxis ii) Chlorphenamine injection iii) Hydrocortisone injection Adrenaline is stable up to a temperature of +30 degrees Celsius.


9. Paediatric Resuscitation

9.1. Trained staff in each area that has paediatric patients attending must be trained in paediatric ILS; untrained staff will attend paediatric BLS. This is provided as part of SCH mandatory training and should be carried out in accordance with the Resuscitation Council (UK) Paediatric Intermediate Life Support Protocol (see appendix 1e).

9.2. Special consideration should be made for paediatric emergencies. The spectrum of diseases and problems that they present with differs as well as their response to treatment to that of an adult. The most obvious reason that children differ is their size and its variation with age.

10. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order

All people are initially presumed to be for cardiopulmonary resuscitation unless a valid DNACPR decision or a valid Advance Decision to Refuse Treatment (ADRT), refusing cardiopulmonary resuscitation, has been made and documented.

10.1. All DNACPR decisions must be based on current legislation and guidance. The DNACPR decision-making process must be measured, monitored and evaluated to ensure a robust governance framework.

10.2. When CPR would not restart the heart and breathing of the individual, it will not be attempted. In these circumstances, there is no obligation to explore an individual’s wishes around CPR, though it could form part of a sensitive discussion about the progression of a life limiting illness and end of life care planning.

10.3. When CPR might restart the heart and breathing of the individual discussion will take place with that individual if this is possible, (or with other appropriate individuals for people without capacity) to clarify their wishes, although people have a right to refuse to have these discussions.

10.4. Effective communication concerning the individual’s resuscitation status will occur between all members of the multidisciplinary healthcare team involved in their care and across the range of care settings.

10.5. An up to date documented DNACPR order (see Appendix 2) indicates that no CPR (BLS/ ILS/ ALS) is attempted on that patient.

10.6. DNACPR orders are compatible with maximal therapeutic care. The patient may be receiving vigorous medical support and yet justifiably be considered for the DNACPR order.

10.7. The overall responsibility of a DNAR order rest with the medical practitioner in charge of the patients care.

10.8. A DNACPR order is valid until the order is revoked by a medical practitioner in charge of the patient’s care. If the patient is admitted to hospital then the DNACPR should be communicated to the consultant in charge. Where possible the patient should present with the form in their yellow folder.

10.9. For a summary of the decision making framework please see appendix 6

11. Pacemakers and Implantable Cardioverter Defibrillators (ICDs)

11.1. These are devices implanted in the thoracic cavity (usually under the collar bone). They are designed to defibrillate the heart at low energy and are used for people at risk of, or with a history of, abnormal heart rhythm.

11.2. They constantly monitor the heart rhythm and can deliver two kinds of treatment:

a) pacing to try to stop the abnormal heart rhythm;


b) administration of one or more low energy defibrillatory shocks to stop the abnormal rhythm and restore the heart back to a normal rhythm.

They therefore deliver the treatment as external defibrillators for the same arrhythmias.

11.3. During a cardiac arrest situation follow BLS/ALS guidelines, chest compressions should be performed as usual. If the implanted device delivers a shock during CPR, the responder may feel a tingling sensation on the patient’s body surface. However, the shocks delivered by the implanted defibrillator will not pose a danger to the person administering CPR.

11.4. Positioning of the external defibrillation pads to avoid damaging an implanted pacemaker or defibrillator

a) Position the external defibrillation pads in a clinically acceptable position that is as far from the pulse generator as possible.

b) When a device is located in an area where a pad would normally be placed, the Resuscitation Council recommends positioning the external defibrillation pad at least 1 inch (2.5 cm) away from the device.

Whenever possible, external defibrillation pads should be placed in an anterior-

posterior position (Figure 1). However, if the device is positioned in the left pectoral region, placement of the external defibrillation pads in the anterior-apex position is also acceptable

c) Post cardiac arrest arrangements should be made to have the pacing/ ICD device check by the local cardiology team

12. Equipment Requirements and Maintenance

12.1. The minimum requirement for non-clinical and clinical community based services is the provision of pocket masks. These will be provided by community managers via the normal procurement process.

12.2. All in-patient units and Felixstowe MIU must have access to an appropriately equipped resuscitation trolley. Where resuscitation trolleys are kept/ used, they must maintain standard contents throughout SCH (see appendix 6). This should be checked against the correct contents list.

12.3. All resuscitation equipment must be stored, maintained and used in accordance with the manufacturer’s instructions.

12.4. All resuscitation trolleys and other equipment must be maintained in a state of readiness at all times and readily accessible. Trolleys/ equipment should be checked by a member of staff twice every 24 hours and replenished immediately following the conclusion of a resuscitation event.

12.5. AEDs and suction units must also be checked simultaneously to ensure they are in working order.

12.6. An AED audit and trolley/ grab-bag/ rucksack audit will be carried out 6 monthly.


12.7. A record of regular maintenance checks should be kept and should include the date and time of the check and signature of the person carrying out the check.

12.8. The Modern Matron/ Team Lead in each unit will have overall responsibility for ensuring processes are in place for checking all equipment and drugs are maintained/ replaced when used.

12.9. The manufacturer’s instructions and maintenance checking record should be readily available for inspection by all members of staff expecting to use the equipment.

13. Training and Education

13.1. All resuscitation training should be based on Resuscitation Council (UK) Guidelines and taught by SCH approved trainers. It is mandatory to receive training every 12 months. All staff should receive the level of training appropriate to their role.

13.2. Basic Life Support including use of AEDs should be taught annually to all staff unless they are receiving ILS

13.3. BLS/ILS/ALS/ AED

13.4. training should be formally updated every 12 months and operators will be expected to practice the skill of safe defibrillation as part of all levels of training; for the level of Life Support training required by staff within SCH see appendix 7

13.5. Staff should ensure they are familiar with their working area and the location/ use of all equipment and drugs

13.6. Staff should ensure they have read and are familiar with other related policies/ guidelines (see 19. below)

14. Reporting Resuscitation Episodes/ Documentation and Audit

14.1. In the areas where there are AEDs and resuscitation trolleys (Community Hospitals/ MIU), the Cardiac Arrest Report Form (see appendix 5) must be used to record each Cardiac Arrest attended by SCH Employees. Blank copies of the form should be kept on the Resuscitation Trolley to enable completion as soon as possible after the event.

14.2. The completed form should be filed in the patient’s records and a copy attached to an incident form which should be submitted to the Resuscitation Committee (Chair and Vice Chair) and the Risk Management Team as soon as possible after the incident

15. Post-resuscitation Care

15.1. Following successful resuscitation clinicians and teams involved must give consideration to the following to ensure that ongoing care of the service user is optimised, this may include:

15.2. Full and complete handover of care to the appropriate service is as follows:-

a) Informing relatives b) Documentation (see 13 above) c) Replenishment and checking of drugs and equipment (see 11 above) d) Reflective Practice and de-briefing


16. Manual Handling

16.1. In situations where the collapsed patient is on the floor, in a chair or in a restricted / confined space, the SCH Manual Handling Policy must be followed to minimise the risks of manual handling and related injuries to both staff and the patient.

16.2. Moving any patient who are unresponsive is a risky situation. Staff must familiarise themselves with the SCH Manual Handling Policy for guidance on safe lifting in resuscitation situations.

17. Infection Control

17.1. All clinical areas should have immediate access to bag valve masks and/ or pocket masks to eliminate the need for direct mouth-to-mouth ventilation. However, in situations where airway protective devices are not immediately available, start chest compressions whilst awaiting an airway device.

17.2. Resuscitation trolleys should be regularly cleaned as part of the areas cleaning regime and all drugs checked to ensure they are intact and in date.

18. Emergency Numbers

18.1. There are no internal emergency numbers at any community units/ areas therefore all staff will dial 999 and state that there is a cardiac arrest situation.

19. Glossary of terms

Glossary of terms and abbreviations used in guidelines: C.P.R. cardiopulmonary resuscitation A.L.S. advanced life support I.L.S. immediate life support B.L.S. basic life support Defib. electrical defibrillation A.E.D. automated external defibrillator D.N.A.C.P.R. do not attempt cardiopulmonary resuscitation I.C.D. implantable cardioverter defibrillators AED automated external defibrillator

20. Cross Reference to related SCH and other Polices/ Guidelines

a) East of England DNACPR Policy/ Order form b) Moving and Handling Policy c) Infection Control Manual d) Medicines Management Policy e) Ipswich Hospital Resuscitation Policy (SCH Policy reviewed by Ipswich Hospital Resuscitation

Officer) f) UK Resuscitation Council Emergency Treatment of Anaphylactic Reactions Guidelines (2008)

http://www.resus.org.uk/pages/reaction.pdf g) NICE Guideline (CG134) “Initial assessment and referral following emergency treatment for an

anaphylactic episode” (2011) http://guidance.nice.org.uk/CG134


http://www.resus.org.uk/pages/reaction.pdf

http://guidance.nice.org.uk/CG134

APPENDIX 1: UK Resuscitation Council Guidelines Algorithms: 1a: Chain of Survival Flowchart


1b: Adult Basic Life Support Flowchart


1c: Adult AED Algorithm


1d: Adult Choking Treatment Algorithm


1e: Paediatric Basic Life Support Algorithm


1f: In-hospital Resuscitation Algorithm


1g: Anaphylaxis Algorhithm


APPENDIX 2: DNCPAR Order Form


APPENDIX 2: Medical Emergency Report Form STRICTLY CONFIDENTIAL (when completed) RESUSCITATION EVENT and CARDIAC ARREST REPORT MET Audit Form To be used in the event of any arrest/ peri-arrest event or medical emergency (i.e. whenever a 999 call is initiated)

Patient name:

Patient DOB:

Date of attendance / admission:

Reason:

Time of collapse / patient found:

Location of victim:

Time of MET call:

Time of 999 call:

Respiratory arrest, cardiac arrest or reason for MET call:

DNAR order

(Yes / No):

Time of commencement of chest compressions or N/A:

Time defibrillator attached or N/A:

Time: Rhythm, or if AED

then “Shock” or “No shock” advised

Airway interventions, e.g. Pocket mask, Bag-valve-mask, iGel, intubation or ‘None’

IV Access / Fluids: State type and volume Drugs given: State concentration and volume

Shock given: ‘Yes’, ‘No’ or Amount of KJ given


Time: Rhythm, or if AED then “Shock” or “No shock” advised

Airway interventions, e.g. Pocket mask, Bag-valve-mask, I-Gel, intubation or ‘None’

IV Access / Fluids: State type and volume Drugs given: State concentration and volume

Shock given: ‘Yes’, ‘No’ or Amount of KJ given

Time of arrival of medical services:

Transfer to A&E (Yes or No):

Time of transfer to A&E:

Return of spontaneous circulation (Yes, No or N/A):

Time of return of spontaneous circulation:

Condition of patient at transfer, or if non-arrest then at arrival of MET:

Airway: Breathing: Circulation: Disability: Exposure: Time of Death: Incident form (Yes / No): Comments / Adverse incidents (Yes / No): Write comments on the back of this form

Other comments:


APPENDIX 3: Standard Resuscitation Trolley/ Grab Bag Contents

RESUSCITATION TROLLEY/ GRAB BAG

CONTENTS

Top of Trolley Side of Trolley Bottom of Trolley • Suitable AED with Pads

attached • Portable suction device

with suction tubing and rigid suction catheter attached

• Laminated check list and check list form

• Equipment audit tool forms

• Cardiac arrest report forms

• Small Sharps Bin • Clock (for timing)

• Small size D Oxygen cylinder with tubing and adult bag-valve-mask attached

• Box of Small Gloves • Box of Medium Gloves • Box of Large Gloves • Aprons • Clothing scissors

Airway Drawer Circulation and Drugs Drawer Breathing Drawer • Oral Pharyngeal airway

size 2x2 • Oral Pharyngeal airway

size 2x3 • Oral Pharyngeal airway

size 2x4 • Nasal Pharyngeal

airway size 6.0x2 • Nasal Pharyngeal

airway size 7.0x2 • I-gel supraglottic airway

size 3.0 • I-gel supraglottic airway

size 4.0 • I-gel supraglottic airway

size 5.0 • Adult size rigid suction

catheter (Yankauer)x2 • Fine bore suction

catheters size 12.0 x2 • McGill’s forceps – adult

size

• Tourniquet • Spare AED Pads x 1 set • Normal Saline 0.9% for injection

5ml x 5 • 5 ml syringes x 2 • Glucagon injection for IM use x

1 • Naloxone 400ug in 1ml pre-

filled syringes x 2 • Salbutamol 5mg Nebule x 2 • An Anaphylaxis shock pack

within a rigid plastic box containing: Chlorpheniramine 10mg in

1ml ampoules x 2 Syringe 1 ml x 2 Needle 23g x 1” x 2 Injection swab x 4 Adrenaline 1 in 1,000 (1mg

in 1ml) or appropriate pre-filled syringe

• Cannulae in a range of sizes in rigid plastic box (in units where staff have cannulation skills

• Adult Oxygen Mask with reservoir x 2

• Adult Mask with nebuliser pot x 2

• Oxygen tubing • Adult Bag-Valve Mask,

with reservoir • Adult Pocket Mask x1


Adult Grab Bag/ Rucksack Paediatric Grab/ Rucksack As per Resuscitation Trolley except for: • Portable compact suction machine

• Paediatric Pocket Mask • Bag-Valve Mask 500ml with a size 1.0 and 3.0

mask x 1 • Paediatric oral pharyngeal airways: Size 0.0 Size 0 Size 1 Size 2

• Paediatric McGill’s Forceps • Paediatric AED Pads • Paediatric mask with nebuliser pot x 1 • Paediatric oxygen mask with reservoir x 1

Paediatric Anaphylaxis Shock pack containing: Chlorpheniramine 10mg in 1ml ampoules x 2 Syringe 1 ml x 2 Needle 23g x 1” x 2 Injection swab x 4 Adrenaline 1 in 1,000 (1mg in 1ml) or

appropriate pre-filled syringe

N.B. Aspirin (oral) for use in peri-arrest situations should be part of ward stock can be stored within box containing cannulae if required. PGD available on the SCH Intranet

S/Internal/ResuscitationTrolleyContents/July14/V1.0


APPENDIX 4: Required Levels of Life Support Training for SCH staff and availability of equipment Team/ Department

Level of training staff receive & provider company

AED on site? Resuscitation trolley available?

Aldeburgh CH

Qualified staff – ILS Unqualified staff – BLS/ AED training

Yes Yes

Newmarket CH (OPD)


Yes Yes

NCH (Inpatient Unit- Rosemary Ward)


Yes Yes

Bluebird Lodge Qualified staff – ILS Unqualified staff – BLS/ AED training

Yes Yes

Felixstowe CH


Yes Yes

Felixstowe MIU

Qualified staff – ILS and PILS Unqualified staff – BLS/ AED training (adult & paediatric)

Yes Yes

Cardiac Rehab All staff – ILS

Yes (3 x Zoll) No

NCH (Day& Treatment)

BLS/ AED training No No

Community Matrons (Haverhill/ Bury)


Admission Prevention Service (E&W)


Specialist Nursing Services


Local Community Health Teams (E&W)


Clerical/Admin staff, Cleaners


Managers BLS/ AED training

No No

Leg Ulcer Clinic staff Community Equipment Staff



APPENDIX 5: Resuscitation Trolley Drugs and Equipment Audit Tool


Electronic version of tool available at: http://nww.suffolkch.nhs.uk/Home/QualityGovernance/ClinicalAudit/AuditToolsRCA.aspx


http://nww.suffolkch.nhs.uk/Home/QualityGovernance/ClinicalAudit/AuditToolsRCA.aspx

APPENDIX 6: DNACPR Summary Decision Making Framework


Appendix 7: Emergency Drugs for Cardiac Arrest and Anaphylaxis which do not require a PGD The Human Medicines Regulations 2012 SCHEDULE 19 Regulation 238 Medicinal products for parenteral administration in an emergency These do not, therefore require a PGD

• Adrenaline 1:1000 up to 1mg for intramuscular use in anaphylaxis • Atropine sulphate and obidoxime chloride injection • Atropine sulphate and pralidoxime chloride injection • Atropine sulphate injection • Atropine sulphate, pralidoxime mesilate and avizafone injection • Chlorphenamine injection • Dicobalt edetate injection • Glucagon injection • Glucose injection • Hydrocortisone injection • Naloxone hydrochloride • Pralidoxime chloride injection • Pralidoxime mesilate injection • Promethazine hydrochloride injection • Snake venom antiserum • Sodium nitrate injection • Sodium thiosulphate injection • Sterile pralidoxime

Please note:

In most emergency situations, oxygen is given to patients immediately without a formal prescription. However, a subsequent written record must be made of what oxygen therapy has been given to every patient (in a similar manner to the recording of all other emergency treatment)

British Thoracic Society, 2008

https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/emergency-oxygen-use-in-adult-patients-guideline/appendix-4-summary-for-prehospital-settings-emergency-oxygen-use-in-adult-patients-guideline/





Title of Policy/Guideline: Resuscitation Policy

Description: This policy is designed to provide direction, guidance and information for staff about resuscitation within Suffolk Community Healthcare (SCH) premises and in patient’s homes ensuring a rapid and competent response in any resuscitation situation. Part 1: Assessment of Impact a) How will the policy meet the needs of different communities and groups? • Age – This policy applies to adults and children.

Within these groups, it is not considered that the age will have any impact on the application of this policy

• Religion or Belief – This organisation is aware of different religions and belief systems but this policy is considered to apply equally to all groups

• Disability – It is anticipated that this policy will impact on all adult patients in equal measure

• Sexual Orientation – It is considered that this policy should apply equally to all patients whatever their sexual orientation

• Ethnicity – This organisation is aware of different practices and different ethnic groups but this policy is considered to meet the needs all such groups

• Socio-economic disadvantage – This policy should not impact to cause any socio-economic disadvantage

• Gender (including transgender) – this policy is intended to meet the needs of all such groups regardless of gender.

• People living in rural areas – This policy should be applied equally regardless of place of residence and should not impact on people living in rural areas

Other: This organisation recognises that some members of society generally have difficulty accessing health services such as people who are homeless, prisoners or street workers. However, this policy should be applied equally to all SCH service-users and individuals accessing SCH property. b) Positive Impact: Reducing Inequalities: How is the Policy likely to have a significant positive impact on equality by reducing inequalities that already exist? Explain how it will meet our duty to: • Promote equal opportunities: this policy will

ensure that all staff are equally aware of the correct procedure so that adherence to the policy is standardised through all patient groups.

• Promote good community relations – As with other policies and guidelines within the organisation, this one aims to ensure that SCH provides quality services to the community of Suffolk ensuring that the whole community has access to a safe healthcare environment. Fostering good relations with partner organisations will be enhance by the application of this policy.

• Get rid of discrimination: staff working within this

policy and within professional guidelines should avoid discrimination at any level.

• Promote positive attitudes towards, encourage participation in and enable more favourable treatment of, disabled people: This policy applies to all patients equally irrespective of any disability and staff will make all reasonable adjustments to


accommodate any disability.

• Get rid of harassment: There are policies in place which prevent harassment both within the organisation and between the staff and patients (e.g. Whistle Blowing Policy, Disciplinary Policy, Adverse Incidents, Code of Conduct, Confidentiality Code of Practice

• Promote and protect human rights: SCH recognises that patients to whom this policy applies are vulnerable and this policy is designed to ensure their human rights are not affected in any way

c) Negative Impact – Potential Discrimination: Could the Policy have a significant impact on equality in relation to each of the following groups or characteristics? • Age – Within the defined age groups it in

anticipated that age will not have a negative impact on this policy

• Religion or Belief – Staff are expected to be aware of the possibility of differing views towards resuscitation issues by religious groups but this should not impact on the application of the policy.

• Disability – This policy should be applied equally regardless of any disability

• Sexual Orientation – This policy will apply equally regardless of sexual orientation.

• Ethnicity – It is not considered that ethnicity will have a negative impact on this policy although the attitudes towards it may vary according to ethnic group.

• Socio-economic groups – It is not anticipated that this policy will have a negative impact in relation to this.

• Gender (including transgender) – This policy will be applied equally regardless of gender.

• People living in rural areas – It is not anticipated that this will have a negative impact.

Other: This organisation recognises that some members of society generally have difficulty accessing health services such as people who are homeless, prisoners or street workers. However, this policy relates to all individuals who are service-users as such will be applied equally and should not have a negative impact. Part 2: Evidence What is the evidence for your answers above? • Age – It is the intention and aims of this policy that

in consultation with statutory and non-statutory bodies that the policy reflects current best evidence and practice and will be applied equally regardless of the age of the recipient within the defined age-group.

• Religion or Belief - It is the intention and aim of this policy that it shall be applied equally according to best practice and not discriminate unfairly based on religion or belief.

• Disability – It is the intention and aim of this policy that it will reflect best evidence based practice and not discriminate based on a physical or mental disability

• Sexual Orientation - It is the intention and aim of this policy that it shall be applied equally according to best practice and not discriminate unfairly based on sexual orientation.

• Ethnicity – It is the intention and aim of this policy that it shall be applied equally according to best practice and not discriminate unfairly based on ethnicity.

• Socio-economic groups - It is the intention and aim of this policy that it shall be applied equally according to best practice and not discriminate unfairly based on socio-economic status

• Gender (including transgender) - It is the intention and aim of this policy that it shall be applied equally according to best practice and not

• People living in rural areas - It is the intention and aim of this policy that it shall be applied equally according to best practice and not discriminate


discriminate unfairly based on gender. unfairly based on ethnicity. Other: This organisation recognises that some members of society generally have difficulty accessing health services such as people who are homeless, prisoners or street workers. However, this policy applies to individuals who are service-users and those on SCH property and therefore will be applied equally and reviewed regularly to ensure it adheres to current best evidence based practice. Part 3: Conclusion B – A negative impact in unlikely. The policy has the clear potential to have a positive impact by reducing and removing barriers and inequalities that currently exist. Part 4: Next Steps Action Plan: To review the operation of the policy annually to ensure there are no changes in its impact. Part 5: For the Record Name and Title of people who carried out the EIA: Sarah Miller

Name of Director who signed EIA: Pamela Chappell

Date EIA completed: 22/7/14

Signature of Director:


resuscitation policy version: status: guideline … policy... · september 2014 . last review date...

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