|Publication: 01/11/2009 --|
|Last review: 31/07/2019|
|Next review: 01/11/2020|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
- LGI Crash Teams & Trauma Teams
- SJUH Adult Crash Tteams
- SJUH Childrens
- Escalation Process
Leeds Teaching Hospitals NHS Trust (LTHT)) has a duty of care to provide an effective Resuscitation service and to ensure that all staff are trained appropriately and regularly updated to a level compatible with their expected degree of competence.
For quick reference the guide below is a summary of actions required.
- All patients, staff and visitors will receive safe, early and appropriate Cardiopulmonary Resuscitation, including early defibrillation when required;
- All staff with frequent, regular patient contact will attend annual resuscitation training relevant to their role. This training will include, as appropriate, anaphylaxis management, identification and response to the deteriorating patient, DNACPR and post resuscitation care;
- All in-patient vital signs will be recorded and an early warning score will be generated as per Management of the Deteriorating Patient Policy. This will indicate whether escalation of care is required and ensure the appropriately skilled healthcare professional is called. This will aid identification and response to patients at risk from cardio-respiratory arrest;
- All patients having an anaphylactic reaction will be managed following the current Resuscitation Council (UK) guidance;
- All cardiac arrest equipment /resuscitation trolleys and resuscitaires must be checked on a daily basis and after use by a registered healthcare practitioner;
- All staff using a defibrillator will attend training on an annual basis to demonstrate practical and theoretical competence in the safe use of a defibrillator;
The Leeds Teaching Hospital NHS Trust resuscitation guidelines fully support the Standards for Clinical Practice and Training published by the Resuscitation Council (UK) 2015,
This resuscitation guideline is based on the recommendations for clinical practice and training in cardiopulmonary resuscitation published by the Resuscitation Council (UK) (2015). It has been developed to describe the process for managing and mitigating risks associated with resuscitation.
CPR is undertaken in an attempt to restore breathing (sometimes with support) and spontaneous circulation in a patient in cardiac and/or respiratory arrest. CPR is a relatively invasive medical therapy and it is therefore essential to identify patients for whom cardiac and/or respiratory arrest represents a terminal event in their illness.
These guidelines should be read in conjunction with the following Trust policies and guidelines:
- Decisions relating to Cardio-Pulmonary Resuscitation and Do Not Attempt Resuscitation Orders (DNACPR) – Decisions
- Policy for the Prevention and Management of the Deteriorating Patient
- Guidelines for Recording and Acting upon Physiological Observations in Adult In- Patients
- Mandatory Training Policy
- Resuscitation Training and Education Requirements Framework - Adult and Paediatric
- LTHT Guideline for deciding to institute intensive care and resuscitate infants of less than 26 weeks gestation
- LTHT Neonatal Resuscitation: Protocols and guidelines relating to neonatal Resuscitation
Defibrillation Of Adults by Suitably Qualified Healthcare Professionals using a Zoll Semi Automated Defibrillator (Guidance)
ZOLL M or R Series Manual Defibrillation Of Adults by Suitably Qualified Healthcare Professionals (Guidance)
A cardiac arrest is the ultimate medical emergency – the correct treatment must be given immediately if the patient is to have any chance of surviving. The interventions that contribute to a successful outcome after a cardiac arrest can be described as the Chain of Survival.
1. Early recognition and call for help
All in patients within LTHT must have physiological observations recorded within 30 minutes of admission and a minimum of 12 hourly thereafter. The overall responsibility for ensuring this occurs rests with the admitting clinician (doctor or nurse).
Prevention of cardiac/cardiopulmonary arrest is key and therefore all inpatients must have an Early Warning Score (EWS) monitored with every set of observations (with the exception of specific specialist areas e.g. ICU, Theatres) and a clear plan of escalation in place, ensuring ‘appropriate’ help is called, with escalation to higher levels of care in a timely manner. This also includes ‘escalation’ plans pertaining to ‘active limitation’ and/or DNACPR attempts.
Refer to the Policy for the Prevention and Management of the Deteriorating Patient for further information.
2. Early CPR
At the point of cardiac arrest/medical emergency a 2222 call should be placed and good quality basic life support should be provided with minimal interruptions in chest compressions. Evidence shows that this is essential to optimise a positive outcome from cardiac and or Respiratory arrest.
3. Early defibrillation
The majority of in-patients do not require defibrillation due to the underlying pathology of cardiac arrests favouring non shockable rhythms. However, if the presenting rhythm is one that does require defibrillation, in order to significantly improve the chance of survival, it is essential that defibrillation is delivered safely and promptly.
4. Post Resuscitation Care
The outcome from cardiac arrest/cardio-pulmonary arrest may be a return of circulation (+/- Spontaneous breathing) or death. Both situations require specific management that should be coordinated by the resuscitation team leader.
Immediately after resuscitation when patients are clinically unstable they will be assessed for the cause of the cardiac arrest/ medical emergency and any specific post resuscitation care requirements. If patients require specialist post resuscitation care and following discussion with the appropriate specialist team adult, paediatric and newborn patients will be transferred to specialist clinical area for further care and management.
Cardiopulmonary resuscitation (CPR) must be attempted on any individual in who cardiac or respiratory function ceases, unless there is a direct instruction not to attempt CPR. Decisions about CPR must be made on the basis of an individual assessment of each patient’s case. In the situation where death is expected as an inevitable result of an underlying disease, and the clinical team is as certain as they can be that CPR would fail, then resuscitation should not be attempted. Further guidance for staff can be found in the policy: Decisions relating to Cardio-Pulmonary Resuscitation and Do Not Attempt Resuscitation Orders (DNAR).
Cardiac Arrest Response
Each of the Trust’s hospital main sites are serviced by appropriate cardiac arrest teams (see appendix). Some peripheral sites, due to service provision, are serviced by the 999 Ambulance service (see appendix) The cardiac arrest team will be summoned by using the universal number 2222. The precise location of the event must be communicated promptly and clearly to the switchboard operator: In the event that any member of the crash team does not attend then a second call must be placed within 5 minutes to the universal number 2222 and an incident form must be completed at the end of the emergency.
For adult patients state adult cardiac arrest and location: Clinical area, block and floor
For paediatric patients state paediatric arrest and location Clinical area, block and floor
For neonates state neonatal arrest and location Clinical area, block and floor
For obstetric medical emergency patients’ state obstetric emergency and location: clinical area, block and floor.
For paediatric trauma state paediatric Trauma call: LGI A&E paediatric resuscitation bay
Once switchboard has been informed they immediately alert the appropriate cardiac arrest team via a speech channel. Each member of the cardiac arrest team must respond at their earliest opportunity. The speech channel is tested at random (minimum of twice weekly) by the Adult Resuscitation Service, to ensure that the system and individual bleeps are in working order, all bleep holders must respond to this test call. Once initiated, Cardiac arrest calls will not be cancelled.
Resuscitation Equipment, Replenishment, Cleaning and Safe Use;
Defibrillators must only be operated by persons specifically trained in their use. The operation of defibrillators by Nurses, Midwives and Allied Health Professionals is subject to their compliance with Trust guidance and attendance at agreed training. The defibrillator must be operationally checked in accordance with the manufacturer’s instructions and every 24 hours and after a cardiac arrest if used in accordance with the resuscitation equipment checking guidance
Resuscitation Trolleys and Resuscitaires (mobile and wall mounted)
The resuscitation trolleys and resuscitaires (mobile and wall mounted) must be stocked in accordance with the standardised lists issued by the Resuscitation Services. Resuscitaires must be available in all Accident and Emergency, Labour & Delivery, Antenatal/Postnatal, Transitional Care, and Neonatal Clinical areas.
All resuscitation trolleys/resuscitaires must be maintained in a state of readiness at all times. Trolleys/resuscitaires must be checked and documented by a qualified member of staff at least once every 24 hours and immediately following conclusion of a resuscitation event.
Resuscitation trolleys are also held in main site entrances. It is the responsibility of the resuscitation service to check and maintain these trolleys with support from the Medical Equipment Assistants.
Adult crash trolleys must have a copy of a blue ‘Information Folder’.
All generic (paediatric) crash trolleys must have a copy of the LTH Trust Paediatric Emergency ‘Red’ File (2003/2006/2010).
All mobile and wall mounted resuscitaires must have laminated copies of: Newborn Life Support Algorithm (RCUK 2010) and LTH Trust Paediatric & Neonatal Resuscitation Chart (2011).
Replacement of Resuscitation Equipment
Replacement equipment is obtained via Medical Equipment Assistants who hold a supply in equipment pool at Leeds General Infirmary and St James’s Hospital.
Replacement equipment for peripheral sites is obtained as follows:
- Wharfedale General Hospital - replacement cardiac arrest trolley equipment held in an `emergency cupboard’. Charge Nurse Ward 1 is responsible for the stocking of the cupboard. Resuscitation Service is responsible for checking stock level in cupboards on a quarterly basis.
- Chapel Allerton Hospital - central equipment store Ward 4. Resuscitation Service is responsible for checking stock level in cupboards on a quarterly basis.
- Seacroft Hospital -emergency cupboard in OPD. Charge Nurse in OPD is responsible for the stocking of the equipment cupboard Resuscitation Service is responsible for checking stock level in cupboards on a quarterly basis.
Disposable items must be replenished at the earliest opportunity. Non disposable items should be de-contaminated/cleaned in accordance with both the manufacturer’s policy and the Trust’s Decontamination of Hospital Equipment Including Medical Devices (2011) and re-instated to the trolley/resuscitaire at earliest opportunity.
Adult and Paediatric/neonatal emergency drug boxes are prepared in manufacturing unit. Drug boxes for clinical areas at SJUH & LGI sites are replaced by contacting Medical Equipment Assistants who hold supplies in the equipment pools.
Replacement emergency drug boxes for peripheral sites are obtained as follows;
- Wharfedale General Hospital - by faxed order to Moor House Pharmacy Store.
- Chapel Allerton Hospital (CAH) - Pharmacy at CAH has replacement stock. If a replacement is urgently required out of hours contact the equipment pool at LGI or SJUH.
- Seacroft Hospital - by faxed order to Moor House Pharmacy Store.
Emergency drug expiry dates must be checked as part of 24 hour check of resuscitation trolleys/resuscitaires. The responsibility for replacing used or out of date emergency drug boxes is held by individual areas.
A full and accurate account of the cardiac arrest and all medications administered must be documented in the patient medical records immediately and prior to transfer to another department.
Documentation using the ppm+ patient record system must be used following an adult cardiac arrest.
If asepsis when sighting intravenous lines has not been possible due to medical urgency then this must be recorded and any line replaced at the next available opportunity in all instances.
Resuscitation Practice and Staff Safety;
All staff working within the Trust must be trained in manual handling activities in accordance with the Trust Mandatory Training policy. Advice from resuscitation council is also available on minimising the risks of manual handling and related injuries during resuscitation to both staff and the patient. (Safer Handling Guidance Resuscitation Council (UK) 2001).
Trust staff must comply with all Infection Prevention and Control Policies available on Trust Intranet. Detailed below is supplementary guidance for staff. Whilst the risk of infection transmission from patient to rescuer during direct mouth-to mouth resuscitation is extremely rare, isolated cases have been reported. It is therefore advisable that direct mouth-to-mouth resuscitation be avoided in the following circumstances:
- All patients who are known to have or suspected of having an infectious disease;
- All undiagnosed patients entering the Accident & Emergency department, outpatients or other admission source;
- Other persons where the medical history is unknown.
All clinical areas have immediate access to airway devices (e.g. a pocket mask) to minimise the need for mouth-to-mouth ventilation. However, in situations where airway protective devices are not immediately available, start chest compressions whilst awaiting an airway device.
The management of suspected anaphylaxis/anaphylactic reactions should be conducted in accordance with the Resuscitation Council (UK) Guidelines (2012) for the management of anaphylaxis and the Trust Guideline for the Management of Anaphylaxis in children.
Leeds Teaching Hospitals NHS Trust supports the principal of standardised equipment when possible for safe and effective patient care. To support this principle the Resuscitation Service will advise and liaise with supplies and clinical areas on the purchase of all adult, paediatric and newborn resuscitation equipment.
The strategy for resuscitation training embodies the statements and guidelines published by the Resuscitation Council (UK) and the European Resuscitation Council, incorporating the most recent updates to these guidelines. This explicitly incorporates current Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy, the identification of patients at risk from cardiac arrest and a strategic approach to implement preventative measures such as Early Warning Systems/ Patient at Risk Systems.
A Training Needs Analysis has been completed to identify Mandatory Training for all staff groups. The details of the mandatory training requirements along with the recording, monitoring and follow-up arrangements for non-attendees are contained in the Trust’s Mandatory Training Policy. A summary of this is contained in Resuscitation Training and Education Requirements - Adult and Paediatric.
Leeds Teaching Hospitals NHS Trust (LTHT) has a duty of care to provide an effective resuscitation service and to ensure that all staff are trained appropriately and regularly updated to a level compatible with their expected degree of competence and speciality of practice.
The purpose of these guidelines are to ensure that:
|Target patient group:||All staff with frequent, regular patient contact|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
All Secondary Healthcare Professionals
Allied Health Professionals
- Advanced Life Support Group (2005) Advanced Paediatric Life Support: Practical approach.(4th edition) Wiley Blackwell London.
- Arafat M, Mattoo T K, (1999) Measurement of blood pressure in children. Recommendations and perceptions on cuff selection. Pediatrics,
- Aylott M, (2006) Developing rigour in observation of the sick child. Paediatric Nursing, 18(8), pp38 – 44. Blood Pressure Association. http://www.bpassoc.org.uk.
- Confidential Enquiry Maternal and Child Health (2008) Why children die: A pilot study 2006 England (South, West, North, East, and West Midlands) Wales and Northern Ireland. CEMACH, London.
- Department of Health (2008) Competencies for recognising and responding to acutely ill patients in hospital. DoH, London. Lockwood C, Conroy-Hiller T, Page T, (2004) Vital signs. International Journal of Evidence Based Healthcare, 2(6), pp207 – 30.
- Mc Gaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M, Outreach and early warning systems (EWS) for the prevention of intensive care admission and death of critically ill patients on general hospital wards. Cochrane Database of systematic reviews 2007, Issue 3. Art. No.:CD005529. DOI:10.1002/14651858.CD005529.pub2.
- Mc Gloin H, Adams S, Singer M, (1999) Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable. Journal of the Royal College of Physicians of London, 33(3), pp255 – 59.
- Mitchell P, Cheung N, Taylor B, Rochtchina E, Islam A, Wang J, Wong T, (2007) Blood pressure and retinal arteriolar narrowing in children. Hypertension, 49, pp1156 – 62.
- Morgan D, Parslow R, Whiteley S, (2008) Implementation of the paediatric advanced warning score in Yorkshire. Unpublished Leeds University. National Confidential Enquiry into Patient Outcomes and Death (2005) An acute problem. NCEPOD, London.
- National Institute for Health and Clinical Excellence (2007) Feverish illness in children. National Collaborating Centre for Women’s and Children’s Health, London.
- National Institute for Health and Clinical Excellence (2007) Clinical Guideline 50. Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital. NICE. London.
- National Patient Safety Agency (2007) Safer care for the acutely ill patient, learning from serious incidents. NPSA, London.
- National Patient Safety Agency (2005) Safer care for the acutely ill patient, learning from serious incidents. NPSA, London.
- Nursing and Midwifery Council (2008) The NMC code of professional conduct: standards for conduct, performance and ethics. NMC, London.
- Paediatric Critical Care Network Assessment of Level of Consciousness in Children. Regional Guidelines
- Resuscitation Council UK (2015) Advanced life support. RCUK, (6th edition), London.
- Roccella E (2004) The fourth report on the diagnosis, evaluation and treatment of high blood pressure in children and adolescents. Pediatrics,114 (2), pp555-76.
- Royal College of Nursing (2007) Standards for assessing, measuring and maintaining vital signs in infants, children and young people. RCN, London.
- Steiner M, DeWalt D, Byerley J, (2004) Is this child dehydrated? Journal of American Medical Association, 29, pp2746 -54.
- Vincent C, Neale G, Woloshynowych M, ( 2001) Adverse events in British hospitals preliminary retrospective record review. BMJ, 322 pp 517 – 519.
Trust Clinical Guidelines Group
LHP version 1.0
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.