RECOGNISING AND RESPONDING TO THE PHYSICALLY … · Cardio-Pulmonary Resuscitation (CPR) This is an emergency procedure for life support consisting of artificial respiration and manual

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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIORATING PATIENT

(COMMUNITY SETTINGS) NOVEMBER 2016

This policy supersedes all previous policies for CPR related to community setting teams

and services

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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016

Policy title Recognising and responding to the physically deteriorating patient (Community Settings)

Policy reference

CL07B

Policy category Clinical

Relevant to All community setting staff in teams /service areas that have clinical contact with patients

Date published December 2016

Implementation date

December 2016

Date last reviewed

N/A

Next review date

January 2018

Policy lead Kevin Cann, Resuscitation Lead

Contact details Email: [email protected] Telephone: 020-3317-7051

Accountable director

Claire Johnston, Director of Nursing and People

Approved by (Group):

Resuscitation Committee 29 September 2016

Approved by (Committee):

Quality Committee 22 November 2016

Document history

Date Version Summary of amendments

Nov 2016 1 Complementary policy focusing on

Community settings

Membership of the policy development/ review team

Resuscitation Lead

Consultation Medical Director, Deputy Medical Director, Clinical Directors, Associate Divisional Directors, Senior Service Managers, Consultants and representative clinical staff in the Community.

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DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.

Contents

1 Introduction 5

2 Aims/Objectives or Purpose 6

3 Scope of the Policy 6

4 Duties and responsibilities 6

5 Definitions 9

6 Physical health monitoring 12

7 Emergency Equipment and Medical Devices for physical health monitoring 13

8 Discovering a collapsed patient and summoning help 15

9 Reporting incidents that include ill health and CPR attempts 19

10 Staff and Patient support following a traumatic event 20

11 Decisions relating to not attempting CPR 20

12 Dissemination and implementation arrangements 21

13 Training requirements 22

14 Monitoring and audit arrangements 23

15 Review of the policy 24

16 References 24

17 Associated documents 25

Appendix 1: Defibrillator poster 26

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Appendix 2: Community setting emergency equipment and drug list 27

Appendix 3: BLS Algorithm 29

Appendix 4: Choking Algorithm 30

Appendix 5: Anaphylaxis Algorithm 31

Appendix 6: Opiate Overdose Algorithm 32

Appendix 7: Sepsis Screening Tool 33

Appendix 8: Datix CPR Audit form example 34

Appendix 9: DNA-CPR Proforma 35

18 Equality Impact Assessment 36

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1. Introduction

This Policy has been developed in order to achieve a consistent approach to Cardio Pulmonary Resuscitation (CPR) and the prevention and management of the deteriorating patient across all community settings within Camden and Islington NHS Foundation Trust (C&I). The policy has been developed to take account of organisational changes and the need for a policy that reflects the varying needs of our services across the trust. As a result two Deteriorating Patient Policies have been developed to meet this, one that is directed towards Inpatient services and on that is directed toward all other clinical services. The Care Quality Commission (CQC) has not set clearly defined regulations around Resuscitation, but has instead given a broad statement that covers the response to a deteriorating patient: “The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.” CQC (2014) Regulation 12(2) (b) The CQC go on to advise that C&I services response to a deteriorating patient should be in line with the current nationally recognised guidelines, this would include:

Resuscitation Council (UK) (2014) Quality standards for cardiopulmonary resuscitation practice and training.

Resuscitation Council (UK)(2016) Decisions relating to Cardiopulmonary Resuscitation

NICE (2007) Acute illness in adults in hospital: recognising and responding to deterioration.

NICE (2013) Quality Standard for End of Life Care For Adults This document fully supports the recommendations for clinical practice and training in cardiopulmonary resuscitation published above and is in line with the C&I Risk management Strategy (2015) and NHSLA Risk Management Standards (2012). It has been developed in line with the following guidelines and they should be read alongside this policy:

Anaphylaxis Guidelines

Naloxone Guidelines

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Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonary resuscitation guidelines

2. Aims/Objectives or Purpose

This policy provides guidance for clinical staff working in the Trust so that they are able to:

Provide prompt, safe and appropriate CPR

Able to detect, prevent and manage the deteriorating patient and the subsequent actions that aim to prevent further deterioration

Follow the correct procedure for patients with ‘Do not attempt Cardio Pulmonary Resuscitation’ orders (DNA-CPR)

Follow due process for ensuring continual availability of resuscitation equipment

Ensure the training needs of staff are met

Monitor compliance with all of the above.

3. Scope of the policy This policy applies to any C&I Team or service that have any type of clinical contact with service users that have been defined as a Community Setting under definitions on page 10 and 11 of this policy, including:

Community Teams

Community Houses

Crisis Houses and Crisis Teams

Day Services

Corporate facilities that have any kind of service user presence

This policy applies to all staff that work within these teams or services that have any clinical contact with service users regardless of previous training or specialties.

4. Duties and responsibilities The Chief Executive has ultimate responsibility for ensuring that mechanisms are in place for the overall implementation, monitoring and revision of policy.

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The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, is responsible for ensuring:

In conjunction with the Policy Lead identifies resource implications to facilitate implementation and compliance.

Training and monitoring systems are in place.

Regular review of the policy takes place. Associate Divisional Directors are responsible for implementation of the policy within their own spheres of management and must ensure that:

All new and existing staff have access to and are informed of the policy

Ensure that local written procedures support and comply with the policy

Ensure the policy is reviewed regularly

Staff training needs are identified and met to enable implementation of the policy.

The Director of Nursing and People is responsible for ensuring:

This policy is reviewed and updated in a timely fashion, in liaison with medical, nursing, pharmacy, training and operational services staff.

That there is a current version of this policy on the Trust intranet and that staff are informed of any policy updates.

Provide six monthly reports to the Quality Committee on the resuscitation event audits, the audit of equipment and training activity in relation to CPR and the detection and management of the deteriorating patient and minutes/action plans from the Resuscitation Committee.

The Assistant Director for Learning & Development is responsible for ensuring that approved training programmes are provided by competent trainers to meet the standards required. The Resuscitation Committee and the Resuscitation Lead is responsible for:

Monitoring and recommending changes to practice ensuring adherence to nation resuscitation guidelines and standards

Recommending and planning adequate provision of training

Determining requirement for the choice of resuscitation equipment

Preparing policies relating to resuscitation and prevention of cardiac arrest

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Ensuring that current guidelines on resuscitation decisions (DNA-CPR) are reflected in the Trusts relevant policies.

Recording and reporting incidents in relation to resuscitation in which patients’ safety may have been at risk

Review and development of action plans based on audits of resuscitation incidents

Matrons, Operational Service managers and Team Managers are responsible for the implementation of CPR in their service area and must ensure that:

The staff they manage have read and understand the CPR Policy, attend training and follow up staff who do not attend

That teams have the correct equipment, that it is fit for purpose ensuring it is stored appropriately, is in date, is accessible, replaced immediately where necessary, audited for quality and that infection control standards are adhered to

Incident forms are correctly completed on Datix and submitted after each resuscitation incident

Recommendations from Resuscitation Committee and serious incident investigations are implemented in a timely fashion, including those from any simulation exercises on site

All clinical staff are responsible for:

Immediately alerting the appropriate response team in the event of a cardiac or potential cardiac emergency. Ensuring an ambulance has been alerted, that the most qualified member of staff in the management of a deteriorating patient leads and coordinates the response ensuring that all available interventions are used effectively. In the absence of nursing staff, it is the responsibility of the most senior staff present to manage the incident until the paramedic team take over

Practice within the current Resuscitation Council (UK) Guidelines (2014) and their own Codes of Professional Conduct

Attend the appropriate resuscitation training annually. This will be monitored by Line Managers and the Learning and Development department.

Participate in the weekly checking of emergency equipment to make sure the equipment is in a state of readiness at all times

Are familiar with the processes of following up any emergency equipment failure during use or checks

Follow the guidelines for assessing and managing the deteriorating patient

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Replenishing, replacing and ordering any emergency equipment used or expired in a timely fashion

All Trust staff are responsible for ensuring that they:

Are familiar with the content of the relevant policy and follow its requirements

Work within, and do not exceed, their own sphere of competence.

5. Definitions

Community Settings

All C&I services listed below for the purpose of this document are considered a Community Setting.

24 hour community units (All Divisions)

Community Mental Health Teams (Rehab and Recovery Division)

Community Mental Health Teams (Community Division)

Community Mental Health Teams (SAMHS)

Community Teams (Substance Misuse Service)

Crisis Teams and Houses

Day Services

This definition of community setting is only related to this document and should not be used as a general definition of services for any other purpose.

Cardiac Arrest

Is the cessation of effective pumping action of the heart. There is abrupt loss of consciousness and breathing stops. Unless treated promptly irreversible brain damage and death follow within minutes. The diagnosis of cardiac arrest is made by the first practitioner to note the signs of:

Sudden collapse;

Loss of responsiveness;

Absence of spontaneous respiration;

Appropriate treatment must be given immediately. If not, after three minutes cerebral damage will result. Cardiac arrest may occur for any number of reasons, however they tend it occur most commonly in the following situations:

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Existing or undiagnosed heart conditions

Blood loss

Overdose

Asphyxia

Hypoglycaemia

Anaphylaxis

Rapid tranquillisation

Respiratory diseases

Choking

Cardio-Pulmonary Resuscitation (CPR)

This is an emergency procedure for life support consisting of artificial respiration and manual external cardiac massage. It aims to establish effective circulation and ventilation in order to prevent irreversible brain damage and death.

Automated External Defibrillation (AED)

The Automated External Defibrillator is a computerised device that delivers defibrillator shocks to a patient in cardiac arrest. They use voice and visual prompts to guide staff. They analyse the heart rhythm to determine the need for a shock. The staff then deliver the shock when is has been ascertained that it is safe to do so.

Recognition of the Deteriorating Patient

This provides the essential skills and knowledge which are required to recognise the deteriorating patient and to instigate the appropriate actions. This includes being able to perform a basic set of physical observations, which consist of:

Temperature

Pulse

Respiratory Rate

Blood Pressure

Oxygen Saturation

Consciousness level

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Basic Life Support (BLS)

The provision of treatment designed to maintain adequate circulation and ventilation to a patient in cardiac arrest without the use of drugs or specialist equipment, until emergency services (999) arrive. Where a simple airway or facemask for mouth to mouth ventilation is used, this is defined as "basic life support with airway adjunct".

Anaphylaxis

Anaphylaxis is a severe, life threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing, life threatening problems involving: the airway (pharyngeal or laryngeal oedema) and / or breathing (bronchospasm and tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes. The acute reaction that occurs usually happens within seconds or minutes of an exposure to the antigen.

Opiate Overdose

Opioid overdose is an acute condition due to excessive opioids. Examples of opioids are: morphine, heroin, tramadol, oxycodone, and methadone. Death can be prevented in opioid overdoses if patients receive basic life support and the administration of naloxone soon after opioid overdose is suspected.

CPR Training

C&I has sourced training that includes and goes beyond the skills of BLS however remains basic in terms of Resuscitation. The adapted training includes:

Use of an AED

Use of Oxygen with a Bag Valve Mask on a person who is not breathing

Responding to a person who is choking

Responding to a person with an acute allergic reaction (Anaphylaxis)

Responding to a person who has taken a suspected opiate overdose

Immediate Life Support (ILS)

The provision of treatment designed to maintain adequate circulation and ventilation to a patient in cardiac arrest additionally using specialist drug and limited emergency equipment until emergency services (999) arrive. It is an

https://en.wikipedia.org/wiki/Acute_(medicine)

https://en.wikipedia.org/wiki/Opioids

https://en.wikipedia.org/wiki/Morphine

https://en.wikipedia.org/wiki/Heroin

https://en.wikipedia.org/wiki/Tramadol

https://en.wikipedia.org/wiki/Oxycodone

https://en.wikipedia.org/wiki/Methadone

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extended training from CPR that gives clinical staff further skills in managing the deteriorating patient. These additional areas include:

Identifying the causes and promote the prevention of cardiopulmonary arrest;

Recognising and treating the deteriorating patient using the ABCDE approach;

Undertake the skills of quality CPR and defibrillation (manual and /or AED) and simple airway manoeuvres;

Utilize non-technical skills to facilitate initial leadership and effective team membership

Do Not Attempt Cardio-Pulmonary Resuscitation (DNA-CPR)

A DNA-CPR order indicates that in the event of a cardiac arrest, CPR will not be initiated. DNAR decisions are the overall responsibility of the Consultant in charge of the patient’s care (GP in the case of nursing homes). Attempts at CPR will not be commenced when it has been assessed that a patient would not survive or when it is not the patient’s wishes. Please refer to section 12

6. Physical Health Monitoring

All physical observations recorded should use the Nations Early Warning (NEWS) scoring system including those taken on admission and on a weekly basis in all 24 hour community and crisis houses. Community mental health teams should also have the ability to monitor the basic physical health of a service user and use NEWS in an effective and cohesive way to monitor a deteriorating patient. The following NEWS clinical indication system shown below gives a basic guide on what is clinically indicated for the NEWS of the patient. Please refer to the trusts physical health and wellbeing policy for more information on NEWS:

A low score (NEW score 1–3) should prompt assessment by a competent registered nurse or doctor who should decide if a change to frequency of clinical monitoring or an escalation of clinical care is required (this can be phone contact with the duty doctor)

A medium score (NEW score of 4–6 or a RED score/score of 3 in a single parameter) should prompt an urgent review by a clinician skilled with competencies in the assessment of acute illness – usually a doctor or acute team nurse, who should consider whether escalation of care to a team with critical-care skills is required (i.e. A&E or Acute hospital)

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A high score (NEW score of 7 or more) should prompt emergency assessment by a clinical team/critical care outreach team with critical-care competencies. This in most circumstances will be your nearest A&E.

7. Emergency Equipment and Medical Devices for physical health

monitoring

All community settings must have available the following Emergency equipment and medications on all sites that facilitate service user visits:

Zoll AED with 2 sets of matching defibrillator pads

Bag Valve Mask

Ligature Cutters

Tough cut shears

High concentration oxygen mask

Face mask

Hand held suction device

Pen torch

Medications include: Oxygen naloxone Adrenaline for anaphylaxis

Where possible all emergency equipment must be stored in an easily accessible area that can be accessed by all staff. All emergency equipment must be kept together in an emergency bag and labeled with the poster shown in Appendix 1 (Full sized A4 posters can be purchased from SP Services on Agresso using the following catalogue number: SS/302). A full list of this equipment with NHS Supply Chain ordering numbers is available in Appendix 2. Oxygen can be ordered via BOC Medical using the following process: Please note that this should be behind a fire door in order to ensure safe storage of oxygen.

The following Medical Devices should be available to all mental health teams in

order to monitor the physical health of a deteriorating patient:

Sphygmomanometers (Electronic blood pressure machines can be used but

there should still be a sphygmomanometer available)

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Stethoscope

Pulse Oximeter

Thermometer

MEWS Charts

All medical devices must be routinely serviced in accordance with the trusts

Medical Devices Policy a local inventory of these devices should be updated

every six months. Medical gas cylinders must bear a label which includes the

filling date and the expiry date. Any equipment that needs to be replaced should

be done so promptly, ensuring that all necessary equipment is available at all

times. All repairs to emergency equipment must be reported immediately in

accordance with the medical devices policy

All equipment must be checked weekly using the Meridian Audit System using the

following link: https://www.oc-

meridian.com/candi/completion/custom/default.aspx?slid=206&did=

Any failure of medical devices should be reported via Datix and immediate repair

must be arranged in line with the Medical Devices Policy .

All Emergency Medication (apart from Oxygen in certain circumstances explained

below) will be delivered from the Trust pharmacy when required. If this medication

is expired or used you must inform the Trust Pharmacy immediately.

For all teams ordering oxygen outside of Highgate Mental Health Centre, teams

must email Pharmacy a request for Oxygen to the Pharmacy generic inbox, this

will be processed and delivery arranged via BOC Medical Supplies directly to your

team. Once your oxygen is received you must email Pharmacy to inform them of

delivery.

If your team is based in Highgate Mental Health Centre then you must email

Pharmacy a request for Oxygen to the Pharmacy generic inbox, this will be

processed and delivered to the Pharmacy on site and delivered to you by the

porters. You will not need to email pharmacy confirmation of receipt.

https://www.oc-meridian.com/candi/completion/custom/default.aspx?slid=206&did

https://www.oc-meridian.com/candi/completion/custom/default.aspx?slid=206&did

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If the teams are in a shared setting then the equipment can be shared amongst

the teams. However all equipment must be located in an area that is obtainable

by all staff. For all sites that chose to share equipment amongst teams there must

be a clear shared agreement that allows for rotation of auditing and ordering

equipment.

8. Managing a collapsed patient

Discovering a collapsed patient

In all instances where a patient is found collapsed or is a witnessed collapse and not breathing correctly the staff must follow the BLS Algorithm in Appendix 3, immediately summon help using the alarm system where available and shouting for help when not, the ambulance service must be called immediately and CPR commenced when indicated. All emergency equipment must be used where clinically indicated.

If you are not at your team base (i.e. in a patients home) then continue BLS Algorithm without emergency equipment.

Transient loss of consciousness

Transient loss of consciousness (TLoC) may be defined as spontaneous loss of consciousness with complete recovery. In this context, complete recovery would involve full recovery of consciousness without any residual neurological deficit. An episode of TLoC is often described as a 'blackout' or a 'collapse'. If someone reports or is suspected to have an episode of TLoC the following steps should be taken:

Record the details of the event, clinical history and physical examination on Care Notes

A 12-lead ECG should be offered during the initial assessment, if this is not possible they should be directed towards A&E to have this done

If any of the following is present then the patient must be immediately transferred to A&E with a recommendation to be seen by a Cardiologist

o An ECG abnormality, heart failure (history or physical signs) or a heart murmur

o TLoC during exertion

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o Family history of sudden cardiac death in people aged younger than 40 years and/or an inherited cardiac condition

o New or unexplained breathlessness

Choking

In instances where a patient is suspected of choking then follow the Choking Algorithm in Appendix 4. If there is any loss of consciousness then begin CPR using the BLS Algorithm in Appendix 3 and phone emergency services immediately. In all cases of loss of consciousness the service user must be transferred to A&E via ambulance. In cases where choking was alleviated quickly and effectively then the patient must be placed on frequent physical health monitoring. Use the NEWS clinical indication system described above to direct you.

Anaphylaxis

In instances where Anaphylaxis is indicated then follow the Anaphylactic Algorithm in Appendix 5. In all instances of a suspected anaphylactic episode the patient must be transferred to A&E via ambulance for monitoring and potential further treatment. Any use of Adrenaline for an anaphylactic episode must be reported via Datix and a new treatment kit requested from pharmacy immediately.

Anaphylaxis can be triggered by any of a very broad range of triggers, but those most commonly identified include food, drugs and venom. The relative importance of these varies very considerably with age, with food being particularly important in children and medicinal products being much more common triggers in older people. Virtually any food or class of drug can be implicated, although the classes of foods and drugs responsible for the majority of reactions are well described. Of foods, nuts are the most common cause; muscle relaxants, antibiotics, NSAIDs and aspirin are the most commonly implicated drugs.

Opiate overdose

In cases of suspected opiate overdose then naloxone should be given via inter-muscular injection. All incidents of suspected opiate overdose should follow the Opiate Overdose Algorithm in Appendix 6. In all incidents of suspected opiate overdose the patient should be transferred to A&E via ambulance for monitoring and potential further treatment. It is important to note that naloxone is a short acting drug and its effects will dissipate quickly. Attendance to A&E must be reinforced to the patient as essential as they are at risk of death if they do not attend. Any use of naloxone must be reported via Datix and a new treatment kit requested from pharmacy immediately.

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Emergency medicine advice suggests supplemental oxygen or bag-valve-mask ventilation where RR< 10/minute or Sp02<92% (on air). Regardless, the severity of respiratory depression defines the acuteness of toxicity, subsequent management and whether or not naloxone is indicated.

Lower initial dose regimens are considered of value where the situation is less immediately life-threatening or where a more controlled effect is desirable, for example palliative care and chronic opioid use. These regimes should only be administered by a doctor and used in line with the Trusts Naloxone Guidelines.

Sepsis

Sepsis, also referred to as blood poisoning or septicaemia, is a potentially life-threatening condition, triggered by an infection or injury. In sepsis, the body’s immune system goes into overdrive as it tries to fight an infection. This can reduce the blood supply to vital organs such as the brain, heart and kidneys. Without quick treatment, sepsis can lead to multiple organ failure and death. Any patient that has a NEWS of 3 or above without any obvious cause must be screened for Sepsis using the Sepsis Screening tool in Appendix 7. Where possible follow recommended treatments on the Sepsis Screening Tool, in all incidents of suspected Sepsis the patient must be transferred to A&E via and emergency ambulance for further treatment.

Handing over to the emergency services

When handing over to the paramedics it is imperative that all information is handed over in a concise and accurate manner. As such it is advised that the following method is used when handing over to paramedics.

S

Story:

Name of caller and ward

Name of patient

Patient’s relevant mental health, current physical health issues

Diagnosis and medication (Psychosis, Clozapine 800mg)

Why you have requested an ambulance (e.g. vomiting, feels unwell, breathlessness, pain, dizziness, fall)

Onset of symptoms (30mins, 2 hours, 1 day, 1 month)

O

Objective Observations (be specific do not use the terms high/low)

Temperature (38.2)

Pulse (120)

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BP (150/90)

Respirations (22)

Oxygen saturation (97%)

Conscious level (Unconscious)

ECG result if available

Blood results if available

S

Signs- report any abnormalities that you or the patient sees and tells you (LOOK, LISTEN AND FEEL)

Report any evidence of bleeding and location (sputum, abdomen, vomit)

Patient in pain, colour of skin (flushed, pale, blue), colour of sputum (green, white)

Abnormal sounds (wheezing, coughing)

Abnormal smells (ketones, urine, alcohol)

If the patient has been receiving CPR when the paramedics arrive ensure that you handover using the method above, in addition you must also include the following:

What time CPR began

How many shocks from the defibrillator have been delivered if any

What drugs have been given if any

If there is a DNA-CPR in place When speaking to the emergency services on the phone it is imperative that you communicate the severity of the incident in a clear and concise manner. If the patient is unconscious with abnormal breathing then hand this over immediately, ensure that the emergency services know the address of where you want them to attend and that there is a member of staff ready to meet them outside of the premises when they arrive.

Documenting all interventions when delivering CPR

When an incident occurs that involves a deteriorating patient or a collapsed patient it is essential that a member of staff records the times that interventions occurred. This allows staff to hand over correctly to the emergency services and the post incident investigation to be completed in an effective manner. The following should be noted:

Time patient discovered if collapsed

Time CPR began

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Time ambulance called

Time defibrillator attached

Number of defibrillator shocks delivered

Any drugs given

Any other equipment used

Staff involved

All of this information must be documented in the Datix that is completed for the

incident in the CPR Audit section. An example of this section can be seen in

Appendix 8.

9. Reporting incidents that include ill health and CPR attempts

Following an incident involving a deteriorating patient, the team leader or most

senior member of staff on duty must ensure that all documentation is completed

fully and accurately. An online incident form must be completed on Datix and in

the cases of a CPR attempt being made the CPR Audit section must be

completed. This will appear on Datix when any category relating to death or ill

health is selected, and example of the CPR Audit form can be found in Appendix

8. The Datix information will be compiled into an audit report by the

Resuscitation Lead and presented to the Quality Committee every 6 months.

In the event of a CPR attempt being made, the Divisional Manager/Matron or the

out-of-hours Senior Manager On-Call must be informed immediately, in the event

of a death the Director On-Call should be informed. If necessary, the Senior

Manager will visit the scene of the incident. In addition to this the following people

should then be contacted if they were not present:

Next of kin/significant other of the patient, although in the event of an

unexpected death the police will inform the relatives. Relatives will then be

given the opportunity to view the body at the mortuary (Refer to Policy &

Procedure relating to a Death on Foundation Trust Premises).

Consultant responsible for the care of the patient;

General practitioner (GP) to be informed at the earliest opportunity by the

consultant;

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In some instances the team might consider contacting the patient’s religious

minister, especially if the patient requires special religious procedures should

resuscitation be unsuccessful.

As soon as is reasonably possible but within 48 hours a staff debrief must take

place. Critical actions and information should be documented in the handler

section of the Datix related to the incident. However any other issues raised

around trauma or personal opinions of the incident should not be documented on

Datix. Any incident that involved the death of a patient should be referred to the

Trauma at Work Pathway (TAWP) that can be found in the same named policy.

10. Staff and Patient support following a traumatic event

Patient Support An incident such as a cardiac arrest can have an impact upon the service user and staff community, not just those involved with the resuscitation attempt. Therefore, a patient support group/meeting should be held at the earliest opportunity where reasonable to provide support, advice and a time to discuss any relevant issues for patients as well as to identify the need for any one-to-one individual support. Staff Support It is recognised that staff involved in a serious incident may suffer a high level of stress or trauma. Support and counselling should be available immediately to either individuals or the team. Support may be provided by senior colleagues or a multi-professional support group could be held at a later date if necessary or requested. Effected staff and Team Leaders are advised to refer to the Trauma at Work Pathway (TAWP) for any incidents that involved the use of CPR or unexpected death of a patient.

11. Decisions relating to not attempting CPR (DNA-CPR)

For the vast majority of patients entering community settings, the likelihood of rapid deterioration is small, however there may be occasions when advance decisions about CPR have been made.

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The overall responsibility for making advance decisions rests with the consultant

or general practitioner in charge of the patient’s care. However, he/she should

discuss the decision for an individual patient with other health professionals and

those close to the patient. It might also be helpful to discuss decisions at the

multidisciplinary team meetings.

Following a decision not to resuscitate, there must be a clear line of communication between medical and nursing staff. The decision, especially the basis for it, must be clearly documented on Care Notes and the completed Cardiopulmonary Resuscitation Decision Proforma attached to Care Notes (Appendix 9). It is the responsibility of the team’s senior medical staff together with their nursing colleagues to discuss the reasons for non-resuscitation with the patient (if s/he is able to understand the information), all members of the multidisciplinary team and the patient’s relatives. The decision not to resuscitate a patient does not and must not preclude the rights of the patient to receive and the duty of practitioners to provide all other appropriate nursing and medical care available. It is advised that all staff involved in the decision making process of completing DNA-CPR documentation read the Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonary resuscitation guidelines. This will provide you with all information relating to how and when to make these decisions.

12. Dissemination and implementation arrangements

This document will be circulated to all managers who will be required to cascade the information to members of their teams. It is available to all staff via the Foundation Trust intranet. Managers will ensure that all staff are briefed on its contents and on what it means for them.

Any enquiries regarding the implementation of this policy should be directed to the Clinical Policy Officer or Resuscitation Lead.

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13. Training requirements

All staff that have clinical contact must complete the Trusts CPR training as a minimum standard of Resuscitation Training in accordance with the Trusts Mandatory Training policy. For all staff that have valid ILS of ALS Training in date then CPR training does not need to be completed until this training has expired.

For training requirements please refer to the Trust’s Mandatory Training Policy and Learning and Development Guide http://cift-ap02/sorce/

14. Monitoring and audit arrangements

http://cift-ap02/sorce/

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Elements to be monitored

Lead How trust will monitor

compliance

Frequency Reporting arrangements

Acting on recommendations

and leads

Changes in practice and lessons to be shared

The duties Resuscitation Lead

Audit of:

Care notes

MEWS forms

6 monthly Resuscitation Committee

Required actions will be identified and completed in a specified timeframe

Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

That early warning systems are in place for the recognition of patients at risk of deteriorating

Resuscitation Lead

Audit of:

MEWS forms

Care notes

Datix forms


Actions to be taken to minimise or prevent further deterioration in patients

Resuscitation Lead

Audit of:

Care Notes

Physical health Care plans


Do not attempt CPR orders (DNA-CPR)

Resuscitation Lead

Audit of all DNA-CPR forms


Audit of CPR events Resuscitation Lead

Audit of

Datix incident forms

Care notes

SUI’s


Checking of

resuscitation

equipment

Resuscitation Lead

Audit of Meridian

Weekly Resuscitation

Committee

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15. Review of the policy

This policy will be reviewed in July 2018 or earlier if there is a significant change

in practice or new regulation.

16. References

Care Quality Commission (2015) Guidance for Providers on Meeting the Regulations. London Available at: http://www.cqc.org.uk/content/regulations-service-providers-and-managers Department of Health (2009) Competencies for Recognising and Responding to Acutely ill Patients in hospital. London European Resuscitation Council (2010) European Resuscitation Council Guidelines for Resuscitation. Elsvier. Available at: http://www.journals.elsevier.com/resuscitation Houses of Parliament (2008) Health and Social Care Act (Regulated Activities) Regulations 2014 (Part 3), No: 2936. London. Available at: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 National Confidential Enquiry into Patient Outcome and Death (2012) Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. London. Available at: http://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf National Institute of Health and Clinical Excellence (2007) Acutely ill patients in hospital. Recognition of and response to acute illness in adult hospitals. London. Available at: http://www.nice.org.uk/guidance/CG50 National Institute of Health and Clinical Excellence (2016) Sepsis. Available at: https://www.nice.org.uk/guidance/ng51 National Institute of Health and Clinical Excellence (2015) Violence and Aggression: Short-term management in Mental Health and Community settings. London. Available at: http://www.nice.org.uk/guidance/NG10

http://www.cqc.org.uk/content/regulations-service-providers-and-managers

http://www.cqc.org.uk/content/regulations-service-providers-and-managers

http://www.journals.elsevier.com/resuscitation

http://www.legislation.gov.uk/ukdsi/2014/9780111117613

http://www.legislation.gov.uk/ukdsi/2014/9780111117613

http://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf

http://www.nice.org.uk/guidance/CG50

https://www.nice.org.uk/guidance/ng51

http://www.nice.org.uk/guidance/NG10

25


National Institute of Health and Clinical Excellence (2015) Transient loss of consciousness ('blackouts') in over 16s. London. Available at: https://www.nice.org.uk/guidance/cg109 Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London. Available at: http://www.nmc.org.uk/standards/code Resuscitation Council (UK) (2014) Quality standards for cardiopulmonary resuscitation practice and training. London. Available at: https://www.resus.org.uk/quality-standards/mental-health-inpatient-care-quality-standards/ Resuscitation Council (2015) Consensus Paper on out of hospital Cardiac Arrest in England. London. Available at: https://www.resus.org.uk/publications/consensus-paper-on-out-of-hospital-cardiac-arrest-in-england/

Resuscitation Council (2016) Advanced Life Support (7th Edition) London.

Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonary resuscitation. London. Available at: https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr

The Sepsis UK Trust (2016) Prehospital management of Sepsis in adults and young people over 12 years. London. Available at: http://sepsistrust.org/wp-content/uploads/2016/07/PH-toolkit-FINAL-2.pdf

17. Associated documents CPR: Deteriorating Patient Policy – CL07

Mental Capacity Act Policy – MHA12

Medical Devices Policy – RM04

Physical Health and Well Being Policy – CL21

Mandatory Training Policy and Learning and Development Guide

https://www.nice.org.uk/guidance/cg109

http://www.nmc.org.uk/standards/code

https://www.resus.org.uk/quality-standards/mental-health-inpatient-care-quality-standards/

https://www.resus.org.uk/quality-standards/mental-health-inpatient-care-quality-standards/

https://www.resus.org.uk/publications/consensus-paper-on-out-of-hospital-cardiac-arrest-in-england/

https://www.resus.org.uk/publications/consensus-paper-on-out-of-hospital-cardiac-arrest-in-england/

https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr

https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr

http://sepsistrust.org/wp-content/uploads/2016/07/PH-toolkit-FINAL-2.pdf

http://sepsistrust.org/wp-content/uploads/2016/07/PH-toolkit-FINAL-2.pdf

26


Appendix 1 Defibrillator Poster

27


Appendix 2 Community setting emergency equipment and drug list

For all items, please check expiry dates, integrity of sterile packaging, contents, quantities and sizes, correct location, and correct labelling. All emergency equipment must be checked weekly. TEAM: SITE: ITEM Grab Bag AMOUNT NHS Supply

Chain Number EXPIRY DATE

Checked by/date

Fishtail Knife (Ligature Cutter)

1

Toughcut Shears 1 SI/016 (SP Services)

Stethoscope 1 FFE317 Razor 1 Pen Torch 1 FFE066 Zoll AED (Pads attached & Battery Checked)

1

Zoll AED Pads

2 8900-0800-01 (Zoll Suppliers)

Oxygen Cylinder

1 Ordered from Bio Medical

Resuscitator manual (bag-valve-mask) disposable Adult with size 5 mask

1 FDE373

High Concentration Oxygen Mask

1 FDD111

Ezy Face Mask 1 RE/008 (SP Services)

Hand Held Suction Device

1 RE/021 (SP Services)

28


Emergency Drugs available to all Community setting Teams and Services

Drug Strength Quantity Rational for

Use Expiry Date

Checked by/date

Adrenaline IM injection

(epinephrin

e)

1mg in 1ml (1 in 1,000)

1 x Epipen

10 x

0.5ml amps

Anaphylaxis

Naloxone IV or IM

injection

400mcg/1ml

3 Pre-filled

Syringes (minijet)

Opioid overdose

29


Appendix 3 Basic Life Support Algorithm

30


Appendix 4 Choking Algorithm

31


Appendix 5 Anaphylaxis Algorithm

32


Appendix 6 Opiate Overdose Algorithm

If the patient is unresponsive and not breathing normally begin CPR

using BLS Algorithm

Administer 400 micrograms naloxone I/M as soon as it arrives

Suspected Opiate overdose O2 Saturation <92% on Oxygen or Respiratory Rate <10 breaths

per minute

Repeat every 2-3 minutes. Each dose is given in subsequent

resuscitation cycles if the patient is not breathing normally

Continue process until an effect is noted, breathing is normal or the

ambulance arrives

33


Appendix 7 Sepsis Screening Tool

34


Appendix 8 Datix CPR Audit Form

35


Appendix 9 DNA-CPR Proforma

36


18. Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A

Documents

RECOGNISING AND RESPONDING TO THE PHYSICALLY … · Cardio-Pulmonary Resuscitation (CPR) This is an emergency procedure for life support consisting of artificial respiration and manual