An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
NHS Ambulance Trust
An Organisation-wide Document for the Management
of the Risks Associated with Resuscitation
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
Contents
1
Introduction ............................................................................................................. 4
2
Purpose .................................................................................................................... 4
3
Explanation of Terms ............................................................................................... 4
4
Duties ....................................................................................................................... 4
4.1
4.2
5
Duties within the Organisation ............................................................................................... 4
Committees and Groups with Overarching Responsibilities .................................................. 5
Resuscitation Equipment ......................................................................................... 6
5.1
5.2
5.3
5.4
Equipment Utilised During and Post Resuscitation ................................................................ 6
Location of Equipment ............................................................................................................ 6
Maintenance of Equipment .................................................................................................... 7
Authorised Users of the Equipment ....................................................................................... 7
6
Resuscitation Training .............................................................................................. 7
7
Post Resuscitation Care ........................................................................................... 8
7.1
7.2
8
Return of a Spontaneous Pulse ............................................................................................... 8
Recognition of Life Extinct Guidelines (ROLE) ......................................................................... 8
Special Circumstances.............................................................................................. 8
8.1
8.2
8.3
8.4
9
Condition of Patient ................................................................................................................ 9
Police Intervention .................................................................................................................. 9
Do Not Attempt Resuscitation Orders (DNAR) ....................................................................... 9
Advanced Directives (Living Wills) .......................................................................................... 9
Equality Impact Assessment .................................................................................... 9
10
10.1
10.2
11
11.1
11.2
12
Monitoring Compliance with the Document ....................................................... 9
Process for Monitoring Compliance ..................................................................................... 10
Standards/Key Performance Indicators ................................................................................ 10
References .......................................................................................................... 10
Legislation ............................................................................................................................. 10
Guidance from Other Organisations ..................................................................................... 10
Associated Documentation ................................................................................ 11
Appendix A - Template Document for Managing the Risks Associated with
Resuscitation................................................................................................................. 13
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
Review and Amendment Log
Version No
Type of Change
Date
Description of change
V.3
Annual review
Mar 2011
Update to section 11 ‘References’
Review against updated Resuscitation
Guidelines
V.3
Amendment
Mar 2011
Addition of amendment log
Addition of example of definition
Addition of examples of associated documents
V.4
Annual review
Mar 2012
Update to section 4 ‘Duties’
Update to section 5 ‘Resuscitation Equipment’
Update to section 11 ‘References’
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details
of all the requirements set out in sections 1-12, where relevant. The organisation may use this
template and adapt it to reflect procedures within the organisation or alternatively use a document
already in existence. Whichever approach is used the organisation must ensure it is compliant with
the minimum requirements of the relevant National Health Service Litigation Authority (NHSLA) Risk
Management Standards.
a
To assist the organisation, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant NHSLA Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the organisation in
relation to style and format of documentation. Please note that a template document entitled An
Organisation-wide Document for the Development and Management of Procedural Documents can
be found on the NHSLA website which may provide the organisation with additional guidance.
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
1
Introduction
This section should give an overview stating the importance of having a process for
managing the risks associated with resuscitation. It should state that the overall aim of the
document is based on reducing clinical risk and increasing patient safety. It should recognise
this will be achieved through staff training and the awareness of risks associated with
resuscitation, including the introduction of appropriate measures to minimise these risks.
Reference could be made to any recently published significant legislative or guidance
documents.
2
Purpose
Within this section the organisation should provide the rationale for the development of the
document. It should include a description of how the organisation intends to ensure that
the process for managing risks associated with resuscitation is managed in the most
effective way. As a minimum the document should include details of each of the minimum
requirements within this process, as identified in the NHSLA Risk Management Standards for
Ambulance Trusts.
The document must describe the organisation’s whole systems approach to managing
resuscitation. It must ensure that there are clear procedures in place to inform and support
all those involved in the process.
3
Explanation of Terms
This section should provide definitions of the terms used within the context of the
document. For example:

DNAR (do not attempt resuscitation)
An order agreed within a health care delivery setting which informs health and social care
professionals not to resuscitate the patient
The following list is a guide only and is not exhaustive:
a
4

Continual availability (of resuscitation equipment)

Training needs analysis

ROLE (recognition of life extinct)

Living wills
Duties
Give a brief overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process. This section should be a brief overview only
and the details of the process for managing this should be incorporated within later sections
of the document. The following list is a guide only and is not exhaustive:
4.1
Duties within the Organisation
Some example responsibilities have been identified below; however, these should
be considered within the context of the individual organisational structure.
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
Chief Executive
This section should state that the chief executive is ultimately accountable for the
implementation of this organisation-wide process.
Individual Professional Responsibilities
This section should define the responsibilities of all clinical staff and any other staff
who are involved in the resuscitation of patients. It should include paramedics,
technicians, extended care practitioners, emergency care assistants, as well as
others, such as those working in the emergency operations centre.
Education Manager
The roles and responsibilities of the individual who has overall responsibility for the
day to day management of education should be documented. This section should
include a description of the management of resuscitation training and
implementation of any associated clinical guidelines.
Education Staff
The roles and responsibilities of all those involved in the day to day delivery of
resuscitation training and implementation of any associated clinical guidelines
should be documented.
Manager(s)
The roles and responsibilities of manager(s) involved in the process for managing the
risks associated with resuscitation should be documented. This section should
include a description of their specific duties relating to the implementation of
resuscitation procedures and any associated clinical guidelines.
All Staff
This section should define the responsibilities of all staff. It should emphasise the
individual responsibilities of all staff in relation to undertaking training and providing
resuscitation where appropriate.
4.2
Committees and Groups with Overarching Responsibilities
Trust Board
For effective implementation of the Organisation-wide Document for the
Management of the Risks Associated with Resuscitation there must be active support
from the most senior members of the organisation. Organisations should detail how
the chief executive and the nominated directors are to gain assurance that this
document is being implemented within the organisation. There must be effective
cooperation at all levels of the organisation in order for this process to be successful.
Committees/Groups
The roles and responsibilities of the committee that is instrumental in the decisions
relating to resuscitation should be documented. The section should include:

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how this committee/group links with all the other relevant risk management
committees;
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation

the role this committee/group has with ensuring continuous development of
this document;

the role the committee/group has in the analysis of the management of
resuscitation;

how this committee/group communicates both up to board level, and down
to the local management levels; and

how the committee/group facilitates organisational learning and
improvement as a result of monitoring the provision of staff support
mechanisms.
It would be considered good practice if the organisation developed terms of
reference for this committee/group including: accountability, responsibility,
authority, membership (including identified co-opted members and deputies),
meeting schedule and quorum, etc. In addition the terms of reference should be
dated and signed.
b
5
Resuscitation Equipment
This section should provide a description of the process for ensuring the continual
availability of resuscitation equipment. This should include a description of the equipment
utilised in the process of resuscitation and aftercare, and how the organisation ensures that
it is checked, stocked and fit for use. This can be summarised under the headings below.
Please note this is not an exhaustive list and the organisation may wish to include additional
headings. Reference could be made here to other related procedural documents.
5.1
Equipment Utilised During and Post Resuscitation
The equipment utilised in the resuscitation of patients and in their aftercare should
be documented. Consideration should be given to all items of equipment, such as:
5.2

basic airway adjuncts, for example, oropharyngeal airways;

advanced airway adjuncts, for example, laryngeal mask airways, tracheal
tubes, cricothyroidotomy kits;

automatic resuscitators and ventilators;

manual ventilators, for example, bag and mask;

intravenous cannulation equipment;

oxygen administration equipment;

suction equipment;

defibrillators (manual and automatic); and

monitoring equipment, for example, ECG, BP, capnography, pulse oximetry.
Location of Equipment
The location of the various items of equipment should be documented for all of the
environments within which they are expected to be utilised. Consideration should
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
be given to ambulance premises, vehicles and the community setting. This section
should provide a description of the process for ensuring the continual availability of
resuscitation equipment in each of these environments.
5.3
Maintenance of Equipment
This section should provide a description of the process for ensuring the continual
serviceability of resuscitation equipment in all environments. This should include
how and when it is checked and how the organisation makes sure it is fit for use.
5.4
Authorised Users of the Equipment
It is anticipated that there are different grades of staff, which may be permanent,
temporary or voluntary, who are authorised to use equipment utilised in the
resuscitation of patients and in their aftercare. The equipment they are authorised
to use may vary dependant on grade, employment status or work environment. The
authorised users of each item of equipment should be documented.
c
6
Resuscitation Training
This section should provide a description of the process for resuscitation training which
should embody the statements and guidelines published, including those by the
Resuscitation Council (UK), the European Resuscitation Council, the Joint Royal Colleges
Ambulance Liaison Committee UK Ambulance Service Clinical Practice Guidelines,
incorporating the most recent versions.
It is expected that each organisation will provide sufficient and appropriate resuscitation
training for each staff group and set this out within the organisational training needs
analysis. The training provided should be appropriate to grade and job role, and should take
into consideration both local and national guidelines.
Resuscitation training programmes should include:

adult basic life support;

child basic life support;

adult advanced life support;

child advanced life support; and

newborn life support.
They should also take into account subjects, such as the management of:
V.4

patients with implanted defibrillators;

patients with implanted cardioverter pacemakers;

laryngectomy patients;

tracheostomy patients;

bariatric patients;

cervical spine injury patients;
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
resuscitation in pregnancy;

traumatic cardiac arrest;

dealing with the death of a child (including sudden unexpected death in infancy);

death in a public place;

role of HM Coroner and the Police; and

communication links with other healthcare providers.
Particular emphasis should be placed on subjects, such as:

moving and handling of patients and equipment;

infection prevention and control; and

medicines management.
Reference should be made here to the organisation’s procedural training document and in
particular to the training needs analysis, however it is not expected that such information is
duplicated within this section.
7
Post Resuscitation Care
This section should provide a description of the process for providing care to patients
following resuscitation. This should consider the location of the patient and the prevailing
circumstances, and provide detail of any minimum standards of care. This can be
summarised under the following headings. Please note this is not an exhaustive list and the
organisation may wish to include additional headings.
Reference could be made here to statements and guidelines published, including those by
the Resuscitation Council (UK), the European Resuscitation Council, the Joint Royal Colleges
Ambulance Liaison Committee UK Ambulance Service Clinical Practice Guidelines,
incorporating the most recent versions.
7.1
Return of a Spontaneous Pulse
There are a number of situations in which this may occur, including: in the patient’s
home, in a public place or during conveyance to a healthcare facility. This section
should provide details of any specific local guidelines, including details of any
minimum standards of patient observation and management. Detail should also be
provided of any specific documentation that should be completed as part of this
process.
d
7.2
Recognition of Life Extinct Guidelines (ROLE)
This section should provide a description of the process for recognising life extinct
following commencement of resuscitation procedures. This should include details of
any specific local guidelines, including details of any minimum standards of patient
observation and management. Detail should also be provided for any specific
documentation that should be completed as part of this process.
8
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Special Circumstances
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This section should provide a description of the circumstances where resuscitation cannot
be commenced. This should consider the location of the patient and the prevailing
circumstances, and provide detail of any minimum standards of care. This can be
summarised under the headings below. Please note that this is not an exhaustive list and
the organisation may wish to include additional headings.
Reference could be made here to statements and guidelines published, including those by
the Resuscitation Council (UK), the European Resuscitation Council, the Joint Royal Colleges
Ambulance Liaison Committee UK Ambulance Service Clinical Practice Guidelines,
incorporating the most recent versions.
8.1
Condition of Patient
There are a number of situations in which due to the physical condition of the
patient resuscitation would not be possible, including: mutilation, the presence of
rigor mortis or post-mortem staining. This section should provide a description of
the procedures to be followed in these circumstances.
8.2
Police Intervention
There are circumstances involving a sudden death where the police may need to be
involved, including: an indication that the death was due to unnatural causes or
where there is reason to suspect a crime has occurred. This section should provide a
description of the procedures to be followed in these circumstances.
e
8.3
Do Not Attempt Resuscitation Orders (DNAR)
There are circumstances where a formal DNAR order is in place for a patient found
to be in need of resuscitation. This section should provide a description of the
procedures to be followed in these circumstances. Consideration should be given to
the operational clinical staff and to those working in the emergency operations
centre.
8.4
Advanced Directives (Living Wills)
There are circumstances where an advanced directive is in place for a patient found
to be in need of resuscitation. This section should provide a description of the
procedures to be followed in these circumstances. Consideration should be given to
the operational clinical staff and to those working in the emergency operations
centre.
9
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
f
10
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Monitoring Compliance with the Document
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10.1
Process for Monitoring Compliance
This section should identify how the organisation plans to monitor compliance with
the Organisation-wide Document for Managing the Risks Associated with
Resuscitation. As a minimum it should include the review/monitoring of all the
minimum requirements within the NHSLA Risk Management Standards. The
following list is a guide to issues which could be considered within this section and
should be added to where appropriate:
10.2

Who will perform the monitoring?

When will the monitoring be performed?

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?

How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
11
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
Listed below are some useful sources of reference material:
V.4
11.1
Legislation

Mental Health Act 1983 (as amended by the Mental Health Act 2007)

Mental Capacity Act 2005
11.2
Guidance from Other Organisations

Advanced Life Support Group and Resuscitation Council (UK) (2008) Pocket guide to
teaching medical instructors

British Medical Association, the Resuscitation Council (UK) and the Royal College of
Nursing (2007) Decisions relating to cardiopulmonary resuscitation

Department of Health (2000) HSC 2000/28 Resuscitation Policy

European Resuscitation Council (2010) European Resuscitation Council Guidelines for
Resuscitation 2010

General Medical Council (2010) Treatment and care towards the end of life: good
practice in decision making
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
Institute of Health and Care Development (IHCD) (2004) Paramedic Training Manual

Institute of Health and Care Development (IHCD) (2006) First Person on Scene - Basic
and Intermediate

Joint Royal Colleges Ambulance Liaison Committee (2006) UK Ambulance Service
Clinical Practice Guidelines

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007)
Emergency admissions: A journey in the right direction

Resuscitation Council (UK) website provides further guidance and info on
resuscitation: www.resus.org.uk

12

Decisions relating to cardiopulmonary resuscitation: A joint statement from
the British Medical Association, the Resuscitation Council (UK) and the Royal
College of Nursing (2007)

Cardiopulmonary Resuscitation: Standards for Clinical Practice and Training
(2008 [2004])

Emergency Treatment of Anaphylactic Reactions - Guidelines for Healthcare
Providers (2008)

Guidance for Safer Handling during Resuscitation in Healthcare Settings.
(2009)

‘Recommended standards for recording - Do not attempt resuscitation
(DNAR) decisions’. Resuscitation Council website (2009)

Resuscitation Guidelines 2010 (2010)

The Legal Status of those who attempt Resuscitation (2010)

Immediate Life Support (3rd edition). (2011)

Adult Advanced Life Support (6th edition). (2011)
Working group of the Resuscitation Council (UK) (2008) Emergency Treatment of
Anaphylactic Reactions - Guidelines for Healthcare Providers
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s).
The following list is a guide only and is not exhaustive:
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
Statutory and mandatory training

Defibrillation use

Prevention and control of infection/decontamination of medical devices

Procurement of equipment/medical devices
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
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Paediatric
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
Appendix A - Template Document for Managing the Risks Associated with
Resuscitation
NHS Trust
An Organisation-wide Document for Managing the Risks
Associated with Resuscitation
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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An Organisation-wide Document for the Management of the Risks Associated with Resuscitation
Contents
1
Introduction ........................................................................................................... 16
2
Purpose .................................................................................................................. 16
3
Explanation of Terms ............................................................................................. 16
4
Duties ..................................................................................................................... 16
4.1
4.2
5
Duties within the Organisation ............................................................................................. 16
Committees and Groups with Overarching Responsibilities ................................................ 16
Resuscitation Equipment ....................................................................................... 16
5.1
5.2
5.3
5.4
Equipment Utilised During and Post Resuscitation .............................................................. 16
Location of Equipment .......................................................................................................... 16
Maintenance of Equipment .................................................................................................. 16
Authorised Users of Equipment ............................................................................................ 16
6
Resuscitation Training ............................................................................................ 16
7
Post Resuscitation Care ......................................................................................... 16
7.1
7.2
8
Return of a Spontaneous Pulse ............................................................................................. 16
Recognition of Life Extinct Guidelines (ROLE) ....................................................................... 16
Special Circumstances............................................................................................ 17
8.1
8.2
8.3
8.4
9
Condition of Patient .............................................................................................................. 17
Police Intervention ................................................................................................................ 17
Do Not Attempt Resuscitation Orders (DNAR) ..................................................................... 17
Advanced Directives (Living Wills) ........................................................................................ 17
Equality Impact Assessment .................................................................................. 17
10
10.1
10.2
11
11.1
11.2
12
Monitoring Compliance with the Document ..................................................... 17
Process for Monitoring Compliance ..................................................................................... 17
Standards/Key Performance Indicators ................................................................................ 17
References .......................................................................................................... 17
Legislation ............................................................................................................................. 17
Guidance from Other Organisations ..................................................................................... 17
Associated Documentation ................................................................................ 17
Appendix A
Checklist for the Review and Approval of Procedural Documents ...... 17
Appendix B
Version Control Sheet ........................................................................... 17
Appendix C
Plan for Dissemination .......................................................................... 17
Appendix D
Equality Impact Assessment Tool ......................................................... 17
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Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment Tool can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
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1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
5
4.1
Duties within the Organisation
4.2
Committees and Groups with Overarching Responsibilities
Resuscitation Equipment
5.1
Equipment Utilised During and Post Resuscitation
5.2
Location of Equipment
5.3
Maintenance of Equipment
5.4
Authorised Users of Equipment
6
Resuscitation Training
7
Post Resuscitation Care
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7.1
Return of a Spontaneous Pulse
7.2
Recognition of Life Extinct Guidelines (ROLE)
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8
Special Circumstances
8.1
Condition of Patient
8.2
Police Intervention
8.3
Do Not Attempt Resuscitation Orders (DNAR)
8.4
Advanced Directives (Living Wills)
9
Equality Impact Assessment
10
Monitoring Compliance with the Document
11
12
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10.1
Process for Monitoring Compliance
10.2
Standards/Key Performance Indicators
References
11.1
Legislation
11.2
Guidance from Other Organisations
Associated Documentation
Appendix A
Checklist for the Review and Approval of Procedural Documents
Appendix B
Version Control Sheet
Appendix C
Plan for Dissemination
Appendix D
Equality Impact Assessment Tool
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