Cardiopulmonary Resuscitation
Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary
Resuscitation Policy
Version 10
Code:
STHK0025
Policy Sponsor
Anne-Marie Stretch
Lead Executive
Medical Director
Recommended by:
Resuscitation Committee
Date Approved :
1 March 2014
Approved
Clinical Effectiveness Council
by:
Date Approved :
1 March 2014
Author(s):
Head of Resuscitation Services
Date issued:
1 March 2014
Review date:
1 March 2017
Target audience:
All Trust Staff
Document purpose
To provide Trust Staff with direction and guidance for
the planning and implementation of a high-quality and
robust resuscitation service to the organisation.
Training requirements
Refer to Trusts Induction, Mandatory and Risk
Management Training Policy 2011
ASSOCIATED DOCUMENTS AND KEY REFERENCES
Operational Policy for the Whiston Medical Emergency Team 1st Edition 2011 (Ref 1)
International Guidelines 2010 for CPR and Emergency Cardiac Care (ECC) (Ref 2)
The Resuscitation Council (UK) Guidelines (2010) (Ref 3) http://www.resus.org.uk/
Trust MEWS Policy (Ref 4).
Medical Emergency Team (Ref 5)
Induction Mandatory and Risk Management Training Policy (Ref 6)
Cardio Pulmonary Resuscitation (CPR) Standards for Clinical Practice and Training, published by the Resuscitation Council (UK) ( amended
2008) (Ref 7).
The Care Quality Commission http://www.cqc.org.uk/ (Ref 8)
NHSLA Risk Management Standards 2010/2011 (Ref 9)
http://www.nhsla.com/safety/Documents/NHS%20LA%20Risk%20Management%20Standards%202013-14.doc
Quality Standards for cardiopulmonary resuscitation practice and training. http://www.resus.org.uk/pages/QSCPR_Main.htm (Ref 10)
Trust document: General Guidance Mental Capacity Act 2005) Version 2 July 2007 (Ref 11).
Trust’s Policy for Resuscitation of Laryngectomy & Tracheostomy Patients) (Ref 12)
Trust’s Newborn Resuscitation Policy (Ref 13)
European Resuscitation Council 2010 Guidelines, https://www.erc.edu/index.php/mainpage/en/ (Ref 14)
Policy for Safe Handling of Patients and Inanimate Loads (Ref 15)
Guidance for safer handling during resuscitation in healthcare (Resuscitation Council (UK) http://www.resus.org.uk/pages/safehand.pdf (Ref
16)
Moving and Handling during cardiac arrest (Resuscitation Council (UK ) (Ref 17)
Trust Protocol for the Immediate Treatment of Anaphylactic Reactions in Adults May 2009 - April 2012 (Ref 18)
Time to Intervene NCEPOD 2012 (Ref 19)
Trust Procurement Policy (Ref 20)
SUI and Incident Reporting Policy (Ref 21)
Advance Decision to Refuse Treatment (Ref 22)
Human Rights Act 1988 (http://www.legislation.gov.uk/ukpga/1998/42/contents Ref 23)
Association of Anaesthetists of Great Britain & Ireland (AAGBI) http://www.aagbi.org/publications/guidelines/docs/dnar_09.pdf. (Ref 24)
National Cardiac Arrest Audit. https://ncaa.icnarc.org (Ref 25)
MET Audit Tool (Appendix 1)
Unified Do Not Attempt Cardiopulmonary Resuscitation NHS North West 2013 (Appendix 2)
Unified Do Not Attempt Cardiopulmonary Resuscitation algorithm (Appendix 3)
Consultation, Communication and Implementation
Date
Consultation Required Authorised By
Authorised
Analysis of the effects
Paul Craven
13/02/2014
on equality
External Stakeholders None
Trust
Resuscitation
Committee Consulted Start date: 10/03/2014
Comments
No adverse effects
End Date: 24/03/2014
Describe the Implementation Plan for the Policy (and
guideline if impacts upon policy)
Timeframe
(Considerations include; launch event, awareness sessions,
implementation
communication / training via Divisions and other management
structures, etc)
Staff Informed of changes to uDNACPR via vodcast on Trust
Jan - March 2014
Intranet
Trust mandatory training
On-going
for
RAG
Who is responsible for delivery
Green
Head of Resuscitation Services
Green
Head of Resuscitation Services
St Helens & Knowsley Teaching Hospitals NHS Trust
Cardiopulmonary Resuscitation Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
Page 3 of 42
Monitoring Compliance with the Policy
Describe Key Performance Indicators (KPIs)
Implementation of uDNACPR/DNACPR
How will the KPI
Monitored?
Ad hoc audits and annual
Trust wide audit
be Which Committee will
Monitor this KPI?
Clinical Effectiveness
Council
Post Resuscitation care process is in place and
implemented according to policy standards.
All Cardiac Arrest
Resuscitation is reviewed by
Resuscitation Services by
monitoring:
- Audit of the processes
outlined within this policy.
- Monitored against an
implementation plan outlined
as per section 5.10 of the
policy.
- Review of incident /
performance data to assess the
effectiveness of the above.
Trust Resuscitation
Committee which
monitors this standard
as a standing agenda
item.
DNA-CPR process is in place and implemented
effectively according to this policy standards
All Cardiac Arrest
Resuscitation is reviewed by
Resuscitation Services
by monitoring:
- Audit of the processes
outlined within this policy.
- Progress report against an
implementation plan outlined
as per section 5.16 of the
policy.
- Review of incident /
Trust Resuscitation
Committee which
monitors this standard
as a standing agenda
item
St Helens & Knowsley Teaching Hospitals NHS Trust
Cardiopulmonary Resuscitation Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
Page 4 of 42
Frequency
of Review
Ad hoc
audit
Quarterly.
Trust wide
audit
annually
Quarterly
Lead
Quarterly
Chair of Trust
Resuscitation
Committee/
Head of
Resuscitation
Services
Head of
Resuscitation
Services
Head of
Resuscitation
Services
performance data to assess the
effectiveness of the above.
Ensure the continual availability of
resuscitation equipment is implemented in
accordance with this policy standards
Training for staff reflects the Trust training
needs analysis
Annual Audit of all Trust
Resuscitation Trolleys
Trust Resuscitation
Committee
Annually
Learning and Development
audit and monitor
attendance. Emails are sent
to non-compliant
wards/departments
Human Resources
Committee
Quarterly
St Helens & Knowsley Teaching Hospitals NHS Trust
Cardiopulmonary Resuscitation Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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Head of
Resuscitation
Services
Assistant Director
of Organisational
Development
Performance Management of the Policy
Who is Responsible for Producing Action Plans if KPIs are not met? Which committee will monitor these action plans?
Head of Resuscitation Services
Clinical Effectiveness Council and Resuscitation
Committee
How will Learning occur?
Trust Mandatory Training (please refer to Trust Training Needs Analysis)
Archiving including retrieval of archived document
This will be stored electronically
Document Version History
DateVersion
Version
Author Designation
01/12/2010
6
Head of Resuscitation
Services
Frequency of Review
(To
be
agreed
Committee)
Quarterly
Who is responsible
Head of Resuscitation Services
By whom will policy be archived and retrieved
IT
Summary of key changes
Changes due to Resuscitation Council (UK) guideline
18/07/2011
7
Head of Resuscitation
Services
Changes due to DNACPR
19/12/2011
8
Head of Resuscitation
Services
Changes due to the introduction of the Medical Emergency Team 09/01/2012
23/10/2013
9
Head of Resuscitation
Services
Changes due to the introduction of the Unified DNACPR (Lilac Forms) 03/02/2014
10/03/2014
10
Head of Resuscitation
Services
Review of whole policy required due to changes required in some processes (uDNACPR,
ICD’s)
St Helens & Knowsley Teaching Hospitals NHS Trust
Cardiopulmonary Resuscitation Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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by
INDEX
Section and Contents
Page No
Executive Summary
9
1
Introduction
10
2
Objectives
10
3
Definitions
11
4
Duties/Accountabilities and Responsibilities
11
5
Emergency Call System and Team Response
13
5.1.4 Cardiac Arrest /Medical Emergency Phone Numbers
14
5.2
Whiston & St Helens emergency teams
16
5.3
Whiston Hospital Paediatric Emergency Resuscitation Team
17
5.4
Resuscitation in Paediatrics
18
5.5
Resuscitation of Laryngectomy and Tracheostomy Patients
19
5.6
Newborn Resuscitation
19
5.7
Defibrillation
19
5.8
Equipment
20
5.9
Drugs
21
5.10 Patient Transfer and Post-Resuscitation Care
22
5.11 Manual Handling
23
5.12 Cross Infection
23
5.13 Anaphylaxis
23
5.14 Procurement
23
5.15 Incident Reporting System (IR1)
24
5.16 Do not attempt Cardiopulmonary Resuscitation
24
Making a DNACPR decision
Specifics of Responsibility for a DNACPR decision
Specifics of Documentation of the DNACPR decision
Specifics of Review of the DNACPR decision
The cancellation of the DNACPR decision
Deterioration of Iatrogenic Origin
Particular Circumstances – Paediatrics
- In the Emergency Department
Rationale for DNACPR decisions
Patients who require surgical procedures with a DNACPR decision
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Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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5.16.2 ICD – Implantable Cardiovertor Defibrillators
26
5.16.5 Unified Do Not Attempt Cardiopulmonary Resuscitation
28
(uDNACPR) Lilac form
5.17
Chaplaincy Service
33
6.0
Equality Analysis
33
7.0
Training
34
8.0
Appendices
34
Appendix 1 Cardiac Arrest Audit Tool
35
Appendix 2 DNA-CPR Form
37
Appendix 3 uDNACPR Form
38
Appendix 4 Algorithm – Algorithm of what to do if a patient comes in
with a Lilac Unified DNACPR Form
39
Appendix 5 Algorithm – Algorithm of what to do if a patient is to be
transferred out of Hospital
Link to Intranet procedural documents/leaflets http://nww.sthk.nhs.uk/pages/AboutUs.aspx?iPageId=4276
St Helens & Knowsley Teaching Hospitals NHS Trust
Cardiopulmonary Resuscitation Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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40
Executive Summary
Policy Aim
The aim of this policy is to support best practice in the event of a patient,
relative, member of staff, member of the public or contractor requiring
cardiopulmonary resuscitation by a member of clinical staff with direct
patient/client contact employed by St Helens and Knowsley Teaching Hospitals
NHS Trust.
Policy Description
The Resuscitation Committee is responsible for the compliance of the
Cardiopulmonary Resuscitation policy within the Trust.
The Trust has an Adult Medical Emergency Team and a Paediatric Emergency
Team available to attend cardiopulmonary arrests or deteriorating patient at all
times on the Whiston site.
Similarly, there is an Emergency Team at St Helens Hospital available to attend
cardiac arrests or medical emergencies for adults or paediatrics at all times.
Clear guidelines are available for when and how to call for the Medical
Emergency team. Whiston Hospital Medical Emergency Team Operational
Policy – V 11 2012 (Ref 1)
National and international guidelines for the management of cardiopulmonary
arrest will be followed (available on the hospital intranet).
Appropriate equipment will be available throughout the Trust for use on patients
and for training purposes.
The practice of Cardiopulmonary Resuscitation (CPR) will be recorded
whenever applied and audited to assess standards of care.
All clinical staff throughout the St Helens & Knowsley NHS Trust will be
provided with regular resuscitation training appropriate to their expected abilities
and roles.
‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) policy is
incorporated within this document.
St Helens & Knowsley NHS Trust acknowledge and incorporate the North of
England, North West unified Do Not Attempt Cardiopulmonary Resuscitation
(uDNACPR) Lilac Forms coming into the Trust. There is specific guidance for
this process within this policy.
St Helens & Knowsley Teaching Hospitals NHS Trust
Cardiopulmonary Resuscitation Policy and Procedures Incorporating
Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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1
INTRODUCTION
1.1
National agreed Quality standards (2013) for cardiopulmonary resuscitation
practice and training set out the expected standards and targets for
resuscitation within the Trust
1.2
International Guidelines (2010) for CPR and Emergency Cardiac Care (ECC)
(Ref 2) have set standards for resuscitation in hospitals, which include the need
for a response time for defibrillation, of less than 3 minutes. This has
necessitated an increase in both training and equipment resources. Therefore,
effective CPR skills along with first responder defibrillation must be evident
throughout St Helens & Knowsley Teaching Hospitals Trust (STHK NHS Trust)
1.3
Clinical Governance requires that national standards be met in order to provide
a consistently high quality service that minimises potential risk to patients.
1.4
In order to achieve resuscitation goals and promote optimal outcome from all
resuscitation attempts, STHK NHS Trust must have a comprehensive
resuscitation service.
1.5
The Resuscitation Council (UK) Guidelines (2010) (Ref 3) include
recommendations for the early recognition and treatment of the acutely ill
patient, and the use of Early Warning Scoring (EWS) Systems. STHK NHS
Trust has a working Medical Early Warning System (MEWS) see Trust MEWS
Policy (Ref 4) in place, which incorporates a track & trigger mechanism for the
early identification of the acutely ill/deteriorating patient, in order to facilitate a
prompt nursing/medical/Medical Emergency Team response (Ref 5). STHK
NHS Trust has an established Critical Care Outreach Service to promote the
system.
1.6
The Trust Induction Mandatory and Risk Management Training Policy Version
4, 2011, including the Training Needs Analysis. (Ref1) will be adopted
throughout the Trust. This is available for all staff on the Trust Intranet. All staff
will be trained appropriately and regularly updated to a level compatible with
their expected degree of competence in line with Trust Induction Mandatory and
Risk Management Training Policy Version 4, 2011 (Ref 6)
2.
OBJECTIVES
2.1
To provide Trust Staff with direction and guidance for the planning and
implementation of a high-quality and robust resuscitation service to the
organisation. The policy for resuscitation incorporates the current published
guidelines for resuscitation (Resuscitation Council (UK) 2010 (Ref 3)
2.2
The provision of the most appropriate care for an individual patient and their
family.
St Helens & Knowsley Teaching Hospitals NHS Trust
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Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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2.3
Establish guidelines that act as a point of reference for medical, nursing staff and
other members of the multi-disciplinary team.
2.4
Provide a structure for training of medical and nursing staff.
2.5
Support the principles of Clinical Governance
2.6
Ensure a consistent level to good practice across the Trust.
3.
DEFINITIONS
HLS – Hospital Life Support
ILS – Immediate Life Support
ALS – Advanced Life Support
MET – Medical Emergency Team (Ref 5)
ET – Emergency Team
ICD – Implantable Cardiovertor Defibrillator
CPR – Cardiopulmonary Resuscitation
DNACPR – Do Not Attempt Cardiopulmonary Resuscitation
uDNACPR – unified Do Not Attempt Cardiopulmonary Resuscitation
Consultant or their delegated deputy – meaning Associate Specialist, Staff Grade or
specialist trainee).
4.
DUTIES/ACCOUNTABILITIES AND RESPONSIBILITIES
Healthcare organisations have an obligation to provide an effective resuscitation
service to their patients and appropriate training to their staff. A suitable
infrastructure is required to establish and continue support for these activities.
4.1
The Trust Board
The Trust Board has responsibility for the appropriate provision of information,
education, training and audit relating to resuscitation and ‘Do Not Attempt Cardio
Pulmonary Resuscitation’ (DNACPR) orders. The Trust Board has overall
responsibility for ensuring that Resuscitation Services has sufficient resources to
facilitate the implementation of all elements of this policy.
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Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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4.2
Clinical Effectiveness Council
The Clinical Effectiveness Council will approve the policy and ensure that assurance
can be given to the Trust Board that the policy is being implemented and monitored
for compliance.
4.3
The Resuscitation Committee
The Resuscitation Committee is the expert advisory Committee on all matters
relating to resuscitation and associated topics e.g. DNACPR. Compliance with
the Resuscitation policy and the associated Key Performance Indicators will be
monitored and evaluated by this Committee, with the appropriate assurance of
risk factors being addressed and fed back to the Clinical Effectiveness Council
for their advice and/or approval. The Resuscitation Committee will ensure that
policy and procedures comply with current national Resuscitation Guidelines (Ref
7), the Care Quality Commission (Ref 8) and NHSLA Standard 4 Criterion 8 The
deteriorating patient (Ref 9).
4.3.1 Resuscitation Committee – Quality Standards for cardiopulmonary
resuscitation practice and training (Ref 10)
The Resuscitation Committee must be part of the organisation’s management
structure (e.g. Clinical Effectiveness Council)
The Resuscitation Committee must include representatives from stakeholder
groups (e.g. doctors, nurses, resuscitation officers, pharmacists, management,
patient/lay representative), and appropriate specialties (e.g. ambulance service,
anaesthesia, cardiology, dentistry, emergency medicine, general practice,
intensive care medicine, mental health, neonatology, obstetrics, paediatrics). The
exact composition of the committee will depend on local needs and
arrangements.
The chair of the Resuscitation Committee must be a senior clinician with an
active and credible involvement in resuscitation. This individual would be
expected to have the authority to drive and implement change.
The Resuscitation Committee must have administrative support.
The Resuscitation Committee is responsible for implementing operational
policies governing cardiopulmonary resuscitation, practice and training.
According to local arrangements, it is recommended that the Resuscitation
Committee provides advice to other local healthcare organisations who do not
have the necessary expertise in resuscitation issues. In some healthcare
communities this is achieved very effectively by having a Resuscitation
Committee that spans all the relevant organisations.
The Resuscitation Committee must determine the level of resuscitation training
required by staff members.
St Helens & Knowsley Teaching Hospitals NHS Trust
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Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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At least twice-yearly meetings of the Resuscitation Committee are
recommended. STHK’s Resuscitation Committee meets quarterly.
Responsibilities of the Resuscitation Committee are included in the Quality
Standards for cardiopulmonary resuscitation practice and training.
4.4
Chief Executive
The Chief Executive has a duty to ensure adequate resources are available to
enable effective implementation of this policy. Also to ensure this policy is
implemented according to the nationally agreed Clinical Standards.
4.5
Medical Director - Executive Lead for Resuscitation
The Medical Director has delegated executive responsibility for assuring the
Board of Directors of the effective implementation of this policy through the
monitoring processes of the Clinical Effectiveness Council.
4.6
The Head of Resuscitation Services
The Head of Resuscitation Services is responsible for ensuring all policy relating
to resuscitation practice is based on best evidence and is implemented and
monitored effectively and efficiently.
4.7
Line manager/Clinical Leads
Line Managers/Clinical Leads will take responsibility for assuring staff
compliance with all elements of this policy within their remit.
4.8
All Staff
Individual STHK NHS Trust staff will take responsibility for familiarising
themselves with this policy and ensure their compliance. The Assistant Director
of Operations is responsible for ensuring that all clinical staff attend appropriate
resuscitation training.
5.
5.
PROCESSES
EMERGENCY CALL SYSTEM AND TEAM RESPONSE
5.1.1 The Trust utilises a Medical Early Warning System (MEWS) which identifies an
escalation pathway based on the patient’s physiological observations and a
scoring system, to try and prevent deterioration of patients. All clinical staff
should be trained in the identification of critically ill patients and the use of
physiological observation charts to enhance the decision making process and
care escalation. This preventative system has a clearly defined action pathway
that must be adhered to. Refer to Trust MEWS Policy (Ref 7).
5.1.2 The Trust Medical Emergency Team must be called to respond to adult medical
emergencies in addition to cardiopulmonary arrest. For more information about
the specifics of the calling criteria for MET please see Whiston Hospital Medical
Emergency Team Operational Policy – V 11 2012
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Do Not Attempt Cardiopulmonary Resuscitation Policy
March 2014 – Version 10
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5.1.3
In the event of a cardiac arrest / medical / obstetric or neonatal emergency
being identified and triggered the appropriate emergency team must be alerted
immediately as detailed below.
5.1.4
When an adult or child collapses on Trust premises with suspected cardiopulmonary arrest the appropriate team must be called. For Adults on the
Whiston site it is the Medical Emergency Team, for a child on the Whiston site
the Paediatric Emergency Team is called (state cardiac arrest).
When an adult or child collapses at St Helens Hospital the Emergency Team
must be called.
Whiston Medical Emergency Team/Paediatric Emergency Team
St Helens Emergency Team Phone Numbers:-
Whiston Hospital 2222. (For procedure document see Resuscitation Services
Intranet page http://nww.sthk.nhs.uk/pages/AboutUs.aspx?iPageId=4276)
St Helens Hospital 2222 for the team and 9999 for a Paramedic Ambulance
at the same time.
The appropriate Emergency Team will respond in all cases and if required full
resuscitation attempts will be instigated without hesitation.
NB: Where there is a specific, current, valid, up to date ‘Do Not Attempt
Cardiopulmonary Resuscitation’ (DNACPR) Red Card at the front of the
patient’s notes the Team must not be called. Similarly if a patient has only
just arrived and is in possession of a valid, correctly completed
UDNACPR (Lilac form) the team must not be called.
In the event that a DNACPR form is subsequently discovered after CPR has
commenced, those efforts should be terminated immediately.
5.1.5
The appropriate adult emergency team must be called and attend for any
cardiac arrest/medical emergency that occurs within any Hospital building on
the main Hospital sites at both Whiston and St Helens Hospital. Please see
5.1.13 for Medical Emergency/Cardiac Arrest calls occurring on Trust property
outside the main hospital buildings.
The MET team will attend for medical emergencies or cardiac arrests occurring
at the Knowsley Resource and Recovery Centre previously known as the
Sherdley Unit. The team will follow the Blue Route signposted from the
Emergency Department main entrance. 5 Boroughs Partnership Staff will call
the Medical Emergency Team to the Knowsley Resource and Recovery Centre
by calling 2222.
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March 2014 – Version 10
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5.1.6
Upon receipt of the medical emergency/cardiopulmonary arrest-call the
Switchboard will immediately relay this to the appropriate Emergency Team ‘on
call’. Members of the team will attend without delay to the specific location and
will stay until relieved of this duty by the team leader.
5.1.8
Medical staff who cannot attend must immediately inform Switchboard that they
cannot attend and must arrange for another approved member of their specialty
to attend on their behalf.
5.1.9
All bleep holders must respond to the test call performed by the switchboard at
approximately 9.30am and 21:30pm each day.
5.1.10 All aspects of cardiopulmonary arrest management will follow the current
guidelines of the Resuscitation Council UK (Ref 4) and the European
Resuscitation Council (Ref 8). In addition the relevant parts of the Mental
Capacity Act 2005 will be adhered to in relation to those patients over 16 (see
Trust document: General Guidance Mental Capacity Act 2005) (Ref 10)
5.1.12 Emergency Team members unfamiliar with the location given should contact
Switchboard using the arrest call number 2222 to clarify the location.
MEDICAL EMERGENCY/CARDIAC ARREST CALLS OCCURING ON TRUST
PROPERTY OUTSIDE MAIN HOSPITAL BUILDINGS
5.1.13 Members of the Medical Emergency Team (MET) will attend Whiston Hospital
Car Parks or Nightingale House if requested. Members of the Emergency Team
(ET) will attend the St Helens Hospital car parks. (See Appendix 4)
5.1.14 Public or staff members who discover a collapsed person/medical emergency
can contact the hospital switchboard by contacting the telephone number
displayed in all hospital car parks including the multi-storey car park.
Switchboard staff will bleep the MET or St Helens ET to attend the appropriate
muster point & follow the response procedure. Switchboard staff will also
request the paramedic ambulance service (NWAS) to attend via a 999 call.
5.1.15 Within Nightingale House staff must call 2222 to summon an emergency
response by the MET team.
5.1.16 Switchboard on receiving a call must immediately put out a Medical Emergency
Team call at Whiston Hospital or an Emergency Team call at St Helens Hospital
via the emergency bleep system. This call will summon the Team to meet at
the designated muster point. The muster point at the Whiston Site is at the
main reception desk. The St Helens Hospital muster points are located at the
main reception desk in the Day Treatment Centre 08.00 to 20.00hrs Monday to
Friday, outside these hours it is at the Security Office in Elyn Lodge.
5.1.17 Security staff will also be summoned via a bleep to the relevant muster point
and they will escort members of the emergency team members to the medical
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March 2014 – Version 10
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emergency or cardiac arrest location (at least two members including a doctor).
The medical emergency bag (grab bag) will be taken from the muster points
within the hospital by either the MET personnel or security staff. The grab bags
will be checked weekly by cardio respiratory staff to ensure the required agreed
contents are present.
5.1.18 If transportation for a collapsed patient is required this shall be via the 999
paramedic service. The patient will be taken directly to the most appropriate
Emergency Department.
5.1.19 The team, if called to the multi-storey car park (MSCP) or the staff car park at
the rear of the MSCP, must be taken over the connecting bridge by security
staff to ensure staff safety. (See flow chart in appendix 5)
5.2
Whiston & St Helens Medical Emergency Team
5.2.1
The Resuscitation Committee as the Trust experts advise on the composition of
the hospital adult Medical Emergency Team and its role. (Refer to 5.2.2 and
5.3)
5.2.2
The adult Medical Emergency Team (Whiston) and Emergency Team (St
Helens) will be called for adult arrest/medical emergency
Whiston Site Adult MET will
include:
St Helen’s Site Adult/Paediatric
Emergency Team will include:
1x Critical Care Doctor
1 x SHO/F2 Medicine
1 x Anaesthetist (on request)
1 x ODP (on request)
1 x Surgical SHO/F2
1 x HO/F1 Medicine (educational
role)
1 x MET nurse
1 x Cardio-Respiratory Staff
1 x MET Porter
The clinician who made the call
1 x Resident Medical Officer
1 x Nurse Clinician (8am-4pm,Mon– Fri)
1 x Cardio-Respiratory Staff (9am5pm,Mon– Fri)
1 x Senior Manager (8am-6pm,Mon– Fri)
1 x Duty Site Manager 7.30 am till 9pm
The clinician who made the call
After 4pm until 8am
RMO
Site manager (ILS or ALS trained)
Ward staff
In addition the clinician who makes the call/ward nurses/ midwives who may be
present at the time. The Trust’s Resuscitation Officers will also attend when
available, in an advisory and monitoring role or if required, to act as team leader.
A duty manager may also attend or be requested to assist with logistical
problems, either during or after the arrest.
5.2.3
The Team leader will allocate a member of staff to liaise with the patient’s
family/partner. If the family/partner wishes to be present at the resuscitation
event then a member of staff should be allocated to provide support
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5.2.4 All medical and nursing staff that are part of the Medical Emergency Team at
Whiston and the Emergency Team at St Helens must be appropriately trained in
Advanced Life Support. Refer to Induction Mandatory and Risk Management
Training Policy (Ref 6) and must hold a current professional registration.
5.2.5 The team leader will assume overall responsibility for the patient during an
emergency call. For adult resuscitation, this will be the role of the Medical SHO,
F2, RMO or Registrar, all must be qualified in Advanced Life Support.
5.2.6 The emergency team leader has a specific role directing the resuscitation
attempt, ensuring it continues in a coordinated manner and directing the overall
management of the patient. The team leader will be responsible for patient
assessment throughout, ensuring that:
 The medical emergency is managed appropriately using the ABCDE
approach
 Adequate Basic Life Support is being performed.
 Adequate airway management is being performed.
 Defibrillation is delivered swiftly and safely.
 Tasks are designated to the other team members who have the most
appropriate skills.
 Current Resuscitation Council UK guidelines (Ref 3) are followed and where
relevant, the provisions of the Mental Capacity Act 2005 (Ref 10) are
complied with.
5.2.7
If resuscitation is successful, it is the emergency team leader’s responsibility to
communicate with those responsible for the further care of the patient.
5.2.8
It is the emergency team leader’s responsibility to make the final decision to
stop the resuscitation attempt after all appropriate avenues of treatment have
been exhausted. This should be done after discussion with all members of the
team, including relatives where appropriate.
5.2.9
It is the emergency team leader’s responsibility to ensure that all necessary
documentation is completed as soon as possible after the resuscitation attempt
including the MET/Resuscitation Documentation Form
5.2.10 After a resuscitation attempt the team leader or a designated person must
speak to the patient’s family/partner in an appropriate environment.
5.3
Whiston Hospital Paediatric Emergency Resuscitation Team
5.3.1
The Resuscitation Committee will advise on the composition of the hospital
Paediatric Resuscitation team and its role.
5.3.2
The Paediatric Emergency Team will be called for paediatric arrest/medical
emergency.
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The paediatric team will include as a minimum:
1 x Anaesthetist (when available)
1 x Paediatric Registrar
1 x Paediatric SHO/F2
1 x Paediatric Nurse Clinician
1 x Senior Paediatric Nurse
1 x Consultant Paediatrician will be called if requested
This is in addition to other doctors, a senior clinical nurse and ward nurses/
midwives who may be present at the time. The Trust’s Resuscitation Officers
may also attend when available.
5.4
Resuscitation in Paediatrics
5.4.1
Special conditions apply when resuscitating children; both in the aetiology of
cardiopulmonary arrest and in the techniques of resuscitation and it is
imperative that experienced personnel, who are aware of these special needs,
are present at the resuscitation attempt.
5.4.2
Paediatric cardiopulmonary arrest team will be called and respond in similar
manner to the adult teams.
5.4.3
The team leader has a specific role directing the resuscitation attempt, ensuring
it continues in a co-coordinated manner and directing the overall management
of the patient. The team leader will be responsible for patient assessment
throughout, ensuring that:

Adequate basic life support is being performed.

Airway management is performed swiftly and in a competent manner.

Defibrillation is delivered swiftly and safely.

Tasks are delegated to the other team members, who have the most
appropriate skills.

Current Resuscitation Council (UK) Paediatric Advanced Life Support (PALS)
guidelines are followed.
NB: The team leader for Paediatric cardiopulmonary resuscitation should normally
be a paediatrician with Advanced Paediatric Life Support (APLS) or
Paediatric Advanced Life Support (PALS)
5.4.5
Ethical issues are especially difficult when resuscitating a child and
consideration will be given to the care of relatives who may be present.
Wherever possible a member of staff will be delegated to stay with them and
liaise with the team on their behalf.
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5.4.6
Neonatal staff will be available specifically to deal with newborn and neonatal
emergencies in the Delivery Suite, Maternity and Special Care Baby Unit
(SCBU) and if necessary in the Emergency Department.
5.5
Resuscitation of Laryngectomy and Tracheostomy Patients
5.5.1
All patients in this hospital with either a laryngectomy of tracheostomy will have
bedside notice in place identifying whether they are a patient with a
laryngectomy (airway ends at stoma) or a tracheostomy (potentially patent
upper airway). Emergency algorithms for managing airway issues are kept at
patient’s bedside in the event of an airway emergency occurring.
5.5.2
Emergency resuscitation of patients with a laryngectomy presents problems as
the upper airway can not be used for CPR. Oxygen can only be delivered via
the stoma. For tracheostomy patients a proportion will similarly not have a
patent upper airway for CPR and may need replacement of the tracheostomy to
deliver adequate respiration. (For further information see the Trust’s Policy for
Resuscitation of Laryngectomy & Tracheostomy Patients (Ref 12)
5.5.3
In the case of a Laryngectomy patient who has stopped breathing the following
action should be taken:
Check the neck, expose the entire neck, check stoma for any blockage and
suction clear, give ventilations with a pocket mask or a resuscitator bag with a
circular infant mask (kept in bottom section of the cardiac arrest trolley) via the
stoma and supplement administer oxygen.
In the case of a patient with a tracheostomy please refer to the Trust’s Policy for
Resuscitation of Laryngectomy & Tracheostomy Patients (Ref 12) which
provides emergency algorithms for managing conditions arising as a result of
tracheostomy problems.
5.6
Newborn Resuscitation
Refer to Trust’s Newborn Resuscitation Policy (Ref 12)
5.7
Defibrillation
5.7.1
Manual defibrillators must only be operated by persons specifically trained in
their use. The operation of manual defibrillator by all Health Care Professionals
is subject to successful completion of an Advanced Life Support course
/Immediate Life Support course or Resuscitation Services Defibrillation Training
Session.
5.7.2
The use of an Automated External Defibrillator (AED) by any member of staff
should be encouraged in the event that there is no member of staff present who
can manually operate a defibrillator use an AED to avoid a delay in a patient
receiving timely treatment. (Resuscitation Council UK) (Ref 3)
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5.8
Equipment
5.8.1
St Helens and Knowsley Teaching Hospital NHS Trust is committed to providing
sufficient equipment in each patient area to support the patient's treatment, and
to comply with the recommendations of both the UK and European
Resuscitation Council. (Ref 14)
5.8.2
All resuscitation trolleys must be maintained in a state of readiness at all times.
Trolleys must be checked by a member of staff at least once every 24 hours
using the trolley check list and immediately following conclusion of a
resuscitation event. Resuscitation trolleys must be replenished immediately
following their use. Stock can be replenished via the Cardio-Respiratory
Department at Whiston Hospital. This includes out of hours. For St Helens
Hospital, stock is replenished via the resuscitation cupboard based on Seddon
Suite
All defibrillators should be checked at the commencement of every shift.
It is the responsibility of the nurse in charge to ensure that the defibrillator checks
are carried out. A pulsing hour glass is confirmation that the defibrillator is
performing its safety self check and is ready for use. An automatically generated
symbol of a red cross denotes a fault has been detected. On observing this symbol
the member of staff must immediately report this to EBME (tel 1272/1273)
/Resuscitation Officer immediately (tel 1888/1724 bleep 7032/7030) a weekly
operational check will be carried out by Cardio-Respiratory staff. If a fault on a
defibrillator is discovered at weekends or out of hours, the Cardio Respiratory
Physiologist on call will replace the defibrillator via the Trust Switchboard.
5.8.3
No equipment is to be added or removed from the resuscitation trolleys unless it
has been discussed with the Head of Resuscitation Services. All clinical staff must
be familiar with the resuscitation equipment that is used in the Trust. This
familiarisation with the equipment is part of Trust local induction training.
5.8.4
The Resuscitation Committee will determine the siting and selection of equipment
for each ward/department as per the current Quality Standards issued by the
Resuscitation Council (UK) (Ref 7). This will depend upon the anticipated workload
and availability of equipment from nearby departments.
5.8.5
Equipment for cardiopulmonary resuscitation, including trolleys, boxes and
defibrillators, will be standardised with minimal local adaptations (which will be
indicated on the checklist).
5.8.6
On Paediatric wards and other areas where children are treated, equipment
suitable for Paediatric resuscitation will be available on the Child, Young Person
& Adult Arrest trolley or in a dedicated Paediatric box such equipment will be
available throughout the Trust, as directed by the Resuscitation Committee.
5.8.7
Defibrillators will include the option of Paediatric pads/paddles in areas where
babies and children are treated.
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Phillips MRX defibrillators with paddles are located within the Emergency
Department, Theatres, Paediatric Dental, 3F Children’s and Young People HDU
and 4D Regional Burns Unit.
5.8.9
Phillips MRX defibrillators with external pacing are located strategically throughout
the Trust and on both MET trolleys.
5.8.10 The Resuscitation Committee will provide appropriate advice to the Trust to ensure
that equipment; particularly defibrillators are in line with current specifications and
technological developments.
5.8.11 Resuscitaires must be checked daily/after use and prior to delivery.
5.8.12 It is the responsibility of the Head of Department/Ward Manager to ensure that
resuscitation equipment is checked daily.
5.8.13 All staff must know the procedure for cleaning and maintenance of reusable
equipment and know which items are for single-use only. Single use items are
indicated on the trolley & box checklists (for procedure document see
Resuscitation Services Intranet page
5.8.14 All clinical staff must know the location of basic equipment within their
immediate working area and know the location of their nearest resuscitation
trolley containing advanced equipment. See Management of Corporate and
Local Induction policy it is the responsibility of staff where the arrest has
occurred to ensure the nearest trolley is collected.
5.8.15 Following a cardiac arrest in a non-clinical area, it is the responsibility of
Emergency team members to ensure that the resuscitation trolley is returned to
its original location, where it must then be checked and re-stocked as per the
policy.
5.9
Drugs
5.9.1
Portable oxygen and suction devices will be available in the ward and
department, and alongside all resuscitation trolleys. Where piped or wall oxygen
and suction are available, these should always be used in preference to
portable devices. It is important to ensure that medical air is not used routinely
during an emergency situation except to drive nebuliser therapy in patients with
chronic risk of C02 retention.
5.9.2
Resuscitation drugs and equipment for circulatory access and fluid
administration is standardised for every resuscitation trolley/box and are
available on every ward/dept.
5.9.3
It is the responsibility of the nurse in charge of the ward or department who
uses the drugs from the trolley/box to replace them as soon as possible from
the stock cupboard which is situated within the Cardio-Respiratory Department
at Whiston and the resuscitation cupboard based on Seddon Suite at St Helens
Hospital.
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5.9.4 The Pharmacy Department is responsible for the drugs in the emergency trolley
drug boxes. The Ward Manager is responsible to ensure that arrangements are
in place to check that the drug box seal is intact and the box is in date within the
emergency trolley. This must be carried out as part of the weekly trolley check
by the ward nursing staff or Allied Health Professional if the task is delegated to
them.
5.10
Patient Transfer and Post-Resuscitation Care
5.10.1 The immediate post-resuscitation phase is characterised by high dependency
and clinical instability. Most patients require either coronary care or intensive
care treatment. Facilities for ongoing care of the patient may not be available at
the location of the cardiopulmonary arrest and transfer of the patient may be
necessary. Therefore, when appropriate, referral to specialists (e.g. Cardiologist
or Intensivist) will be made by the Medical Emergency Team/Emergency Team
leader. It will be the responsibly of the team leader at the resuscitation event to
ensure that the transfer of care from one group of clinicians to another is safe,
appropriate and efficient.
5.10.2 The team leader will not leave the patient until transfer has occurred unless
he/she has delegated care to another appropriate colleague.
5.10.3 The patient’s condition should be stabilised as far as possible prior to transfer,
but this should not delay definitive treatment. Careful coordination is required to
ensure that no delays occur. The nurse present should do this in conjunction
with the doctor responsible for clinical care.
5.10.4 Equipment for transfer, including drugs, should be kept readily accessible and
appropriate monitoring equipment should be obtained. The patient must be
transferred with defibrillator/monitor, airway equipment, oxygen and appropriate
drugs. A full medical and nursing handover of the patient’s care must be evident
verbal and written, including details of drugs given and any defibrillation used.
This will be monitored via the standard cardiac arrest audit. It may be necessary
to liaise with the ambulance service for incidents outside the hospital.
5.10.5 An anaesthetist and Operating Department Practitioner (ODP) or a doctor and
an appropriately trained nurse should accompany a patient being transferred.
Relatives should be informed of the transfer of the patient.
5.10.6 In the event of a cardiac arrest in a non-clinical area, or if the person is an
outpatient, once stabilised the casualty will be taken to the most appropriate
department, usually the Emergency Department for post resuscitation
management.
5.10.7 Following successful resuscitation in a clinical area the decision must be made
within regards to transfer to Coronary Care/Intensive Care Unit/High
Dependency Unit (CCU/ICU/HDU/ITU). The patient should be stabilised first if
possible, but this should not delay definitive treatment.
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5.11
Manual Handling
See Policy for Safe Handling of Patients and Inanimate Loads (Ref 15) and
Guidance for safer handling during resuscitation in healthcare (Resuscitation
Council (UK) (Ref 16)
5.11.1 A mechanical lift using a hoist is the safest method of lifting a patient from the
floor.
5.11.2 If in a confined space - the patient will usually be rolled onto sliding sheets with
one person protecting the head and two persons sliding the person in small
stages into an open space so that a hoist can be used.
5.11.3 Lifting an adult in an emergency is a high risk activity and should only be
undertaken in life threatening or exceptional circumstances, where no other
option is available.
5.12
Cross Infection
Whilst the risk of infection transmission from patient to rescuer during direct mouthto-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 Emergency department, Outpatients or
other admission source;`
Other persons where the medical history is unknown.
All clinical areas should 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. If there are no contraindications
consider giving mouth-to-mouth ventilations.
5.13
Anaphylaxis
The management of suspected anaphylaxis / anaphylactoid reactions should be
conducted in accordance with the Resuscitation Council (UK) Guidelines (Ref 4)
for the management of anaphylaxis. (See Trust Anaphylaxis Protocol (Ref 18) All
Trust cardiac arrest trolleys contain emergency anaphylaxis kits in the Blue
Cardiac Arrest Drugs Box.
5.14
Procurement
All resuscitation equipment purchasing is subject to the organisation’s
standardisation strategy; therefore all resuscitation equipment purchased must be
sanctioned by the Head of Resuscitation Services/Resuscitation Committee prior to
ordering. Refer to Trust Procurement Policy (Ref 19)
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5.15
Incident Reporting System (Datix)
5.15.1 To comply with the recommendations of Time to Intervene from NCEPOD 2012
(Ref 20) – All cardiac arrest events that receive as a minimum 1 chest compression
and or defibrillation must generate a DATIX entry to enable the Trust to achieve
this. The DATIX must be completed by the first member of STHK staff who
discovered the person who has had a cardiac arrest or had the person brought to
their attention by a non-staff member. The DATIX must be completed in line with
the Trusts SUI and DATIX Reporting Policy (Ref 21)
5.15.2 Should a resuscitation event incur delays, errors, equipment failure etc it is the
policy of St Helens & Knowsley Hospital Teaching NHS Trust that all such
incidents, clinical, non-clinical and all near misses must be reported. The DATIX
Reporting System has been developed to capture all incidents and near misses.
See SUI and DATIX Reporting Policy (Ref 21)
5.15.3 The responsibility for reporting the incident lies with all staff, at all levels, within
the Trust. Guidance on incident reporting can be found in the Trust's SUI and
DATIX Incident Reporting Policy
An example of an incident includes:
 A failure or delay in starting resuscitation
 A failure of the 2222 call-out system
 Failure of oxygen supplies during cardiac arrest
 Failure of any equipment during cardiopulmonary resuscitation
An example of a near miss includes:
Incomplete ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR)
Discovery of missing equipment from the resuscitation trolley during routine
checks
 Discovery of damaged bag valve mask during checking


5.15.3 The aim of incident reporting is to understand the cause of adverse healthcare
events and to learn from them and not to blame individuals who have made
mistakes.
5.16
Do Not Attempt Cardiopulmonary Resuscitation (NHSLA 4.8)
Individual Consultants (or their appointed deputy) are responsible for the
DNACPR decision making process in relation to the care of individual patients.
Whilst the Consultant or his/her designated deputy remains responsible for this
process, it remains the responsibility of individual staff members to ensure that
they are aware of and understand the DNACPR procedure
It is essential that the patient and/or family/carer/next of kin etc are involved as
early as possible in the decision making process. If this is not possible
communication must take place with relevant people as soon as possible after
the decision making process unless this is against the patient expressed
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wishes. The time and date of this delayed consultation must be recorded in the
patient’s clinical record by a senior authorising doctor.
The Trust has two patient information leaflets available relating to DNACPR:
“Decisions about Cardiopulmonary Resuscitation” and an easy read version
entitled “What happens when your heart and breathing stop”. The latter is
specifically designed to be used by medical staff and carers to aid discussion
and patient awareness.
5.16.1 Making a DNACPR Decision


Every DNACPR decision must be assessed on the basis of the individual
patient, taking into account his or her particular circumstances and taking into
account any valid patient’s advance decision. A DNACPR decision should
only be made after appropriate consultation with relevant people and
consideration of all relevant aspects of the patient’s condition including:
-
The likely clinical outcome, including successful restarting of the heart
and breathing and the overall benefit achieved by successful
resuscitation
-
The patient (or their representatives) known or ascertainable wishes.
e.g. Advance Decision to Refuse Treatment (Ref 22) Advance Decision
to Refuse Treatment policy)
-
The patient’s human rights including the right to life and the right to be
free from degrading treatment. Refer to The Human Rights Act 1988
(Ref 23)
-
“The views of all members of the medical and nursing team, including
those involved in a patient’s primary and secondary care will be
relevant although due regard should be had to the patient’s right to
confidentiality. The views of these people and others close to the
patient are valuable informing a decision.
-
The decision maker (the individual Consultant or their appointed
deputy) must therefore carefully consider and decide whether the
burden of potential CPR clearly outweighs the potential benefits.
If there is no valid and applicable Advance Decision made by the patient that
refuses a specific treatment, there is a common law duty of care to give
appropriate treatment to incapacitated patients when such treatment is
clearly in their clinical best interests. Relevant individuals such as relatives or
carers should be consulted as to their views, but the final decision as to what
decision is in the patient’s best interests rests with the individual consultant
(or their appointed deputy) responsible for considering whether a DNACPR
decision is appropriate.
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







All inpatients, outpatients, visitors and staff are assumed to be for CPR
unless there are clear instructions to the contrary.
A patient’s status is either “FOR CPR” or “DNACPR”.
A DNACPR decision applies solely to CPR. It has NO implications for any
other decisions concerning the patient’s general clinical management.
All other treatment and care, which is appropriate for the patient, must be
given and must not be influenced by any DNACPR decision. The withdrawing
or withholding of any other treatment or clinical management is a separate
issue.
A DNACPR decision becomes an order, with immediate effect, when the
decision has been clearly documented in the medical notes and the
DNACPR form is fully completed - this must be placed at the front of the
patient’s notes.
See Do Not Attempt Cardiopulmonary Resuscitation
(DNACPR) Form - Appendix 2).
There must be clear documentation in the patient’s health record of the
expressed wishes of the patient and other relevant individual’s (particularly
involved family members or carers) by a designated member of the clinical
team.
There must be effective communication by the senior clinician in charge of
the DNACPR decision to all other medical and nursing staff.
The responsibility for the determination of a DNACPR decision involves:
i) The patient - where they have made a valid and applicable Advance
Decision refusing such treatment once they lose capacity, or,
ii) The relevant Consultant / nominated deputy where the patient lacks
capacity and has not made such a valid and applicable advance decision,
or,
iii) The welfare attorney (see 5.16.2), where the patient lacks capacity, and
there is a valid and applicable lasting power of Attorney.
Only such persons can determine the patient’s DNACPR status.
5.16.2 ICD – Implantable Cardiovertor Defibrillators
If a patient has an ICD, then this must be deactivated once a DNACPR order
has been completed. The necessary form needs to be completed by a senior
doctor (registrar or above). The form is available on the hospital intranet. Paper
copies are also kept on CCU with a magnet (1E).
Once the form has been completed, during normal working hours, please
contact the Cardio-respiratory department on ext 1428, informing them of the
patient and what device they have implanted. Please note, you should move
the patient to a monitored bed for the time between reversing the order and the
device being reactivated. If the patient has not got their identification card, you
will need to phone the implanting centre (which is usually LHCH) and ask for the
pacing clinic. The centre will be able to determine what type of device the
patient has implanted. Out of hours and in emergencies, a magnet can be
placed over the device, which will switch off the ‘shock’ capacity whilst it is in
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contact with the skin. This must be done by a doctor. An appropriate magnet
can be found on CCU.
5.16.3 The Responsibility for Authorising a DNACPR Decision

The decision regarding a patient’s resuscitation status is the responsibility
of the consultant or their delegated deputy (associate specialist, staff
grade or specialist trainee). This person must always take into account the
factors listed in the Mental Capacity Act ‘best interests’ checklist’. Section
3 page 8 of the General Guidance Mental Capacity Act 2005 (Ref 10).

Documentation of DNA-CPR decision should be by:
1. writing the details of the decision contemporaneously in the patient’s
clinical records, and
2. completing a DNACPR red card.

When the consultant responsible for the patient and their delegated
deputy are not immediately available to document the decision, the
decision may be documented by a more junior member of medical staff
following discussion with the consultant or their delegated deputy. The
discussion must be documented and the DNACPR red card completed by
the junior doctor on behalf of the consultant or their delegated deputy. The
name and grade of the authorising doctor must be documented on the
DNACPR red card. This must be countersigned by the consultant or
deputy at the earliest opportunity.

If a DNACPR order is not recorded to be indefinite the decision needs to
be reviewed during every senior doctor’s ward round. If a patient has a
pre-existing indefinite uDNACPR order or a new indefinite DNACPR (Red
card) order from their current admission the decision does NOT need to
be reviewed on every senior ward round

Any patient, who currently has an indefinite DNACPR order decision, who
has significantly improved during their admission or express that they
have concerns about the DNACPR decision must have this decision
reviewed at the earliest opportunity.

It is recommended that any DNACPR decision be reviewed if the clinical
condition of the patient improves significantly.

If the patient is discharged, the DNACPR (red card) decision and form are
immediately rescinded. If the patient is subsequently readmitted to
hospital, this will be classed as a new event and the patient’s DNACPR
status must be reconsidered, unless the patient was discharged with a
unified DNACPR (Lilac form) which they bring to Hospital with them on
their subsequent new re-admission.
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If a decision is made during a patient’s admission that a patient should not be
resuscitated INDEFINITLY a uDNACPR (Lilac form) should be completed
following discussion with the patient and/or family if appropriate prior to the
patients discharge by a consultant or delegated deputy.
5.16.4 The Cancellation of a DNACPR Decision
The decision regarding a patient’s resuscitation status is the responsibility of the
consultant or their delegated deputy. A DNACPR decision may be reversed for
clinical or patient specific reasons. This must entail a similar discussion and
documentation in the clinical record. The DNACPR red card reversal statement
must also be completed.
Regarding reversal of a DNACPR order, the following rules apply:
 The original DNACPR order must be cancelled and the form clearly filed in
the patient notes, at the back of the record.
 The reversal must be named, signed and dated and the reason for
reversal given by the consultant responsible or their delegated deputy.
 The decision must then be communicated by the person signing the
reversal to appropriate members of the medical / nursing team.
 The names of any other person(s) consulted in the decision and the
reason for reversal of the original order should (if applicable) be given.
 Once the patient is discharged from hospital, the DNACPR is automatically
reversed, unless a uDNACPR Lilac Form has been completed.
 There may be exceptional circumstances of an iatrogenic nature whereby
even in the presence of a DNACPR Order, intervention would be
appropriate and the DNACPR decision is automatically cancelled. e.g.
during or directly following a medical procedure or drug administration.
Iatrogenic means deterioration induced inadvertently by a physician or surgeon,
or by medical treatment or diagnostic procedures. An example would be in the
circumstances of an acute reversible deterioration due to medical therapy/
intervention (or omission of prescribed intervention).
5.16.5 Unified Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) Lilac
Form
A regionally agreed uDNACPR form has been developed (see appendix 2) and
was introduced in Feb 2014. St Helens and Knowsley Teaching Hospitals NHS
Trust recognises the form as a valid DNACPR form and has incorporated it into
the existing DNACPR policy. Outlined below is the management of DNACPR in
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regards to the uDNACPR documentation (known as the lilac form). Specifically
it will describe how to manage a patient who
1) attends hospital with a valid uDNACPR and/or
2) is discharged with a new uDNACPR decision (using the lilac form)
5.16.6 Patient Attends Hospital With a Valid UDNACPR decision (Lilac Form)
If a patient (or their representative) presents with a correctly completed
uDNACPR (lilac) form to St Helens and Knowsley Teaching Hospitals this
uDNACPR decision is considered to be valid if the patient does not have
capacity as it will have been completed by the patient whilst they had capacity
or their representative whilst they did not have capacity. However, at the earliest
convenient time (within 24 hours or on the post take ward round) a senior doctor
may review where indicated the original DNACPR decision. The default position
is that uDNACPR forms are considered valid unless there is a clear reason to
reverse a uDNACPR decision. If it is affirmed that the uDNACPR remains valid
the Trust’s red coloured DNACPR documentation (the ‘red card’) must be
completed and placed in the front of the patient’s case notes. The original
uDNACPR (Lilac) form presented with the patient is then returned to the patient
or their representative. In this scenario it is NOT necessary to re-discuss the
DNACPR decision that had led to the completion of a valid uDNACPR lilac
form.
In the very unlikely event that, after discussion with the patient, the clinician
identifies just cause to cancel the DNACPR decision the reason(s) should be
documented in the medical records. The lilac form should be crossed through with
2 diagonal lines in black ink and “CANCELLED” written clearly between them. The
form should also be signed and dated. If the patient does not have capacity the
original decision should remain valid as a default position. If a uDNACPR decision
is reversed the patient’s GP surgery must be informed by telephone and in writing
(by means of the ICE discharge documentation) prior to discharge from the Trust.
If the patient survives their hospital admission it must be ensured that the lilac
uDNACPR form has been returned to the patient to take to their discharge
destination.
5.16.7 Patient Is Discharged From Hospital with a New uDNACPR Decision (lilac
form)
If, following clinical assessment, a patient who does not have a pre-existing
DNACPR decision is considered not to be for cardio-pulmonary resuscitation, the
Trust DNACPR red card is completed. If it is deemed appropriate for the patient to
be discharged with an indefinite DNACPR decision the patient’s Consultant (or
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their delegated deputy ST3 and above) must arrange prompt completion of the lilac
uDNACPR form. It is important to discuss the decision with the patient (or their
representative if the patient does not have capacity). The decision to discharge a
patient from the Trust with a uDNACPR lilac form should generally be considered
to be indefinite. This needs to be clearly documented. It will occasionally be
appropriate to define a review period, which would allow sufficient time for the
patient’s General Practitioner to review the decision in the community. It is
mandatory for the uDNACPR order to be documented within the ICE discharge
letter. It is recommended that the patient’s GP Surgery is also contacted by
telephone for patients who do not have an indefinite uDNACPR decision.
5.16.8 Discharging Patients
On discharge from hospital it is important to ensure that patients, who were
admitted with a uDNACPR lilac form, have been given their original form back.
Patients who have a new indefinite DNACPR decision made during their admission
should be given the lilac copy of the uDNACPR documentation and advised to
carry the form with them in the event of future admissions. It needs to be
emphasised that the lilac form is not valid unless presented with the patient on their
admission. One white copy of the form remains in the medical notes to be
scanned in the alert section of the electronic records and one white copy is sent to
Resuscitation Services for audit purposes.
Prior to discharge, the patient must be informed of the on-going DNACPR decision.
If the patient does not have capacity or has capacity but it is envisaged that
discussion with the patient would cause undue distress to the patient, the DNACPR
decision must be discussed with the patient’s representative. This will usually be
the patient’s next of kin or other appointed advocate. The use of the lilac
uDNACPR form should also be discussed. A uDNACPR form cannot be issued
without discussion with either the patient or their representative. If the uDNACPR
(Lilac form) is completed ready for a pending discharge the completed form should
be placed at the front of the patient’s notes and given to the patient or their
representative during the discharge process.
When transferring a patient between locations (either ward to ward or other
healthcare setting) it is important that:
•
the receiving location staff are informed of the DNACPR decision.
In regards to ambulance transfer, if a discussion has taken place related to
deterioration during transfer the ‘Other Important Information’ section of the lilac
form must be completed, stating the patient’s preferred destination (this cannot be
a public place) and the name and telephone number of the patient’s representative.
If the patient deteriorates during transfer without this information they will be taken
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to the nearest Emergency Department. If the patient dies during transfer they will
be taken to the nearest Emergency Department.
5.16.9 Particular Circumstances
Paediatrics and DNACPR
The Royal College of Paediatrics and Child Health have produced the following
guidelines which identify five situations where it may be appropriate to consider
withholding or withdrawal of curative medical treatment:

Brain Dead Children- where artificial ventilation and Intensive Care are futile.

Permanent Vegetative State- a child’s brain is so damaged by injury or lack of
oxygen that they cannot react or relate to the outside world.

No Chance- such severe disease that treatment may delay death but without
alleviating suffering.

No Purpose- survival possible with treatment, but only with such severe mental
or physical impairment that the child will never be capable of choice and his/her
suffering would be unreasonable for them to bear.

Unbearable Situation- child and/or family feel further treatment for progressive
and irreversible illness is more than they can bear, e.g. aggressive treatment of
oncology patients.
The courts have recognised that a child (someone under the age of 16) can in law
be competent to make their own decisions providing he or she has sufficient
understanding and intelligence to enable him or her to understand fully what is
proposed (“Gillick” competent). However, a refusal by a competent child does not
have the same force as a child consenting to treatment, and can be overridden by
those with parental responsibility or the Court (acting in that child’s best interest).
In essence a child can give permission for but cannot refuse a procedure if it is in
the child’s best interests. [NB: at age 18, a person is viewed as an adult with
capacity, with full rights to give or refuse permission].
Young people aged 16 and 17 who are not Gillick competent due to a disturbance
in the functioning of the mind or brain, may be treated either under the doctrine of
Parental Responsibility, or alternatively in their best interests under the Mental
Capacity Act 2005 (see above for details).
5.17
DNACPR within the Emergency Department
The nature of an Emergency Department often means that little or nothing is
known about the previous medical condition of a patient. With this in mind the
basic rule must be to start resuscitation in persons suffering cardiac or
respiratory arrest, unless there is clear reason not to do so.
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5.17.1 Patients Who May Require Surgical Procedures with a DNACPR Decision
It is essential that patients who may require surgical procedures with DNACPR
decisions in place are referred as early as possible to the anaesthetic and
surgical teams. A review of the DNACPR decision by the anaesthetist and
surgeon with the patient, proxy decision maker, other doctor in charge of the
patient’s care, and relatives or carers, if indicated, is essential before
proceeding with surgery and anaesthesia.
There are two available options for managing the DNACPR decision in the
peri-operative period:
Option one: the DNACPR decision is to be discontinued. Surgery and
anaesthesia are to proceed with cardiopulmonary resuscitation (CPR) to
be used if cardiopulmonary arrest occurs.
Option two: the DNACPR decision is to be modified to permit the use of
drugs and techniques commensurate with the provision of anaesthesia.
The agreed DNACPR management option should be documented in the
patient’s notes. The DNACPR management option should be communicated to
all the healthcare staff managing the patient in the operating theatre and
recovery areas.
The DNACPR management option should, under most circumstances,
apply for the period when the patient is in the operating theatre and
recovery areas. The DNACPR decision should be reinstated when the
patient returns to the ward, unless in exceptional circumstances.
Association of Anaesthetists of Great Britain & Ireland (AAGBI) Ref 24
5.17.2 Transfer of Patients Nearing End of Life – DNACPR order
If it is deemed appropriate for the patient to be discharged with an indefinite
DNACPR decision the patient’s Consultant (or middle grade doctor equivalent)
must complete the lilac uDNACPR form (Please see 5.16.4 point 2).
5.17.3 The Rationale for Medical Consultant or Designated Deputy Decision for
DNACPR
There must be robust clinical evidence that the current path of the disease
process is relentless and that the inevitable outcome is death.
Alternatively, in the event of CPR being successful the patient’s existence would be
followed by a length and quality of life, which would not be in the best interests of
the patient. In the absence of a valid, applicable Advance Decision to Refuse
Treatment (ADRT), or a valid, applicable Lasting Power of Attorney, the decision
regarding patient’s best interests when a patient is incompetent to decide, rests
with the consultant or his/her deputy.
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5.17.4 Chaplaincy Service
Chaplaincy services are available for spiritual care if requested by the
patient/relatives. They can be contacted on Ex 1657 or bleep 7099/7272.
6.
EQUALITY ANALYSIS
Equality Analysis Stage 1 Screening
1
Title of Policy:
2
Policy Author(s):
3
Lead Executive:
4
Policy Sponsor
5
Target Audience
6
Document Purpose:
7
Please state how the policy is relevant to the
Trusts general equality duties to:
 eliminate discrimination
 advance equality of opportunity
 foster good relations
8
List key groups involved or to be involved in
policy development (e.g. staff side reps, service
users, partner agencies) and how these groups
will be engaged
Cardiopulmonary Resuscitation Policy and
Procedures incorporating Do Not Attempt
Cardiopulmonary Resuscitation Policy
Head of Resuscitation Services
Medical Director
Director of Human Resources
All Trust Staff
Trust Resuscitation Committee
Trust Clinical Performance Council
NB Having read the guidance notes provided when assessing the questions below you must consider;
 Be very conscious of any indirect or unintentional outcomes of a potentially discriminatory nature
 Will the policy create any problems or barriers to any protected group?
 Will any protected group be excluded because of the policy?
 Will the policy have a negative impact on community relations?
If in any doubt please consult with the Patient and Workforce Equality Lead
9
Does the policy significantly affect one group less or more favourably than another on the basis
of: answer ‘Yes/No’ (please add any qualification or explanation to your answer particularly if you
answer yes)
Yes/No
.

Race/ethnicity


Disability (includes Learning Disability,
physical or mental disability and sensory
impairment)
Gender

Religion/belief (including non-belief)

Sexual orientation

Age
Comments/ Rationale
No
No
No
No
No
No
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
Gender reassignment

Pregnancy and Maternity

Marriage and Civil partnership

10
11
12
13
No
No
No
Carer status
No
Will the policy affect the Human Rights of any of
the above-protected groups?
No
If you have identified potential discrimination, are
there any exceptions valid, legal and/or
justifiable?
No
If you have identified a negative impact on any of
the above-protected groups, can the impact be
avoided or reduced by taking different action?
How will the effect of the policy be reviewed after
implementation?
N/A
On-going National Cardiac Arrest Audit (Ref 25)
Annual DNACPR Audit
If you have entered yes in any of the above boxes you must contact the Patient and Workforce Equality
Lead (ext 7609/ Annette.craghill@sthk.nhs.uk) to discuss the outcome and ascertain whether a Stage 2
Equality Analysis Assessment must be completed.
Name of manager completing assessment:
Paul Craven
Job Title of Manager completing assessment
Head of Resuscitation Services
Date of Completion:
14/02/2014
7.
TRAINING
Refer to Trust Induction Mandatory and Risk Management Training Policy Training Needs
Analysis (TNA) (Ref 6)
8.
APPENDICES
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Appendix 1
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Appendix 2
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Appendix 3
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Appendix 4
Algorithm of what to do if a patient comes in with a Lilac Unified DNACPR
Form to St Helens & Knowsley Teaching Hospitals NHS Trust
LILAC FORM
(USUALLY
INDEFINITE
DNACPR)
Patient with capacity –
check consent
Confirm decision is still
valid with senior doctor
YES
CONVERT
TO RED
CARD
RETURN
COMPLETED
LILAC FORM
TO PATIENT
(Do not file in Notes)
No
CANCEL LILAC
FORM. WRITE
CANCELLED SIGN &
DATE
Inform GP
It is not necessary to
re-visit DNACPR
conversations
GIVE LILAC
FORM BACK
TO PATIENT
YES
PATIENT
SURVIVES
ADMISSION
N
NO
ORIGINAL LILAC FORM
STANDS FOR THE JOURNEY
HOME
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Appendix 5
Algorithm of what to do if a patient is to be transferred out of
St Helens and Knowsley Teaching Hospitals NHS Trust with a
DNACPR Order
THIS NEEDS TO BE A CONSULTANT/MIDDLE GRADE EQUIVALENT
DECISION
DNACPR
ORDER
WHISTON
Is the decision still valid
on discharge?
YES
COMPLETE LILAC
UNIFIED DNACPR
FORM
No Further
Action
Decision regarded as indefinite unless
a review date is specified.
LILAC COPY STAYS WITH
PATIENT, 1 WHITE COPY TO
REMAIN IN NOTES AND
OTHER WHITE COPY TO BE
SENT TO RESUSCITATION
SERVICES OFFICE, LEVEL 2
NO
Ensure Mandatory ICE
DISCHARGE box
completed
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