RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIORATING .
RECOGNISING AND RESPONDING TO THEPHYSICALLY DETERIORATING PATIENT(COMMUNITY SETTINGS)NOVEMBER 2016This policy supersedes all previous policies for CPR related to community setting teamsand services1
Policy titleRecognising and responding to the physically deteriorating patient (CommunitySettings)PolicyreferencePolicy categoryCL07BRelevant toAll community setting staff in teams /service areas that have clinical contact with patientsDate publishedDecember 2016ImplementationdateDate lastreviewedNext reviewdatePolicy leadDecember 2016Contact detailsEmail: kevin.cann@candi.nhs.ukAccountabledirectorClaire Johnston, Director of Nursing and PeopleApproved by(Group):Resuscitation Committee29 September 2016Approved by(Committee):Quality Committee22 November 2016DocumenthistoryClinicalN/AJanuary 2018Kevin Cann, Resuscitation LeadDateNov 2016Membership ofthe policydevelopment/review teamConsultationVersion1Telephone: 020-3317-7051Summary of amendmentsComplementary policy focusing onCommunity settingsResuscitation LeadMedical Director, Deputy Medical Director, Clinical Directors, Associate DivisionalDirectors, Senior Service Managers, Consultants and representative clinical staff in theCommunity.2RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
DO NOT AMEND THIS DOCUMENTFurther copies of this document can be found on the Foundation Trust intranet.Contents1Introduction52Aims/Objectives or Purpose63Scope of the Policy64Duties and responsibilities65Definitions96Physical health monitoring7Emergency Equipment and Medical Devices for physical health monitoring 138Discovering a collapsed patient and summoning help159Reporting incidents that include ill health and CPR attempts1910Staff and Patient support following a traumatic event2011Decisions relating to not attempting CPR2012Dissemination and implementation arrangements2113Training requirements2214Monitoring and audit arrangements2315Review of the policy2416References2417Associated documents25Appendix 1: Defibrillator poster263RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 201612
Appendix 2: Community setting emergency equipment and drug list 2718Appendix 3: BLS Algorithm29Appendix 4: Choking Algorithm30Appendix 5: Anaphylaxis Algorithm31Appendix 6: Opiate Overdose Algorithm32Appendix 7: Sepsis Screening Tool33Appendix 8: Datix CPR Audit form example34Appendix 9: DNA-CPR Proforma35Equality Impact Assessment364RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
1. IntroductionThis Policy has been developed in order to achieve a consistent approach toCardio Pulmonary Resuscitation (CPR) and the prevention and management ofthe deteriorating patient across all community settings within Camden andIslington NHS Foundation Trust (C&I). The policy has been developed to takeaccount of organisational changes and the need for a policy that reflects thevarying needs of our services across the trust. As a result two DeterioratingPatient Policies have been developed to meet this, one that is directed towardsInpatient services and on that is directed toward all other clinical services.The Care Quality Commission (CQC) has not set clearly defined regulationsaround Resuscitation, but has instead given a broad statement that covers theresponse to a deteriorating patient:“The provider must have arrangements to take appropriate action if there is aclinical or medical emergency.”CQC (2014) Regulation 12(2) (b)The CQC go on to advise that C&I services response to a deteriorating patientshould be in line with the current nationally recognised guidelines, this wouldinclude: Resuscitation Council (UK) (2014) Quality standards for cardiopulmonaryresuscitation practice and training.Resuscitation Council (UK)(2016) Decisions relating to CardiopulmonaryResuscitationNICE (2007) Acute illness in adults in hospital: recognising and responding todeterioration.NICE (2013) Quality Standard for End of Life Care For AdultsThis document fully supports the recommendations for clinical practice andtraining in cardiopulmonary resuscitation published above and is in line with theC&I Risk management Strategy (2015) and NHSLA Risk Management Standards(2012).It has been developed in line with the following guidelines and they should beread alongside this policy: Anaphylaxis GuidelinesNaloxone Guidelines5RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonaryresuscitation guidelines2. Aims/Objectives or PurposeThis policy provides guidance for clinical staff working in the Trust so that they areable to: Provide prompt, safe and appropriate CPRAble to detect, prevent and manage the deteriorating patient and thesubsequent actions that aim to prevent further deteriorationFollow the correct procedure for patients with ‘Do not attempt CardioPulmonary Resuscitation’ orders (DNA-CPR)Follow due process for ensuring continual availability of resuscitationequipmentEnsure the training needs of staff are metMonitor compliance with all of the above.3. Scope of the policyThis policy applies to any C&I Team or service that have any type of clinicalcontact with service users that have been defined as a Community Setting underdefinitions on page 10 and 11 of this policy, including: Community TeamsCommunity HousesCrisis Houses and Crisis TeamsDay ServicesCorporate facilities that have any kind of service user presenceThis policy applies to all staff that work within these teams or services that haveany clinical contact with service users regardless of previous training orspecialties.4. Duties and responsibilitiesThe Chief Executive has ultimate responsibility for ensuring that mechanismsare in place for the overall implementation, monitoring and revision of policy.6RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
The Associate Director, Governance and Quality Assurance, via the Clinicaland Corporate Policy Manager, is responsible for ensuring: In conjunction with the Policy Lead identifies resource implications tofacilitate implementation and compliance.Training and monitoring systems are in place.Regular review of the policy takes place.Associate Divisional Directors are responsible for implementation of the policywithin their own spheres of management and must ensure that: All new and existing staff have access to and are informed of the policyEnsure that local written procedures support and comply with the policyEnsure the policy is reviewed regularlyStaff training needs are identified and met to enable implementation of thepolicy.The Director of Nursing and People is responsible for ensuring: This policy is reviewed and updated in a timely fashion, in liaison withmedical, nursing, pharmacy, training and operational services staff.That there is a current version of this policy on the Trust intranet and that staffare informed of any policy updates.Provide six monthly reports to the Quality Committee on the resuscitationevent audits, the audit of equipment and training activity in relation to CPRand the detection and management of the deteriorating patient andminutes/action plans from the Resuscitation Committee.The Assistant Director for Learning & Development is responsible forensuring that approved training programmes are provided by competent trainersto meet the standards required.The Resuscitation Committee and the Resuscitation Lead is responsible for: Monitoring and recommending changes to practice ensuring adherence tonation resuscitation guidelines and standardsRecommending and planning adequate provision of trainingDetermining requirement for the choice of resuscitation equipmentPreparing policies relating to resuscitation and prevention of cardiac arrest7RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
Ensuring that current guidelines on resuscitation decisions (DNA-CPR) arereflected in the Trusts relevant policies.Recording and reporting incidents in relation to resuscitation in whichpatients’ safety may have been at riskReview and development of action plans based on audits of resuscitationincidentsMatrons, Operational Service managers and Team Managers are responsiblefor the implementation of CPR in their service area and must ensure that: The staff they manage have read and understand the CPR Policy, attendtraining and follow up staff who do not attendThat teams have the correct equipment, that it is fit for purpose ensuring it isstored appropriately, is in date, is accessible, replaced immediately wherenecessary, audited for quality and that infection control standards areadhered toIncident forms are correctly completed on Datix and submitted after eachresuscitation incidentRecommendations from Resuscitation Committee and serious incidentinvestigations are implemented in a timely fashion, including those from anysimulation exercises on siteAll clinical staff are responsible for: Immediately alerting the appropriate response team in the event of a cardiacor potential cardiac emergency. Ensuring an ambulance has been alerted,that the most qualified member of staff in the management of a deterioratingpatient leads and coordinates the response ensuring that all availableinterventions are used effectively. In the absence of nursing staff, it is theresponsibility of the most senior staff present to manage the incident until theparamedic team take overPractice within the current Resuscitation Council (UK) Guidelines (2014) andtheir own Codes of Professional ConductAttend the appropriate resuscitation training annually. This will be monitoredby Line Managers and the Learning and Development department.Participate in the weekly checking of emergency equipment to make sure theequipment is in a state of readiness at all timesAre familiar with the processes of following up any emergency equipmentfailure during use or checksFollow the guidelines for assessing and managing the deteriorating patient8RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
Replenishing, replacing and ordering any emergency equipment used orexpired in a timely fashionAll Trust staff are responsible for ensuring that they: Are familiar with the content of the relevant policy and follow its requirementsWork within, and do not exceed, their own sphere of competence.5. DefinitionsCommunity SettingsAll C&I services listed below for the purpose of this document are considered aCommunity Setting. 24 hour community units (All Divisions)Community Mental Health Teams (Rehab and Recovery Division)Community Mental Health Teams (Community Division)Community Mental Health Teams (SAMHS)Community Teams (Substance Misuse Service)Crisis Teams and HousesDay ServicesThis definition of community setting is only related to this document and shouldnot be used as a general definition of services for any other purpose.Cardiac ArrestIs the cessation of effective pumping action of the heart. There is abrupt loss ofconsciousness and breathing stops. Unless treated promptly irreversible braindamage and death follow within minutes. The diagnosis of cardiac arrest is madeby the first practitioner to note the signs of: Sudden collapse;Loss of responsiveness;Absence of spontaneous respiration;Appropriate treatment must be given immediately. If not, after three minutescerebral damage will result. Cardiac arrest may occur for any number of reasons,however they tend it occur most commonly in the following situations:9RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
Existing or undiagnosed heart conditionsBlood lossOverdoseAsphyxiaHypoglycaemiaAnaphylaxisRapid tranquillisationRespiratory diseasesChokingCardio-Pulmonary Resuscitation (CPR)This is an emergency procedure for life support consisting of artificial respirationand manual external cardiac massage. It aims to establish effective circulationand ventilation in order to prevent irreversible brain damage and death.Automated External Defibrillation (AED)The Automated External Defibrillator is a computerised device that deliversdefibrillator shocks to a patient in cardiac arrest. They use voice and visualprompts to guide staff. They analyse the heart rhythm to determine the need for ashock. The staff then deliver the shock when is has been ascertained that it issafe to do so.Recognition of the Deteriorating PatientThis provides the essential skills and knowledge which are required to recognisethe deteriorating patient and to instigate the appropriate actions. This includesbeing able to perform a basic set of physical observations, which consist of: TemperaturePulseRespiratory RateBlood PressureOxygen SaturationConsciousness level10RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
Basic Life Support (BLS)The provision of treatment designed to maintain adequate circulation andventilation to a patient in cardiac arrest without the use of drugs or specialistequipment, until emergency services (999) arrive. Where a simple airway orfacemask for mouth to mouth ventilation is used, this is defined as "basic lifesupport with airway adjunct".AnaphylaxisAnaphylaxis is a severe, life threatening, generalised or systemic hypersensitivityreaction. It is characterised by rapidly developing, life threatening problemsinvolving: the airway (pharyngeal or laryngeal oedema) and / or breathing(bronchospasm and tachypnoea) and/or circulation (hypotension and/ortachycardia). In most cases, there are associated skin and mucosal changes. Theacute reaction that occurs usually happens within seconds or minutes of anexposure to the antigen.Opiate OverdoseOpioid overdose is an acute condition due to excessive opioids. Examples ofopioids are: morphine, heroin, tramadol, oxycodone, and methadone. Death canbe prevented in opioid overdoses if patients receive basic life support and theadministration of naloxone soon after opioid overdose is suspected.CPR TrainingC&I has sourced training that includes and goes beyond the skills of BLS howeverremains basic in terms of Resuscitation. The adapted training includes: Use of an AEDUse of Oxygen with a Bag Valve Mask on a person who is not breathingResponding to a person who is chokingResponding to a person with an acute allergic reaction (Anaphylaxis)Responding to a person who has taken a suspected opiate overdoseImmediate Life Support (ILS)The provision of treatment designed to maintain adequate circulation andventilation to a patient in cardiac arrest additionally using specialist drug andlimited emergency equipment until emergency services (999) arrive. It is an11RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
extended training from CPR that gives clinical staff further skills in managing thedeteriorating patient. These additional areas include: Identifying the causes and promote the prevention of cardiopulmonary arrest;Recognising and treating the deteriorating patient using the ABCDEapproach;Undertake the skills of quality CPR and defibrillation (manual and /or AED)and simple airway manoeuvres;Utilize non-technical skills to facilitate initial leadership and effective teammembershipDo Not Attempt Cardio-Pulmonary Resuscitation (DNA-CPR)A DNA-CPR order indicates that in the event of a cardiac arrest, CPR will not beinitiated. DNAR decisions are the overall responsibility of the Consultant incharge of the patient’s care (GP in the case of nursing homes). Attempts at CPRwill not be commenced when it has been assessed that a patient would notsurvive or when it is not the patient’s wishes. Please refer to section 126. Physical Health MonitoringAll physical observations recorded should use the Nations Early Warning(NEWS) scoring system including those taken on admission and on a weeklybasis in all 24 hour community and crisis houses. Community mental healthteams should also have the ability to monitor the basic physical health of aservice user and use NEWS in an effective and cohesive way to monitor adeteriorating patient. The following NEWS clinical indication system shown belowgives a basic guide on what is clinically indicated for the NEWS of the patient.Please refer to the trusts physical health and wellbeing policy for more informationon NEWS: A low score (NEW score 1–3) should prompt assessment by a competentregistered nurse or doctor who should decide if a change to frequency ofclinical monitoring or an escalation of clinical care is required (this can bephone contact with the duty doctor)A medium score (NEW score of 4–6 or a RED score/score of 3 in a singleparameter) should prompt an urgent review by a clinician skilled withcompetencies in the assessment of acute illness – usually a doctor or acuteteam nurse, who should consider whether escalation of care to a team withcritical-care skills is required (i.e. A&E or Acute hospital)12RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
A high score (NEW score of 7 or more) should prompt emergencyassessment by a clinical team/critical care outreach team with critical-carecompetencies. This in most circumstances will be your nearest A&E.7. Emergency Equipment and Medical Devices for physical healthmonitoringAll community settings must have available the following Emergency equipmentand medications on all sites that facilitate service user visits: Zoll AED with 2 sets of matching defibrillator padsBag Valve MaskLigature CuttersTough cut shearsHigh concentration oxygen maskFace maskHand held suction devicePen torchMedications include: Oxygen naloxone Adrenaline for anaphylaxisWhere possible all emergency equipment must be stored in an easily accessiblearea that can be accessed by all staff. All emergency equipment must be kepttogether in an emergency bag and labeled with the poster shown in Appendix 1(Full sized A4 posters can be purchased from SP Services on Agresso using thefollowing catalogue number: SS/302). A full list of this equipment with NHS SupplyChain ordering numbers is available in Appendix 2.Oxygen can be ordered via BOC Medical using the following process:Please note that this should be behind a fire door in order to ensure safestorage of oxygen.The following Medical Devices should be available to all mental health teams inorder to monitor the physical health of a deteriorating patient: Sphygmomanometers (Electronic blood pressure machines can be used butthere should still be a sphygmomanometer available)13RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT(COMMUNITY SETTINGS) JULY 2016
StethoscopePulse OximeterThermometerMEWS ChartsAll medical devices must be routinely serviced in accordance with the trustsMedical Devices Policy a local inventory of these devices should be updatedevery six months. Medical gas cylinders must bear a label which includes thefilling date and the expiry date. Any equipment that needs to be replaced shouldbe done so promptly, ensuring that all necessary equipment is available at alltimes. All repairs to emergency equipment must be reported immediately inaccordance with the medical devices policyAll equipment must be checked weekly using the Meridian Audit System using thefollowing link: /default.aspx?slid 206&did Any failure of medical devices should be reported via Datix and immediate repairmust be arranged in line with the Medical Devices Policy .All Emergency Medication (apart from Oxygen in certain circumstances explainedbelow) will be delivered from the Trust pharmacy when required. If this medicationis expired or used you must inform the Trust Pharmacy immediately.For all
RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016 Ensuring that current guidelines on resuscitation decisions (DNA-CPR) are reflected in the Trusts relevant policies. Recording and reporting incidents in relation to resuscitation in which patients’ safety may have been at risk
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