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1
RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIORATING PATIENT
(COMMUNITY SETTINGS) NOVEMBER 2016
This policy supersedes all previous policies for CPR related to community setting teams
and services
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Policy title Recognising and responding to the physically deteriorating patient (Community Settings)
Policy reference
CL07B
Policy category Clinical
Relevant to All community setting staff in teams /service areas that have clinical contact with patients
Date published December 2016
Implementation date
December 2016
Date last reviewed
N/A
Next review date
January 2018
Policy lead Kevin Cann, Resuscitation Lead
Contact details Email: [email protected] Telephone: 020-3317-7051
Accountable director
Claire Johnston, Director of Nursing and People
Approved by (Group):
Resuscitation Committee 29 September 2016
Approved by (Committee):
Quality Committee 22 November 2016
Document history
Date Version Summary of amendments
Nov 2016 1 Complementary policy focusing on
Community settings
Membership of the policy development/ review team
Resuscitation Lead
Consultation Medical Director, Deputy Medical Director, Clinical Directors, Associate Divisional Directors, Senior Service Managers, Consultants and representative clinical staff in the Community.
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
DO NOT AMEND THIS DOCUMENT
Further copies of this document can be found on the Foundation Trust intranet.
Contents
1 Introduction 5
2 Aims/Objectives or Purpose 6
3 Scope of the Policy 6
4 Duties and responsibilities 6
5 Definitions 9
6 Physical health monitoring 12
7 Emergency Equipment and Medical Devices for physical health monitoring 13
8 Discovering a collapsed patient and summoning help 15
9 Reporting incidents that include ill health and CPR attempts 19
10 Staff and Patient support following a traumatic event 20
11 Decisions relating to not attempting CPR 20
12 Dissemination and implementation arrangements 21
13 Training requirements 22
14 Monitoring and audit arrangements 23
15 Review of the policy 24
16 References 24
17 Associated documents 25
Appendix 1: Defibrillator poster 26
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Appendix 2: Community setting emergency equipment and drug list 27
Appendix 3: BLS Algorithm 29
Appendix 4: Choking Algorithm 30
Appendix 5: Anaphylaxis Algorithm 31
Appendix 6: Opiate Overdose Algorithm 32
Appendix 7: Sepsis Screening Tool 33
Appendix 8: Datix CPR Audit form example 34
Appendix 9: DNA-CPR Proforma 35
18 Equality Impact Assessment 36
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
1. Introduction
This Policy has been developed in order to achieve a consistent approach to Cardio Pulmonary Resuscitation (CPR) and the prevention and management of the deteriorating patient across all community settings within Camden and Islington NHS Foundation Trust (C&I). The policy has been developed to take account of organisational changes and the need for a policy that reflects the varying needs of our services across the trust. As a result two Deteriorating Patient Policies have been developed to meet this, one that is directed towards Inpatient services and on that is directed toward all other clinical services. The Care Quality Commission (CQC) has not set clearly defined regulations around Resuscitation, but has instead given a broad statement that covers the response to a deteriorating patient: “The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.” CQC (2014) Regulation 12(2) (b) The CQC go on to advise that C&I services response to a deteriorating patient should be in line with the current nationally recognised guidelines, this would include:
Resuscitation Council (UK) (2014) Quality standards for cardiopulmonary resuscitation practice and training.
Resuscitation Council (UK)(2016) Decisions relating to Cardiopulmonary Resuscitation
NICE (2007) Acute illness in adults in hospital: recognising and responding to deterioration.
NICE (2013) Quality Standard for End of Life Care For Adults This document fully supports the recommendations for clinical practice and training in cardiopulmonary resuscitation published above and is in line with the C&I Risk management Strategy (2015) and NHSLA Risk Management Standards (2012). It has been developed in line with the following guidelines and they should be read alongside this policy:
Anaphylaxis Guidelines
Naloxone Guidelines
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonary resuscitation guidelines
2. Aims/Objectives or Purpose
This policy provides guidance for clinical staff working in the Trust so that they are able to:
Provide prompt, safe and appropriate CPR
Able to detect, prevent and manage the deteriorating patient and the subsequent actions that aim to prevent further deterioration
Follow the correct procedure for patients with ‘Do not attempt Cardio Pulmonary Resuscitation’ orders (DNA-CPR)
Follow due process for ensuring continual availability of resuscitation equipment
Ensure the training needs of staff are met
Monitor compliance with all of the above.
3. Scope of the policy This policy applies to any C&I Team or service that have any type of clinical contact with service users that have been defined as a Community Setting under definitions on page 10 and 11 of this policy, including:
Community Teams
Community Houses
Crisis Houses and Crisis Teams
Day Services
Corporate facilities that have any kind of service user presence
This policy applies to all staff that work within these teams or services that have any clinical contact with service users regardless of previous training or specialties.
4. Duties and responsibilities The Chief Executive has ultimate responsibility for ensuring that mechanisms are in place for the overall implementation, monitoring and revision of policy.
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, is responsible for ensuring:
In conjunction with the Policy Lead identifies resource implications to facilitate implementation and compliance.
Training and monitoring systems are in place.
Regular review of the policy takes place. Associate Divisional Directors are responsible for implementation of the policy within their own spheres of management and must ensure that:
All new and existing staff have access to and are informed of the policy
Ensure that local written procedures support and comply with the policy
Ensure the policy is reviewed regularly
Staff training needs are identified and met to enable implementation of the policy.
The Director of Nursing and People is responsible for ensuring:
This policy is reviewed and updated in a timely fashion, in liaison with medical, nursing, pharmacy, training and operational services staff.
That there is a current version of this policy on the Trust intranet and that staff are informed of any policy updates.
Provide six monthly reports to the Quality Committee on the resuscitation event audits, the audit of equipment and training activity in relation to CPR and the detection and management of the deteriorating patient and minutes/action plans from the Resuscitation Committee.
The Assistant Director for Learning & Development is responsible for ensuring that approved training programmes are provided by competent trainers to meet the standards required. The Resuscitation Committee and the Resuscitation Lead is responsible for:
Monitoring and recommending changes to practice ensuring adherence to nation resuscitation guidelines and standards
Recommending and planning adequate provision of training
Determining requirement for the choice of resuscitation equipment
Preparing policies relating to resuscitation and prevention of cardiac arrest
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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
Review and development of action plans based on audits of resuscitation incidents
Matrons, Operational Service managers and Team Managers are responsible for the implementation of CPR in their service area and must ensure that:
The staff they manage have read and understand the CPR Policy, attend training and follow up staff who do not attend
That teams have the correct equipment, that it is fit for purpose ensuring it is stored appropriately, is in date, is accessible, replaced immediately where necessary, audited for quality and that infection control standards are adhered to
Incident forms are correctly completed on Datix and submitted after each resuscitation incident
Recommendations from Resuscitation Committee and serious incident investigations are implemented in a timely fashion, including those from any simulation exercises on site
All clinical staff are responsible for:
Immediately alerting the appropriate response team in the event of a cardiac or potential cardiac emergency. Ensuring an ambulance has been alerted, that the most qualified member of staff in the management of a deteriorating patient leads and coordinates the response ensuring that all available interventions are used effectively. In the absence of nursing staff, it is the responsibility of the most senior staff present to manage the incident until the paramedic team take over
Practice within the current Resuscitation Council (UK) Guidelines (2014) and their own Codes of Professional Conduct
Attend the appropriate resuscitation training annually. This will be monitored by Line Managers and the Learning and Development department.
Participate in the weekly checking of emergency equipment to make sure the equipment is in a state of readiness at all times
Are familiar with the processes of following up any emergency equipment failure during use or checks
Follow the guidelines for assessing and managing the deteriorating patient
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Replenishing, replacing and ordering any emergency equipment used or expired in a timely fashion
All Trust staff are responsible for ensuring that they:
Are familiar with the content of the relevant policy and follow its requirements
Work within, and do not exceed, their own sphere of competence.
5. Definitions
Community Settings
All C&I services listed below for the purpose of this document are considered a Community Setting.
24 hour community units (All Divisions)
Community Mental Health Teams (Rehab and Recovery Division)
Community Mental Health Teams (Community Division)
Community Mental Health Teams (SAMHS)
Community Teams (Substance Misuse Service)
Crisis Teams and Houses
Day Services
This definition of community setting is only related to this document and should not be used as a general definition of services for any other purpose.
Cardiac Arrest
Is the cessation of effective pumping action of the heart. There is abrupt loss of consciousness and breathing stops. Unless treated promptly irreversible brain damage and death follow within minutes. The diagnosis of cardiac arrest is made by the first practitioner to note the signs of:
Sudden collapse;
Loss of responsiveness;
Absence of spontaneous respiration;
Appropriate treatment must be given immediately. If not, after three minutes cerebral damage will result. Cardiac arrest may occur for any number of reasons, however they tend it occur most commonly in the following situations:
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Existing or undiagnosed heart conditions
Blood loss
Overdose
Asphyxia
Hypoglycaemia
Anaphylaxis
Rapid tranquillisation
Respiratory diseases
Choking
Cardio-Pulmonary Resuscitation (CPR)
This is an emergency procedure for life support consisting of artificial respiration and manual external cardiac massage. It aims to establish effective circulation and ventilation in order to prevent irreversible brain damage and death.
Automated External Defibrillation (AED)
The Automated External Defibrillator is a computerised device that delivers defibrillator shocks to a patient in cardiac arrest. They use voice and visual prompts to guide staff. They analyse the heart rhythm to determine the need for a shock. The staff then deliver the shock when is has been ascertained that it is safe to do so.
Recognition of the Deteriorating Patient
This provides the essential skills and knowledge which are required to recognise the deteriorating patient and to instigate the appropriate actions. This includes being able to perform a basic set of physical observations, which consist of:
Temperature
Pulse
Respiratory Rate
Blood Pressure
Oxygen Saturation
Consciousness level
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Basic Life Support (BLS)
The provision of treatment designed to maintain adequate circulation and ventilation to a patient in cardiac arrest without the use of drugs or specialist equipment, until emergency services (999) arrive. Where a simple airway or facemask for mouth to mouth ventilation is used, this is defined as "basic life support with airway adjunct".
Anaphylaxis
Anaphylaxis is a severe, life threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing, life threatening problems involving: the airway (pharyngeal or laryngeal oedema) and / or breathing (bronchospasm and tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes. The acute reaction that occurs usually happens within seconds or minutes of an exposure to the antigen.
Opiate Overdose
Opioid overdose is an acute condition due to excessive opioids. Examples of opioids are: morphine, heroin, tramadol, oxycodone, and methadone. Death can be prevented in opioid overdoses if patients receive basic life support and the administration of naloxone soon after opioid overdose is suspected.
CPR Training
C&I has sourced training that includes and goes beyond the skills of BLS however remains basic in terms of Resuscitation. The adapted training includes:
Use of an AED
Use of Oxygen with a Bag Valve Mask on a person who is not breathing
Responding to a person who is choking
Responding to a person with an acute allergic reaction (Anaphylaxis)
Responding to a person who has taken a suspected opiate overdose
Immediate Life Support (ILS)
The provision of treatment designed to maintain adequate circulation and ventilation to a patient in cardiac arrest additionally using specialist drug and limited emergency equipment until emergency services (999) arrive. It is an
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
extended training from CPR that gives clinical staff further skills in managing the deteriorating patient. These additional areas include:
Identifying the causes and promote the prevention of cardiopulmonary arrest;
Recognising and treating the deteriorating patient using the ABCDE approach;
Undertake the skills of quality CPR and defibrillation (manual and /or AED) and simple airway manoeuvres;
Utilize non-technical skills to facilitate initial leadership and effective team membership
Do Not Attempt Cardio-Pulmonary Resuscitation (DNA-CPR)
A DNA-CPR order indicates that in the event of a cardiac arrest, CPR will not be initiated. DNAR decisions are the overall responsibility of the Consultant in charge of the patient’s care (GP in the case of nursing homes). Attempts at CPR will not be commenced when it has been assessed that a patient would not survive or when it is not the patient’s wishes. Please refer to section 12
6. Physical Health Monitoring
All physical observations recorded should use the Nations Early Warning (NEWS) scoring system including those taken on admission and on a weekly basis in all 24 hour community and crisis houses. Community mental health teams should also have the ability to monitor the basic physical health of a service user and use NEWS in an effective and cohesive way to monitor a deteriorating patient. The following NEWS clinical indication system shown below gives a basic guide on what is clinically indicated for the NEWS of the patient. Please refer to the trusts physical health and wellbeing policy for more information on NEWS:
A low score (NEW score 1–3) should prompt assessment by a competent registered nurse or doctor who should decide if a change to frequency of clinical monitoring or an escalation of clinical care is required (this can be phone contact with the duty doctor)
A medium score (NEW score of 4–6 or a RED score/score of 3 in a single parameter) should prompt an urgent review by a clinician skilled with competencies in the assessment of acute illness – usually a doctor or acute team nurse, who should consider whether escalation of care to a team with critical-care skills is required (i.e. A&E or Acute hospital)
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
A high score (NEW score of 7 or more) should prompt emergency assessment by a clinical team/critical care outreach team with critical-care competencies. This in most circumstances will be your nearest A&E.
7. Emergency Equipment and Medical Devices for physical health
monitoring
All community settings must have available the following Emergency equipment and medications on all sites that facilitate service user visits:
Zoll AED with 2 sets of matching defibrillator pads
Bag Valve Mask
Ligature Cutters
Tough cut shears
High concentration oxygen mask
Face mask
Hand held suction device
Pen torch
Medications include: Oxygen naloxone Adrenaline for anaphylaxis
Where possible all emergency equipment must be stored in an easily accessible area that can be accessed by all staff. All emergency equipment must be kept together in an emergency bag and labeled with the poster shown in Appendix 1 (Full sized A4 posters can be purchased from SP Services on Agresso using the following catalogue number: SS/302). A full list of this equipment with NHS Supply Chain ordering numbers is available in Appendix 2. Oxygen can be ordered via BOC Medical using the following process: Please note that this should be behind a fire door in order to ensure safe storage of oxygen.
The following Medical Devices should be available to all mental health teams in
order to monitor the physical health of a deteriorating patient:
Sphygmomanometers (Electronic blood pressure machines can be used but
there should still be a sphygmomanometer available)
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Stethoscope
Pulse Oximeter
Thermometer
MEWS Charts
All medical devices must be routinely serviced in accordance with the trusts
Medical Devices Policy a local inventory of these devices should be updated
every six months. Medical gas cylinders must bear a label which includes the
filling date and the expiry date. Any equipment that needs to be replaced should
be done so promptly, ensuring that all necessary equipment is available at all
times. All repairs to emergency equipment must be reported immediately in
accordance with the medical devices policy
All equipment must be checked weekly using the Meridian Audit System using the
following link: https://www.oc-
meridian.com/candi/completion/custom/default.aspx?slid=206&did=
Any failure of medical devices should be reported via Datix and immediate repair
must be arranged in line with the Medical Devices Policy .
All Emergency Medication (apart from Oxygen in certain circumstances explained
below) will be delivered from the Trust pharmacy when required. If this medication
is expired or used you must inform the Trust Pharmacy immediately.
For all teams ordering oxygen outside of Highgate Mental Health Centre, teams
must email Pharmacy a request for Oxygen to the Pharmacy generic inbox, this
will be processed and delivery arranged via BOC Medical Supplies directly to your
team. Once your oxygen is received you must email Pharmacy to inform them of
delivery.
If your team is based in Highgate Mental Health Centre then you must email
Pharmacy a request for Oxygen to the Pharmacy generic inbox, this will be
processed and delivered to the Pharmacy on site and delivered to you by the
porters. You will not need to email pharmacy confirmation of receipt.
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
If the teams are in a shared setting then the equipment can be shared amongst
the teams. However all equipment must be located in an area that is obtainable
by all staff. For all sites that chose to share equipment amongst teams there must
be a clear shared agreement that allows for rotation of auditing and ordering
equipment.
8. Managing a collapsed patient
Discovering a collapsed patient
In all instances where a patient is found collapsed or is a witnessed collapse and not breathing correctly the staff must follow the BLS Algorithm in Appendix 3, immediately summon help using the alarm system where available and shouting for help when not, the ambulance service must be called immediately and CPR commenced when indicated. All emergency equipment must be used where clinically indicated.
If you are not at your team base (i.e. in a patients home) then continue BLS Algorithm without emergency equipment.
Transient loss of consciousness
Transient loss of consciousness (TLoC) may be defined as spontaneous loss of consciousness with complete recovery. In this context, complete recovery would involve full recovery of consciousness without any residual neurological deficit. An episode of TLoC is often described as a 'blackout' or a 'collapse'. If someone reports or is suspected to have an episode of TLoC the following steps should be taken:
Record the details of the event, clinical history and physical examination on Care Notes
A 12-lead ECG should be offered during the initial assessment, if this is not possible they should be directed towards A&E to have this done
If any of the following is present then the patient must be immediately transferred to A&E with a recommendation to be seen by a Cardiologist
o An ECG abnormality, heart failure (history or physical signs) or a heart murmur
o TLoC during exertion
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
o Family history of sudden cardiac death in people aged younger than 40 years and/or an inherited cardiac condition
o New or unexplained breathlessness
Choking
In instances where a patient is suspected of choking then follow the Choking Algorithm in Appendix 4. If there is any loss of consciousness then begin CPR using the BLS Algorithm in Appendix 3 and phone emergency services immediately. In all cases of loss of consciousness the service user must be transferred to A&E via ambulance. In cases where choking was alleviated quickly and effectively then the patient must be placed on frequent physical health monitoring. Use the NEWS clinical indication system described above to direct you.
Anaphylaxis
In instances where Anaphylaxis is indicated then follow the Anaphylactic Algorithm in Appendix 5. In all instances of a suspected anaphylactic episode the patient must be transferred to A&E via ambulance for monitoring and potential further treatment. Any use of Adrenaline for an anaphylactic episode must be reported via Datix and a new treatment kit requested from pharmacy immediately.
Anaphylaxis can be triggered by any of a very broad range of triggers, but those most commonly identified include food, drugs and venom. The relative importance of these varies very considerably with age, with food being particularly important in children and medicinal products being much more common triggers in older people. Virtually any food or class of drug can be implicated, although the classes of foods and drugs responsible for the majority of reactions are well described. Of foods, nuts are the most common cause; muscle relaxants, antibiotics, NSAIDs and aspirin are the most commonly implicated drugs.
Opiate overdose
In cases of suspected opiate overdose then naloxone should be given via inter-muscular injection. All incidents of suspected opiate overdose should follow the Opiate Overdose Algorithm in Appendix 6. In all incidents of suspected opiate overdose the patient should be transferred to A&E via ambulance for monitoring and potential further treatment. It is important to note that naloxone is a short acting drug and its effects will dissipate quickly. Attendance to A&E must be reinforced to the patient as essential as they are at risk of death if they do not attend. Any use of naloxone must be reported via Datix and a new treatment kit requested from pharmacy immediately.
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Emergency medicine advice suggests supplemental oxygen or bag-valve-mask ventilation where RR< 10/minute or Sp02<92% (on air). Regardless, the severity of respiratory depression defines the acuteness of toxicity, subsequent management and whether or not naloxone is indicated.
Lower initial dose regimens are considered of value where the situation is less immediately life-threatening or where a more controlled effect is desirable, for example palliative care and chronic opioid use. These regimes should only be administered by a doctor and used in line with the Trusts Naloxone Guidelines.
Sepsis
Sepsis, also referred to as blood poisoning or septicaemia, is a potentially life-threatening condition, triggered by an infection or injury. In sepsis, the body’s immune system goes into overdrive as it tries to fight an infection. This can reduce the blood supply to vital organs such as the brain, heart and kidneys. Without quick treatment, sepsis can lead to multiple organ failure and death. Any patient that has a NEWS of 3 or above without any obvious cause must be screened for Sepsis using the Sepsis Screening tool in Appendix 7. Where possible follow recommended treatments on the Sepsis Screening Tool, in all incidents of suspected Sepsis the patient must be transferred to A&E via and emergency ambulance for further treatment.
Handing over to the emergency services
When handing over to the paramedics it is imperative that all information is handed over in a concise and accurate manner. As such it is advised that the following method is used when handing over to paramedics.
S
Story:
Name of caller and ward
Name of patient
Patient’s relevant mental health, current physical health issues
Diagnosis and medication (Psychosis, Clozapine 800mg)
Why you have requested an ambulance (e.g. vomiting, feels unwell, breathlessness, pain, dizziness, fall)
Onset of symptoms (30mins, 2 hours, 1 day, 1 month)
O
Objective Observations (be specific do not use the terms high/low)
Temperature (38.2)
Pulse (120)
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
BP (150/90)
Respirations (22)
Oxygen saturation (97%)
Conscious level (Unconscious)
ECG result if available
Blood results if available
S
Signs- report any abnormalities that you or the patient sees and tells you (LOOK, LISTEN AND FEEL)
Report any evidence of bleeding and location (sputum, abdomen, vomit)
Patient in pain, colour of skin (flushed, pale, blue), colour of sputum (green, white)
Abnormal sounds (wheezing, coughing)
Abnormal smells (ketones, urine, alcohol)
If the patient has been receiving CPR when the paramedics arrive ensure that you handover using the method above, in addition you must also include the following:
What time CPR began
How many shocks from the defibrillator have been delivered if any
What drugs have been given if any
If there is a DNA-CPR in place When speaking to the emergency services on the phone it is imperative that you communicate the severity of the incident in a clear and concise manner. If the patient is unconscious with abnormal breathing then hand this over immediately, ensure that the emergency services know the address of where you want them to attend and that there is a member of staff ready to meet them outside of the premises when they arrive.
Documenting all interventions when delivering CPR
When an incident occurs that involves a deteriorating patient or a collapsed patient it is essential that a member of staff records the times that interventions occurred. This allows staff to hand over correctly to the emergency services and the post incident investigation to be completed in an effective manner. The following should be noted:
Time patient discovered if collapsed
Time CPR began
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Time ambulance called
Time defibrillator attached
Number of defibrillator shocks delivered
Any drugs given
Any other equipment used
Staff involved
All of this information must be documented in the Datix that is completed for the
incident in the CPR Audit section. An example of this section can be seen in
Appendix 8.
9. Reporting incidents that include ill health and CPR attempts
Following an incident involving a deteriorating patient, the team leader or most
senior member of staff on duty must ensure that all documentation is completed
fully and accurately. An online incident form must be completed on Datix and in
the cases of a CPR attempt being made the CPR Audit section must be
completed. This will appear on Datix when any category relating to death or ill
health is selected, and example of the CPR Audit form can be found in Appendix
8. The Datix information will be compiled into an audit report by the
Resuscitation Lead and presented to the Quality Committee every 6 months.
In the event of a CPR attempt being made, the Divisional Manager/Matron or the
out-of-hours Senior Manager On-Call must be informed immediately, in the event
of a death the Director On-Call should be informed. If necessary, the Senior
Manager will visit the scene of the incident. In addition to this the following people
should then be contacted if they were not present:
Next of kin/significant other of the patient, although in the event of an
unexpected death the police will inform the relatives. Relatives will then be
given the opportunity to view the body at the mortuary (Refer to Policy &
Procedure relating to a Death on Foundation Trust Premises).
Consultant responsible for the care of the patient;
General practitioner (GP) to be informed at the earliest opportunity by the
consultant;
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
In some instances the team might consider contacting the patient’s religious
minister, especially if the patient requires special religious procedures should
resuscitation be unsuccessful.
As soon as is reasonably possible but within 48 hours a staff debrief must take
place. Critical actions and information should be documented in the handler
section of the Datix related to the incident. However any other issues raised
around trauma or personal opinions of the incident should not be documented on
Datix. Any incident that involved the death of a patient should be referred to the
Trauma at Work Pathway (TAWP) that can be found in the same named policy.
10. Staff and Patient support following a traumatic event
Patient Support An incident such as a cardiac arrest can have an impact upon the service user and staff community, not just those involved with the resuscitation attempt. Therefore, a patient support group/meeting should be held at the earliest opportunity where reasonable to provide support, advice and a time to discuss any relevant issues for patients as well as to identify the need for any one-to-one individual support. Staff Support It is recognised that staff involved in a serious incident may suffer a high level of stress or trauma. Support and counselling should be available immediately to either individuals or the team. Support may be provided by senior colleagues or a multi-professional support group could be held at a later date if necessary or requested. Effected staff and Team Leaders are advised to refer to the Trauma at Work Pathway (TAWP) for any incidents that involved the use of CPR or unexpected death of a patient.
11. Decisions relating to not attempting CPR (DNA-CPR)
For the vast majority of patients entering community settings, the likelihood of rapid deterioration is small, however there may be occasions when advance decisions about CPR have been made.
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
The overall responsibility for making advance decisions rests with the consultant
or general practitioner in charge of the patient’s care. However, he/she should
discuss the decision for an individual patient with other health professionals and
those close to the patient. It might also be helpful to discuss decisions at the
multidisciplinary team meetings.
Following a decision not to resuscitate, there must be a clear line of communication between medical and nursing staff. The decision, especially the basis for it, must be clearly documented on Care Notes and the completed Cardiopulmonary Resuscitation Decision Proforma attached to Care Notes (Appendix 9). It is the responsibility of the team’s senior medical staff together with their nursing colleagues to discuss the reasons for non-resuscitation with the patient (if s/he is able to understand the information), all members of the multidisciplinary team and the patient’s relatives. The decision not to resuscitate a patient does not and must not preclude the rights of the patient to receive and the duty of practitioners to provide all other appropriate nursing and medical care available. It is advised that all staff involved in the decision making process of completing DNA-CPR documentation read the Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonary resuscitation guidelines. This will provide you with all information relating to how and when to make these decisions.
12. Dissemination and implementation arrangements
This document will be circulated to all managers who will be required to cascade the information to members of their teams. It is available to all staff via the Foundation Trust intranet. Managers will ensure that all staff are briefed on its contents and on what it means for them.
Any enquiries regarding the implementation of this policy should be directed to the Clinical Policy Officer or Resuscitation Lead.
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
13. Training requirements
All staff that have clinical contact must complete the Trusts CPR training as a minimum standard of Resuscitation Training in accordance with the Trusts Mandatory Training policy. For all staff that have valid ILS of ALS Training in date then CPR training does not need to be completed until this training has expired.
For training requirements please refer to the Trust’s Mandatory Training Policy and Learning and Development Guide http://cift-ap02/sorce/
14. Monitoring and audit arrangements
23
Elements to be monitored
Lead How trust will monitor
compliance
Frequency Reporting arrangements
Acting on recommendations
and leads
Changes in practice and lessons to be shared
The duties Resuscitation Lead
Audit of:
Care notes
MEWS forms
6 monthly Resuscitation Committee
Required actions will be identified and completed in a specified timeframe
Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders
That early warning systems are in place for the recognition of patients at risk of deteriorating
Resuscitation Lead
Audit of:
MEWS forms
Care notes
Datix forms
6 monthly Resuscitation Committee
Actions to be taken to minimise or prevent further deterioration in patients
Resuscitation Lead
Audit of:
Care Notes
Physical health Care plans
6 monthly Resuscitation Committee
Do not attempt CPR orders (DNA-CPR)
Resuscitation Lead
Audit of all DNA-CPR forms
6 monthly Resuscitation Committee
Audit of CPR events Resuscitation Lead
Audit of
Datix incident forms
Care notes
SUI’s
6 monthly Resuscitation Committee
Checking of
resuscitation
equipment
Resuscitation Lead
Audit of Meridian
Weekly Resuscitation
Committee
24
15. Review of the policy
This policy will be reviewed in July 2018 or earlier if there is a significant change
in practice or new regulation.
16. References
Care Quality Commission (2015) Guidance for Providers on Meeting the Regulations. London Available at: http://www.cqc.org.uk/content/regulations-service-providers-and-managers Department of Health (2009) Competencies for Recognising and Responding to Acutely ill Patients in hospital. London European Resuscitation Council (2010) European Resuscitation Council Guidelines for Resuscitation. Elsvier. Available at: http://www.journals.elsevier.com/resuscitation Houses of Parliament (2008) Health and Social Care Act (Regulated Activities) Regulations 2014 (Part 3), No: 2936. London. Available at: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 National Confidential Enquiry into Patient Outcome and Death (2012) Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. London. Available at: http://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf National Institute of Health and Clinical Excellence (2007) Acutely ill patients in hospital. Recognition of and response to acute illness in adult hospitals. London. Available at: http://www.nice.org.uk/guidance/CG50 National Institute of Health and Clinical Excellence (2016) Sepsis. Available at: https://www.nice.org.uk/guidance/ng51 National Institute of Health and Clinical Excellence (2015) Violence and Aggression: Short-term management in Mental Health and Community settings. London. Available at: http://www.nice.org.uk/guidance/NG10
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
National Institute of Health and Clinical Excellence (2015) Transient loss of consciousness ('blackouts') in over 16s. London. Available at: https://www.nice.org.uk/guidance/cg109 Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London. Available at: http://www.nmc.org.uk/standards/code Resuscitation Council (UK) (2014) Quality standards for cardiopulmonary resuscitation practice and training. London. Available at: https://www.resus.org.uk/quality-standards/mental-health-inpatient-care-quality-standards/ Resuscitation Council (2015) Consensus Paper on out of hospital Cardiac Arrest in England. London. Available at: https://www.resus.org.uk/publications/consensus-paper-on-out-of-hospital-cardiac-arrest-in-england/
Resuscitation Council (2016) Advanced Life Support (7th Edition) London.
Resuscitation Council (UK) (2016) Decisions relating to cardiopulmonary resuscitation. London. Available at: https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr
The Sepsis UK Trust (2016) Prehospital management of Sepsis in adults and young people over 12 years. London. Available at: http://sepsistrust.org/wp-content/uploads/2016/07/PH-toolkit-FINAL-2.pdf
17. Associated documents CPR: Deteriorating Patient Policy – CL07
Mental Capacity Act Policy – MHA12
Medical Devices Policy – RM04
Physical Health and Well Being Policy – CL21
Mandatory Training Policy and Learning and Development Guide
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Appendix 1 Defibrillator Poster
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Appendix 2 Community setting emergency equipment and drug list
For all items, please check expiry dates, integrity of sterile packaging, contents, quantities and sizes, correct location, and correct labelling. All emergency equipment must be checked weekly. TEAM: SITE: ITEM Grab Bag AMOUNT NHS Supply
Chain Number EXPIRY DATE
Checked by/date
Fishtail Knife (Ligature Cutter)
1
Toughcut Shears 1 SI/016 (SP Services)
Stethoscope 1 FFE317 Razor 1 Pen Torch 1 FFE066 Zoll AED (Pads attached & Battery Checked)
1
Zoll AED Pads
2 8900-0800-01 (Zoll Suppliers)
Oxygen Cylinder
1 Ordered from Bio Medical
Resuscitator manual (bag-valve-mask) disposable Adult with size 5 mask
1 FDE373
High Concentration Oxygen Mask
1 FDD111
Ezy Face Mask 1 RE/008 (SP Services)
Hand Held Suction Device
1 RE/021 (SP Services)
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RECOGNISING AND RESPONDING TO THE PHYSICALLY DETERIOATING PATIENT (COMMUNITY SETTINGS) JULY 2016
Emergency Drugs available to all Community setting Teams and Services
Drug Strength Quantity Rational for
Use Expiry Date
Checked by/date
Adrenaline IM injection
(epinephrin
e)
1mg in 1ml (1 in 1,000)
1 x Epipen
10 x
0.5ml amps
Anaphylaxis
Naloxone IV or IM
injection
400mcg/1ml
3 Pre-filled
Syringes (minijet)
Opioid overdose
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Appendix 3 Basic Life Support Algorithm
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Appendix 4 Choking Algorithm
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Appendix 5 Anaphylaxis Algorithm
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Appendix 6 Opiate Overdose Algorithm
If the patient is unresponsive and not breathing normally begin CPR
using BLS Algorithm
Administer 400 micrograms naloxone I/M as soon as it arrives
Suspected Opiate overdose O2 Saturation <92% on Oxygen or Respiratory Rate <10 breaths
per minute
Repeat every 2-3 minutes. Each dose is given in subsequent
resuscitation cycles if the patient is not breathing normally
Continue process until an effect is noted, breathing is normal or the
ambulance arrives
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Appendix 7 Sepsis Screening Tool
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Appendix 8 Datix CPR Audit Form
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Appendix 9 DNA-CPR Proforma
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18. Equality Impact Assessment Tool
Yes/No Comments
1. Does the policy/guidance affect one group less or more favourably than another on the basis of:
Race No
Ethnic origins (including gypsies and travellers) No
Nationality No
Gender No
Culture No
Religion or belief No
Sexual orientation including lesbian, gay and bisexual people
No
Age No
Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
2. Is there any evidence that some groups are affected differently?
No
3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
N/A
4. Is the impact of the policy/guidance likely to be negative?
No
5. If so can the impact be avoided? N/A
6. What alternatives are there to achieving the policy/guidance without the impact?
N/A
7. Can we reduce the impact by taking different action?
N/A