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CPR - Guidance for clinical practice and training in Primary Care

 ! This document was superseded by Quality standards for CPR practice and training.

The Project Team

Michael Colquhoun (Co - Chairman) General Practitioner, Malvern, Honorary Secretary Resuscitation Council (UK)
David Gabbott (Co - Chairman) Consultant Anaesthetist, Gloucestershire Royal NHS Trust , Executive Committee, Resuscitation Council (UK)
Graham Archard General Practitioner, Christchurch, Royal College of General Practitioners
Simon Brown General Practitioner, Sandhurst, Medical Advisor to Royal Berkshire Ambulance Service, British Association for Immediate Care (BASICS)
John Hall General Practitioner, Bromsgrove, Medical Advisor to Hereford and Worcester Ambulance Service NHS Trust, National Association of Primary Care Groups
Michael Johnson Association of Medical Secretaries Practice Managers Administrators and Receptionists (AMSPAR)
Paul Leaman Director of Operations, Essex Ambulance Service
Una McKay Resuscitation Services Manager, North Bristol Trust, Association of Resuscitation Training Officers
Sarah Mitchell Director, Resuscitation Council (UK)
Joe Neary General Practitioner, Wisbech, Chairman of Clinical and Special Projects Network, Royal College of General Practitioners
Margaret Raby Community Midwife, Exmouth
Adrian Reyes-Hughs Director of Policy and Standards, United Kingdom Central Council    
Sally Ward Practice Nurse, Walsall
Geralyn Wynne Clinical Governance Manager, Harrow and Hillingdon Healthcare NHS Trust

This report was written by Michael Colquhoun, David Gabbott and Sarah Mitchell

Contents

Introduction
Summary
Managinging a resuscitation attempt outside hospital
The Nominated Person
Resuscitation equipment
Training in resuscitation techniques
Resuscitation of children and the newborn
Performance management
Ethical issues
Appendix 1 - Minimum recommended equipment
Appendix 2 - AED algorithm
References and bibliography

Throughout this publication the use of the term Primary Care Organisations (PCO) is intended to embrace the terms Primary Care Trust (PCT), Primary Care Group (PCG), Local Health Care Co-operative (LHCC) and Local Health Care Group (LHCG).
    
The term ‘practice’ refers to Primary Health Care Centres, General Practitioners’ surgeries and other places where the Primary Health Care Team may be based. 

Introduction

Sudden cardiac arrest, particularly from coronary heart disease remains one of the commonest causes of death in the United Kingdom and many such deaths occur outside hospital. All health care professionals who work in the community may be required to resuscitate a victim of cardiopulmonary arrest.
   
Throughout this document, our priority is to provide advice that will do the most good for those most likely to survive a cardiopulmonary arrest. Hence our main concern is the treatment of patients with ventricular fibrillation with early external defibrillation. This is the single intervention that most radically improves the prognosis of cardiopulmonary arrest. While the outcome of treated ventricular fibrillation is much better than asystole or pulseless electrical activity (PEA) - formerly known as electromechanical dissociation (EMD) - all cardiac emergencies warrant early effective intervention. We should not underestimate the importance of being able to treat any patient who has had a cardiopulmonary arrest, regardless of the initial presenting rhythm.
    
Published evidence testifies to the effectiveness of resuscitation by general practitioners, the ambulance service and others who are equipped with defibrillators. Data held by the British Heart Foundation confirm the efficacy of resuscitation by general practitioners in this situation. When cardiac arrest complicates the early stages of acute myocardial infarction for example, a rhythm likely to respond to attempted defibrillation is present in 90% of patients. Approximately 60% of those who arrest at home (and 75% of those who arrest on surgery premises) subsequently survive to leave hospital after early defibrillation by their doctor.
    
The current National Service Framework for Coronary Heart Disease in England explicitly recognises the importance of early defibrillation, specifying that patients with symptoms of a possible heart attack should be attended to by someone trained and equipped to defibrillate within 8 minutes of calling for help to maximise the chance of successful resuscitation should it be necessary. When ventricular fibrillation occurs, the earlier defibrillation is attempted the more favourable the outcome.
   
Advances in defibrillator technology have produced a generation of machines that are relatively inexpensive, easy to use and which require minimal maintenance.
  
In this document, the first of its kind, we seek to provide guidance about resuscitation standards and training for those working in the community as part of the Primary Health Care Team. Although the persons most likely to attempt resuscitation are general practitioners and nursing staff, any professional health care worker may contribute either directly or indirectly. Receptionist staff for example may make a very important contribution, as they often receive urgent calls and summon the emergency services.

We hope the advice provided in this document is applicable to the conditions that exist in most general practices or healthcare centres in the United Kingdom. Additional issues will be involved when individual doctors work with the ambulance service in an organised immediate care scheme e.g. BASICS, particularly with regard to the management of trauma. It is not our intention to advise in these circumstances.

Much of the basis for our recommendations are drawn from scientific papers or reports published previously by the Resuscitation Council (UK), the Royal College of Anaesthetists, the British Heart Foundation and the British Medical Association. By providing such guidance, it is hoped that the standards of care for those who require resuscitation outside hospital will be improved and maintained and that ultimately the number of people who survive a cardiopulmonary arrest will increase.

Our intention is to advise on best practice and we have not directly addressed the question of funding for training and equipment, particularly defibrillators. We feel, however, that funding for resuscitation services should be the responsibility for the PCO and not individual general practitioners themselves.

Summary

  • Cardiopulmonary arrest is a common and treatable cause of premature death. The earlier that effective treatment is provided, the more likely the patient is to survive.
  • All members of the Primary Health Care Team who have contact with patients should be trained and equipped, to a level appropriate for their expected role, to resuscitate patients who suffer cardiopulmonary arrest in the community. The minimum standard should be proficiency in BLS. The majority of the team should be capable (with appropriate training) of using an automated external defibrillator (AED).
  • National and international guidelines for the management of cardiopulmonary arrest should be followed. For the Primary Health Care Team this refers to the guidelines on basic life support and use of an AED.
  • Every healthcare practice should be equipped with an automated external defibrillator (AED) and appropriate arrangements should exist to ensure that it is readily available in the surgery whenever it may be required. Equally, there should always be someone capable of using the AED whenever patients may be in the building. An AED should also be available to those providing medical cover outside normal practice hours, whether working as individuals, in Primary Care Centres or community hospitals, as part of a deputising service, co-operative or any other similar out-of-hours service. Other basic resuscitation equipment for managing the airway and administering drugs should also be accessible.
  • Primary Care Organisations (PCOs) should ensure that appropriate training takes place within the trust i.e. within individual practices or a centre for training. Resuscitation Officers, either employed by the trust or under a service level agreement with an acute trust, will usually be required to ensure this occurs. Funding should be provided to maintain the highest standards of training and practice in resuscitation throughout the PCO.
  • Resuscitation attempts should be audited to maintain and improve standards of practice. Cardiopulmonary arrest occurring in the community is an appropriate subject for ‘critical incident debriefing’ within any practice.
  • Effective ‘Do Not Attempt Resuscitation (DNAR)’ policies should be agreed on in accordance with guidelines published from the British Medical Association, Resuscitation Council (UK) and Royal College of Nursing. Where such a DNAR decision relates to an individual patient it must be communicated to relatives and all staff involved with the patient’s care including the ambulance service and other emergency services. The use of any such policy should be the subject of audit and form part of any communication strategy for future service improvements.

Managing a resuscitation attempt outside hospital

Ventricular fibrillation complicating the early stages of acute myocardial infarction is the most common cause of cardiopulmonary arrest that members of the Primary Health Care Team will encounter. Success is greatest when the event is witnessed and attempted defibrillation is performed with the minimum of delay.

A significant number of patients collapse at home in the presence of the doctor, while a further proportion actually suffer a cardiopulmonary arrest at the doctor’s surgery. All health care workers in the community who encounter a cardiopulmonary arrest must be trained and equipped to attempt defibrillation and perform other resuscitation techniques as appropriate. Outcome will be optimal when the first person to attend the patient with ventricular fibrillation is trained and equipped to attempt immediate defibrillation.

It is imperative to provide the optimal response for those at risk of suffering cardiopulmonary arrest and the importance of responding rapidly to patients with chest pain, possibly due to acute myocardial infarction, cannot be over emphasised.

Every emergency ambulance in the UK carries a defibrillator and the ambulance service should be involved at the earliest opportunity as part of a dual response. The doctor can provide additional diagnostic skills and knowledge about the patient and their circumstances and work with the ambulance crew to provide co-ordinated management.

When attempted defibrillation is delayed, the chances of successful resuscitation are greatly enhanced if a bystander performs BLS. All medical, nursing and paramedical staff should be trained to perform BLS and should practice the techniques regularly on a training manikin. It is highly desirable that other staff e.g. reception staff, who come into contact with patients can also perform BLS.

Modern automated external defibrillators (AEDs) have simplified the process of defibrillation considerably. ECG interpretation and charging of the machine in preparation to shock are now automated. This has greatly reduced training requirements and extended the range of personnel who can attempt defibrillation. The use of such machines should be within the capabilities of all medical and nursing staff working in the community. Increasingly trained lay persons are successfully employing AEDs and it is quite appropriate for reception, administrative and secretarial staff to be trained in their use.

All practices should acquire an AED. Arrangements for its deployment will depend on local circumstances. Similarly those providing out of hours cover in Primary Care Centres or as part of a deputising service or co-operative should have access to an AED. Manual defibrillators are also appropriate for use in the same circumstances, but the greater training required and lack of portability necessarily limits the range of personnel who can use them.

The Nominated Person

PCOs should have a named person responsible for co-ordinating resuscitation services within the trust. They should liaise closely with a nominated person in each practice and with any organisations responsible for undertaking training in the practices of the trust. Resuscitation Officers, specifically employed by the PCO, would be ideally suited to this role.

A nominated person with an interest and knowledgeable background in resuscitation should ideally implement the tasks of administering the resuscitation services within a practice. Their role should include the purchase, maintenance and replacement of equipment, the arrangement of suitable training for all the Primary Health Care Team and the audit of performance.

Resuscitation equipment

Resuscitation equipment will be used relatively infrequently and there is much to be said for selecting items that are both easy to use and maintain. Staff must know where to find equipment at the time it is needed and training in its use must be undertaken to a level appropriate to the individual’s expected role.

Each practice should have a named individual with responsibility for checking the state of readiness of all resuscitation drugs and equipment, including the AED on a regular basis, ideally once a week. In common with drugs, disposable items like the adhesive electrodes have a finite shelf life and will require replacement from time to time if unused.

Defibrillators:

Modern ‘first responder’ AEDs are light, portable, compact, relatively inexpensive and easy to use. Most machines currently available perform self-checks and advise if maintenance or replacement of batteries is required. The success of defibrillation is crucially time dependent, with the chances of successful resuscitation declining by about 10% every minute attempted defibrillation is delayed. Attempted defibrillation will usually be performed earlier when practices have their own defibrillator rather than depending on the ambulance service to provide one.

An AED should therefore be available wherever and whenever sick patients are seen. It should be placed in the surgery and taken to patients visited elsewhere if it seems likely that there is a chance of cardiopulmonary arrest occurring. After the machine is used the manufacturers instructions should be followed to return it to a state of readiness with the minimum of delay. Disposable items must be reordered to ensure adequate stocks are available.

Airway management:

Expired air ventilation is the minimum standard expected and should be performed with a pocket mask incorporating a one way valve to prevent secretions from the patient reaching the rescuer. Other simple airway barrier devices do not permit ventilation to be performed as effectively as the pocket mask and many provide significant resistance to lung inflation.

Devices such as the oro-pharyngeal airway (Guedel airway) are suitable for use by those who are appropriately trained and a range of sizes may need to be kept available. For those with appropriate experience the laryngeal mask airway (LMA) may have an increasing role in management of the airway for unconscious patients outside hospital.

Tracheal intubation and the use of other advanced airway techniques are only appropriate for use by those who have undergone extensive training and who practice the skills regularly.

Oxygen:

Current resuscitation guidelines emphasise the use of oxygen, and this should be available whenever possible. Oxygen cylinders should be appropriately maintained and national safety standards followed. Each practice should have guidelines that allow non-medical staff to administer high flow oxygen in certain medical emergencies such as cardiopulmonary arrest.

Suction:

The requirement for batteries is a disadvantage with equipment that is likely to be used infrequently. Similarly, the need for mains electricity adds greatly to cost and restricts the location where the device can be used. For these reasons simple, mechanical, portable, hand-held suction devices are recommended.

Drugs:

Few drugs have been shown to materially influence the outcome of cardiopulmonary arrest and few are recommended for routine use. Epinephrine/adrenaline (1mg intravenously) has an established role to increase the effectiveness of basic life support and is recommended in current international resuscitation guidelines. Atropine has an established role in the treatment of bradycardia, asystole and pulseless electrical activity (PEA) at a slow rate. The dose in asystole and slow PEA is 3mg given once only (lower doses are often effective in the treatment of bradycardia). The minimum standard is to have both these drugs available. Amiodarone is recommended for ventricular fibrillation resistant to defibrillation - the dose is 300mg intravenously. There is no established role for the use of alkalising agents, buffers or calcium salts before hospital admission. The use of naloxone is appropriate in suspected cases of opiate overdose causing respiratory arrest.

Drugs should be given by the intravenous route, preferably through a catheter placed in a large vein, for example in the antecubital fossa, and flushed in with a bolus of IV fluid. In an emergency, drugs may be administered from a syringe through a needle sited in a large peripheral vein. The risk of extravasation in this circumstance is acceptable if the patient is the victim of cardiopulmonary arrest. Many drugs may be given via the bronchial route if a tracheal tube is in place; for epinephrine/adrenaline and atropine the dose is double the IV dose.

Universal precautions:

Standard procedures should be followed to minimise the risk of cross infection. Gloves should be available together with a suitable means of disposing of contaminated sharps.

Training in resuscitation techniques

Training and practice are necessary to acquire skill in resuscitation techniques. Theoretical training alone without actual practice in a simulated environment, for example on training manikins, is likely to be of limited value. The use of manikins should therefore be mandatory. Resuscitation skills decline rapidly and regular updates and retraining using manikins are necessary to maintain adequate skill levels. Formal studies have shown that repeated tuition and practice is the most successful method of learning and retaining skills in resuscitation.

The level of resuscitation skill (or skill attainment) required by different members of the Primary Health Care Team will necessarily differ according to the individual’s role and in some cases, their enthusiasm. The aim of an individual healthcare practice however, should be to provide a competent response at all times with the resources available.

All those in direct contact with patients should be trained in BLS and related resuscitation skills such as the recovery position; as a minimum they should be able to provide effective BLS with an airway adjunct such as a pocket mask. Doctors, nurses and other paramedical workers like physiotherapists should also be able to use an AED effectively. Other personnel, for example receptionists, may also be trained to use an AED; they are nearly always present when a practice is open and may have to respond before more highly trained help is available.

It is unacceptable for patients who sustain a cardiopulmonary arrest to await the arrival of the ambulance service before basic resuscitation is performed and a defibrillator is available.

Training should be provided to teach to the level required by the trainees. In many cases, particularly for higher levels of skill attainment, the services of a Resuscitation Officer will be required. PCOs should engage their services according to their requirements. Ambulance service training schools can also provide training to a similar level of competency. The voluntary aid societies and comparable organisations also train their members in resuscitation skills, including the use of an AED and may be engaged to provide training for some members of the Primary Health Care Team. Knowledgeable members of the practice team could undertake training for the other members of their own practice.

No evidence base exists on which to provide definite recommendations about the frequency of refresher training for those specifically working in Primary Health Care Teams. A consensus view, based on studies of comparable providers and the practice of the organisations responsible for their actions, suggests that doctors and nurses should have refresher training in basic life support every six to twelve months. Retraining in the use of the AED for this group of workers should be carried out at least as frequently.

The importance of acquiring and maintaining competency in resuscitation skills may be an appropriate subject to include in an employee’s job description. It is also a suitable subject for inclusion in individual personal development plans and may in due course form part of revalidation procedures.

Resuscitation of children and the newborn

Cardiopulmonary arrest is fortunately very uncommon in infants and children. There is a fundamental difference in the approach to the resuscitation of children compared with adults. Most children have healthy hearts and do not suffer primarily a cardiac arrest. In the majority of cases cardiopulmonary arrest follows respiratory arrest. The arrest rhythm in most cases is asystole or pulseless electrical activity (PEA) where the prognosis is poor. Prevention of cardiopulmonary arrest by the effective treatment of respiratory failure is the most important practical consideration and emphasises the importance of basic airway management skills and high flow oxygen for all those who see sick children.

Ventricular fibrillation is a less common presentation of cardiopulmonary arrest in children, but the same treatment principles apply. For children under the age of eight manual defibrillators capable of delivering low energy shocks with paediatric electrodes are recommended. Modern AEDs designed for use in adults can be used in children aged eight or more. Special infant electrodes are advised when used below this age and are available from some manufacturers. Further information on this subject is contained in the Resuscitation Council’s statement on the use of biphasic defibrillators and AEDs in children.

Special considerations relate to the resuscitation of the newborn. Planned home births should take place in the presence of two midwives, one to care for the mother and a second to care for the baby. They should be trained in appropriate resuscitation techniques for the newborn and mother and carry suitable equipment. Midwives must clarify arrangements for emergency support in the event of resuscitation being necessary with the supervisor of midwives in advance of the delivery date. Clear methods of communication and a means of obtaining help must be in place in the case of such an emergency. This must be clearly understood by all those attending a birth in the community. Doctors who undertake intra-partum obstetric care should also be suitably trained and equipped to provide resuscitation for pregnant mothers, the newborn child and the mother after delivery.

Performance management

The process and outcome of all resuscitation attempts should be the subject of audit. This might be carried out both at the level of an individual healthcare practice and the local area in which services are based.

Audit of the process of resuscitation should include the availability and performance of the individuals involved in the resuscitation attempt and the standard and reliability of the equipment used. The subsequent transfer of the patient and liaison with the ambulance service might also be considered. The methods by which urgent calls are received and processed should be the subject of regular review and is also a suitable subject for audit at practice level. The process of audit should also include procedures for allowing feedback and discussion after the event. All members of the practice team involved should be included. This might take the form of ‘critical incident’ debriefing.

Local review of the resuscitation attempts undertaken should highlight any serious deficiencies in the training, equipment or process surrounding any resuscitation attempt. The Risk Manager of a PCO should be made aware of any problems, difficulties or considerations of relevance in the area they serve. Where audit has identified deficiencies it is imperative that steps are taken to improve performance. Likewise, any significant improvement in the service should be made widely available and examples of good practice should be shared.

The training of members of the Primary Health Care Team in resuscitation techniques appropriate to their expected role is also a suitable subject for audit and might be undertaken at both practice level or within a PCO.

Accurate records of all resuscitation attempts should be kept for audit, training and for medico-legal reasons. The responsibility for this will rest with the most senior member of the practice team. Such records may need to be sent to the Risk Manager or Record Management Department of the local PCO. The electronic data stored by most AEDs during a resuscitation attempt is an additional resource that should be used for audit purposes. The effectiveness of local ‘Do Not Attempt Resuscitation’ (DNAR) policies is also a suitable subject for audit.

 

Ethical issues

It is essential to identify individuals in whom cardiopulmonary arrest is a terminal event and where resuscitation is inappropriate.

Community hospitals, hospices, nursing homes and similar establishments where the Primary Health Care Team are responsible for the care of patients should be encouraged to implement ‘Do Not Attempt Resuscitation’ (DNAR) policies so that inappropriate or unwanted resuscitation attempts are avoided. National guidelines published by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing provide detailed guidance upon which local practice can be based. (Please refer to Decisions relating to Cardiopulmonary Resuscitation for further details)

The overall responsibility for a DNAR decision rests with the doctor in charge of the patient’s care; this will usually be the general practitioner most directly involved with the care of the patient. The opinions of other members of the medical and nursing team, the patient and their relatives should be accounted for in reaching the decision.

The most senior member of the medical team should enter the DNAR decision and the reasons for it in the medical records. Exactly what relatives are told should be documented as should any comments made. The decision should be reviewed regularly in the light of the patient’s condition.

Any DNAR decision should be recorded in the nursing notes where applicable and effectively communicated to all members of the multidisciplinary team involved with the patient’s care. This should include all those who may become involved such as the emergency medical services. In this way inappropriate 999 telephone calls are avoided at the time of death.

Appendix 1 - Minimum Recommended Equipment

a) Minimum recommended equipment 

Oxygen mask with reservoir bag 
Pocket Mask and one way valve 
Automated defibrillator with electrodes and razor 
Syringe and needles 
Oxygen 
Epinephrine/Adrenaline 
Atropine 
Tape 
Gloves 
Sharps box 
Scissors 
Suction 
Saline flush 
Tissues 

b) Additional items 

Intravenous cannulae 
IV fluids 
Oropharyngeal (Guedel) airways 
Amiodarone 
Naloxone 

Appendix 2 - The universal AED resuscitation algorithm

AED algorithm.

 

References and Bibliography

  1. Resuscitation Guidelines 2005. Resuscitation Council (UK), London 2005
     
  2. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. An international consensus on science. Resuscitation, 2000; 46: 1 - 448
     
  3. Cardiopulmonary Resuscitation. Guidance for clinical practice and teaching in hospitals. Resuscitation Council (UK), London 2000
     
  4. Advanced life support course. Provider Manual 4th Edition. Resuscitation Council (UK), London 2000
     
  5. Resuscitation for the Citizen 6th Edition. Resuscitation Council (UK), London 2000
     
  6. ABC of Resuscitation. Editors Colquhoun MC, Handley AJ and Evans TR. 4th Edition, BMJ Books, London 1999
     
  7. Resuscitation in Primary Care. Colquhoun MC and Jevon P. Butterworth Heinemann, Oxford 2001
     
  8. Guidelines for the Provision of Anaesthetic Services - Resuscitation. Royal College of Anaesthetists, July, 1999
     
  9. One thousand heart attacks in the Grampian. The place of cardiopulmonary resuscitation in general practice. Pai GR, Haites NE, Rawles JM. British Medical Journal, 1987; 294: 352 - 354
     
  10. Treatable arrhythmias in cardiac arrests seen outside hospital. Colquhoun MC, Julian DG. Lancet, 1992; 339: 1167
     
  11. The British Heart Foundation recommends early defibrillation. Colquhoun MC, Pentecost BL. British Medical Journal, 1995; 310: 735
     
  12. Automated external defibrillation. Colquhoun MC. British Journal of General Practice,1993; 43: 95 - 96
     
  13. Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. British Medical Association, London 2007
     
  14. The legal status of those who attempt resuscitation. Resuscitation Council (UK), London 2000

July 2001

 

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