Resuscitation Council UK statement on COVID–19 in relation to non-acute hospital settings

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15 April 2020

This statement is for healthcare workers (HCWs) who are performing CPR in non-acute hospital settings.

These include, but are not limited to, community hospitals, mental health, learning disability and autism in- patient settings, or alternatively could be described as categories 4 – 8 in the most recent hospital census1 . Each hospital should review the level of care they can provide, and the response provided in order to decide if this is the level of guidance required for their staff.

1. Purpose

1.1. COVID-19 is thought to spread in a way similar to seasonal influenza; from person-to-person through close contact and droplets. Standard principles of infection control and droplet precautions are the main control strategies and should be followed rigorously. Aerosol transmission can also occur. Attention to hand hygiene and containment of respiratory secretions produced by coughing and sneezing are the cornerstones of effective infection control.

1.2. All HCWs managing those with suspected or confirmed COVID-19 must follow local and national guidance for infection control and the use of PPE.

1.3. During CPR, there is always the potential for rescuers to be exposed to bodily fluids, and for procedures (e.g. chest compressions, tracheal intubation or ventilation) to generate an infectious aerosol or droplets. Individual healthcare organisations should carry out local risk assessments, based on the latest guidance from RCUK/DHSC/PHE regarding PPE for HCWs to develop local guidance.

1.4. Resuscitation team members must be trained to put on/remove PPE safely (including respirator fit testing where appropriate) and to avoid self-contamination.  For more information - https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-aerosol-generating-procedures

2.  Guidance on CPR in patients with a COVID-19 like illness or a confirmed case of COVID-19 in non-acute hospital settings

2.1  Resuscitation is an invasive medical procedure and should only be provided after careful consideration with the patient of the benefits and burdens provided by resuscitation. These discussions should be compliant with mental capacity act and may require the involvement of a Lasting Power of Attorney. Conversations and treatment escalation planning must be a priority. Where appropriate patients should have an individual emergency care treatment plan which includes recommendations for the appropriateness of cardiopulmonary resuscitation. If appropriate, ensure “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions are well documented and communicated.

2.2  Staff should follow PPE guidance for HCWs while delivering care within 2 metres (minimum fluid resistant surgical mask, gloves, apron, eye protection). This will provide protection for droplet transmission and contamination from surfaces. 

2.3  The non-acute hospital setting must source and stock level 3 PPE equipment for use in a  cardiac arrest if such an event is likely to occur . Staff must be trained in its use and the equipment stored with resuscitation equipment so that it is easily accessible at the time of need.

2.4  Identify as early as possible any patients who are at risk of acute deterioration or cardiac arrest. Take appropriate steps to prevent cardiac arrest and avoid unprotected CPR. Use of physiological track-and-trigger systems (e.g. NEWS2) will enable early detection of acutely ill patients. For those for whom resuscitation would be inappropriate, decisions must be made and communicated. Consider discussion with acute hospitals on the need to transfer the patient for acute/advanced medical care.

2.5  In a situation when a patient is unresponsive, to minimise the risk of droplet transmission.

Assessment includes –

  • Look for the absence of signs of life and normal breathing. Do not listen or feel for breathing by placing your ear and cheek close to the patient’s mouth
  • Feel for a carotid pulse if trained to do so
  • Shout for help early so helpers can start to don level 3 PPE if needed
  • If a patient is unresponsive and not breathing normally, call the resuscitation team (if available) and/or the ambulance service in accordance with local protocols. When calling, state the risk of COVID-19.

2.6 Whilst awaiting helpers to don level 3 PPE, the rescuer should attach a defibrillator to assess the initial rhythm and administer up to 3 shocks if an initial shockable rhythm is present as early defibrillation has a high chance of success.  If using a manual defibrillator, deliver up to 3 shocks, as indicated. If using an AED, administer shocks as guided by the AED. Early defibrillation for a shockable cardiac arrest gives the best chance of survival.

2.7  Do not deliver chest compression or ventilation unless wearing level 3 PPE (FFP3 mask, eye /face protection, fluid-resistant long-sleeved gown, gloves). These are considered an aerosol generating procedure which requires level 3 PPE for all those in the immediate vicinity of the resuscitation attempt.

2.8  In some hospitals, HCWs will have additional airway management skills and will be able to takeover CPR as soon as their PPE Level 3 is donned. In other trusts, this ALS response will be provided via the ambulance service, or resuscitation team. Every non-acute hospital as defined above with HCWs that have additional respiratory response training or any form of on-site resuscitation team must ensure via risk assessment  the appropriate amount of Level 3 PPE is available and accessible on site.

2.9  As soon as helpers in level 3 PPE arrive, the first rescuer must withdraw to a safe distance  of over 2 metres.

2.10 For cardiac arrest due to ligature, it is imperative that the ligature is removed as soon as safely possible. Hospitals with patients at high risk of such a situation should ensure that they have staff trained to provide emergency ventilation (e.g. delivery of assisted ventilation with a bag-valve-mask), as well as an adequate supply of level 3 PPE to facilitate this response safely. Due to the potential hypoxic nature of the cardiac arrest, it is particularly important that the advanced life support team is called as soon as possible.

3. Post event considerations

3.1 Follow PHE hygiene guidance for safely removing PPE. Remove PPE safely to avoid self contamination and dispose of clinical waste bags as per local guidelines. Hand hygiene has an important role in decreasing transmission. Thoroughly wash hands with soap and water; alternatively, alcohol hand rub is also effective.

3.2  Dispose of, or clean, all equipment used during CPR following the manufacturer’s recommendations and local guidelines. Any work surfaces used for airway/resuscitation equipment will also need to be cleaned according to local guidelines. Specifically, ensure equipment used in airway interventions (e.g. laryngoscopes, face masks) is not left lying on the patient’s pillow but is instead placed in a tray. Do not leave the Yankauer sucker placed under the patient’s pillow; instead, put the contaminated end of the Yankauer inside a disposable glove. 

3.3  Team debrief at the end of the resuscitation attempt.

Additional information

This supplements guidance available from the Department of Health and Social Care (DHSC) and Public Health England (PHE) as well as Public Health Wales, Health Protection Scotland (HPS) and Department of Health Northern Ireland (DHNI), and may change based on increasing experience in the care of patients with COVID-19, as well as the effect of the outbreak on health services. It is therefore important to always check the latest guidance on the DHSC/PHE/PHW/HPS/DHNI websites.

1The most recent hospital census lists the following healthcare categories -

  1. General acute hospital      
  2. Specialist hospital (acute only)
  3. Mixed service hospital       
  4. Mental Health (including Specialist services)
  5. Learning Disabilities           
  6. Mental Health and Learning Disabilities
  7. Community hospital (with inpatient beds)
  8. Other inpatient                  
  9. Other Reportable Site     

Published 15 April 2020

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