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GP mythbuster 1: Resuscitation in GP surgeries
This GP mythbuster includes information about resuscitation during the coronavirus (COVID-19) pandemic.
We are aware of concerns about the risk of transmission of COVID-19. We emphasise the guidance issued by Resuscitation Council UK. This confirms the crucial importance of doing CPR for the person in cardiac arrest.
Resuscitation Council UK has issued:
- statements and resources on coronavirus (COVID-19), CPR and resuscitation
- statements on coronavirus (COVID-19) for primary care settings
- updated statement on Public Health England PPE guidance (28 April 2020).
NHS England and NHS Improvement state that all practices should be able to show they can assess and appropriately manage severely ill patients who may present to them with COVID-19.
Resuscitation Council UK guidance has been updated due to the need for personal protective equipment (PPE) for staff. Public Heath England have updated COVID-19: infection prevention and control guidance. This is informed by the governmental advisory NERVTAG. There is some dissonance between these different guidelines.
The Academy of Royal Colleges suggest organisations and clinicians should agree on local policy about availability and use of PPE in resuscitation situations. This is to provide proper protection for staff. It is expected they are guided by the consensus view of clinicians likely to be involved in resuscitation. It is also expected local decisions are:
- transparently agreed
- adequately resourced.
Resuscitation of adults and paediatrics
All GP practices must be equipped to deal with a medical emergency. This includes resuscitation. Resuscitation Council UK has produced updated resuscitation guidelines including:
All staff should be suitably trained. Online training may be acceptable given the constraints of the pandemic. Staff must understand their responsibilities in the event of an emergency. This includes the location of equipment, medicines and how to get help.
Resuscitation Council UK has produced quality standards for cardiopulmonary resuscitation (CPR) practice and training. These state that practices should have:
- immediate access to appropriate resuscitation equipment and drugs when needed
- a way for all staff to call for help
- staff trained to use equipment according to their roles
- local risk assessment overseen by a designated resuscitation lead
- PPE and sharps boxes available
- reliable system for equipment checks and replacement following manufacturer instructions
- appropriate equipment and medication considered.
Minimum suggested equipment
Resuscitation Council UK lists minimum suggested equipment to support CPR in primary care settings. The list is not comprehensive. It should be interpreted, and risk assessed on a place by place basis. Individual practice needs will vary.
The following items should be available for immediate use:
- Automated External Defibrillator (AED)
- adhesive defibrillator pads – spare set also recommended
- oxygen, including cylinder with key and tubing where necessary
- pocket mask (adult) with oxygen port - this may be used inverted in infants
- protective equipment - gloves, aprons, eye protection
- absorbent towel – to dry chest if necessary
- razor – to shave chest to apply pads if needed
- PPE for staff.
Pulse oximeters are useful for managing a deteriorating patient as well as for chronic respiratory disease.
Equipment for clinicians with enhanced skills
Resuscitation Council (UK) recommends a list of equipment for clinicians trained to deal with patients at increased risk of cardiorespiratory arrest.
Automatic External Defibrillators (AEDs)
Adult defibrillator pads are suitable for paediatric use from the age of 8 years. The European Resuscitation Council Guidelines clarify which AEDs are suitable for children.
Use a local risk assessment to decide where an AED should be kept.
Oxygen and oximetry
Review and consider Guidance on oxygen use in adults in healthcare and emergency settings (British Thoracic Society (BTS), 2017). This includes:
- oxygen is a treatment for hypoxaemia not breathlessness
- oxygen should be prescribed according to a target saturation range with monitoring.
- BTS recommends targets for normal or near normal saturations for all acutely ill patients apart from those:
- at risk of hypercapnic respiratory failure or
- receiving terminal palliative care.
- There are syndromes where routine oxygen therapy is no longer routinely recommended unless a patient is hypoxaemic. This includes acute coronary syndrome (myocardial infarction) and stroke.
- staff who administer oxygen should be suitably trained.
- Give controlled supplementary oxygen to all hypoxaemic patients with acute severe asthma titrated to maintain a SpO2 level of 94-98%.
- For patients with known hypercapnic respiratory failure (CO2 retainer), aim for oxygen saturation of 88% - 92%.
Do not delay oxygen therapy if there is no pulse oximetry available but start monitoring as soon as it becomes available.
Primary Care Respiratory Society recommend that pulse oximetry:
- is a useful non-invasive investigation that is easily performed and reproducible in primary care. It rapidly detects changes in oxygen saturation before the patient is compromised
- is not an infallible test. Clinical judgement is required. Do not use pulse oximetry in isolation, or without training, but to support a comprehensive assessment and examination.
This guidance concludes:
"‘the evidence for benefit is clear and it is difficult to justify failure to use pulse oximetry with the current evidence-based guidelines in influenza, community acquired pneumonia, asthma and COPD."
NICE guideline [NG51] recommends measuring oxygen saturations in adults and children with potential sepsis. This includes:
- in community settings if equipment is available
- where taking a measurement does not delay assessment of treatment.
Where to keep resuscitation drugs
Resuscitation drugs should be readily accessible in an emergency and not locked away. Resuscitation Council UK guidance states:
- keep emergency drugs in a box clearly marked ‘for emergency use’
- boxes should be tamper evident
- keep boxes at strategic and accessible sites. Not in a locked cupboard.
Resuscitation Council UK recommends staff in primary care, including non-clinical, should undergo regular training in adult and child resuscitation appropriate to their role. For example, clinical staff should be able to:
- recognise cardiorespiratory arrest
- call for help
- start cardiopulmonary resuscitation (CPR) with defibrillation as appropriate
- receive annual training updates that include assessment.
You must keep documentary evidence of approved and completed resuscitation training. There is no specific requirement for a particular type of training. Practices can tailor it to local needs. Appropriate online training may be acceptable especially given the current constraints of the pandemic.
There are good examples of in-situ simulation training where staff practice in their premises. In-situ training tests the physical environment for delivering resuscitation and highlights human factors. There is evidence that in-situ training has improved processes and increased GPs’ confidence in managing time critical emergencies.
National Early Warning Score (NEWS)
There is limited evidence for the predictive value of NEWS (Royal College of Physicians) in primary care. Yet NHS England advise there are benefits to using NEWS. It:
- is an objective assessment
- complements clinical judgement
- helps communication with ambulance and acute services, where it is widely used and understood
- is endorsed by the National Quality Board as a standardised system for assessing the severity of acute illness in adults
- provides a ‘common language’, so it helps communication between clinicians.
When we inspect
Under the safe key question, we consider how practice staff recognise and manage patients who are:
- critically ill or
- at risk of deterioration, or
- in cardiac or respiratory arrest.
We expect each GP practice to have a named resuscitation lead to make sure:
- staff have access to resuscitation advice, training and practice
- quality standards are maintained
- equipment is checked regularly.
We use these regulations when we review if the practice is safe, effective, responsive, caring and well led. This mythbuster relates to:
It is part of our key lines of enquiry (KLOEs). In particular:
- Last updated:
- 09 July 2021