GP mythbuster 1: Emergency care in general practice

Resuscitation

During a cardiac arrest, it is vital to start cardiopulmonary resuscitation (CPR) quickly and use defibrillation as early as possible. For every minute without CPR or defibrillation, a person’s chance of survival decreases by 10%. Early intervention can double, triple or even quadruple a person’s chances of survival. 

All GP practices must have the necessary equipment, skills and knowledge to manage medical emergencies, including resuscitation. 

Quality standards

According to the Resuscitation Council UK’s quality standards, all primary care providers must have:

• immediate access to appropriate resuscitation equipment and drugs when needed
• a way for staff to call for help, such as a telephone, alarm bell, portable radio or computer-based alert system
• staff trained to use the available equipment, according to their roles
• a local risk assessment, overseen by a designated resuscitation lead, which considers:
  • patient groups (for example, adults or children)
  • likelihood of a cardiorespiratory arrest
  • training of staff likely to be available to assist in an emergency
  • availability of advanced equipment and life support skills (for example, expected ambulance service response times)
• access to single-use and latex-free resuscitation equipment where possible
• appropriate personal protective equipment (for example, gloves, aprons, and eye protection) and sharps boxes
• a reliable system to check and replace equipment that follows the manufacturer’s instructions (the exact frequency of checks will depend on local circumstances but should be at least weekly).

Staff training

The Resuscitation Council UK recommends all primary care staff, including non-clinical staff, receive regular resuscitation training for both adults and children appropriate to their role.

This training can be online or face-to-face. Staff should receive resuscitation training at induction and at regular intervals thereafter to maintain the necessary skills and knowledge.

Clinical staff should train at least once a year. Non-clinical staff should generally also receive annual updates, but a local risk assessment may allow longer intervals if they have limited contact with patients.

Practices must keep evidence of approved and completed resuscitation training. There is no specific requirement for a particular type of training, and each practice can tailor it to local needs. As a minimum, all staff must know how to:

• recognise when someone is in cardiorespiratory arrest
• summon help
• start CPR using chest compressions.

Additionally, all clinical members of staff must be able to attempt defibrillation using an automated external defibrillator (AED) as soon as possible after a collapse, where appropriate.

See the Resuscitation Council UK’s Quality Standards: Primary Care and the Adult and Paediatric Resuscitation Guidelines.

Resuscitation equipment

The Resuscitation Council UK recommends that, as a minimum, all primary care services should ensure the following items are available for immediate use:

• automated external defibrillator (AED), preferably with facilities for paediatric use
• adhesive defibrillator pads (a spare set is also recommended)
• oxygen cylinder with key and tubing where necessary
• adult pocket mask with oxygen port
• protective equipment, including gloves, aprons and eye protection
• razor (to shave chest to apply pads, if needed)
• absorbent towel (to dry chest if necessary)
• stethoscope.

It is also recommended to have a blood glucose meter, glucometer strips and lancets to assess a patient’s blood sugar levels.

Where staff have enhanced skills or patients are at increased risk of cardiorespiratory arrest, practices should have the following equipment for immediate use:

• portable suction
• oropharyngeal airways (in sizes 0, 1, 2, 3 and 4)
• self-inflating bag with reservoir (adult and child sizes)
• clear face masks (in sizes 0, 1, 2, 3 and 4).

The Resuscitation Council UK also recommends having additional equipment accessible in an emergency. See Quality standards: primary care equipment and drugs list.

Note: this is not a full list. Each practice should assess the risks in their own individual practice and consider the skills of staff. For example, where practices employ staff with more advanced resuscitation or critical care skills, they should make further provisions to allow them to use those skills.

Paediatric defibrillator pads

Some models of defibrillators can be used on both adults and children, usually based on body weight. Other models may require additional paediatric defibrillator pads for use on a child.

Your practice should consider this as part of your risk assessment. If both adult and paediatric pads are needed, store them together with the AED. Where both adult and paediatric pads are stocked, adult pads should be kept attached to the AED by default.

Storage of resuscitation equipment

You should undertake a risk assessment to determine where to store the resuscitation equipment in the practice. This is to ensure staff have immediate access to all required resuscitation equipment.

Do not store resuscitation equipment in locked cupboards or rooms, as this can cause delay when there is an emergency. Storing emergency equipment in consultation rooms may not be appropriate if this means interrupting a consultation to access it.

The Resuscitation Council UK recommends using a standard AED sign to let staff and members of the public know where the defibrillator is kept.

The Circuit

The Circuit is a national defibrillator network. It enables NHS ambulance services to identify the location of the nearest registered defibrillator when you call 999 in response to a suspected cardiac arrest. Ambulance services can then instruct callers to collect the defibrillator, so they can use it before the ambulance arrives.

Healthcare providers, including those regulated by CQC, may opt to join this scheme. We recommend that healthcare providers consider registering their device onto The Circuit.

If your practice decides to join this scheme, we expect you to:

• appropriately risk assess the decision
• ensure measures are in place to respond to the use of a defibrillator, including replacing any equipment used in an emergency (for example, replacing pads)

It is also important to make staff aware that bystanders may ask to use the defibrillator and that it can be released to them.

Emergency medicines

GPs and other healthcare professionals must have the required knowledge, skills and equipment for managing expected medical emergencies. This includes being able to access a range of medicines for use in acute situations, including both at the practice and during home visits.

Healthcare professionals may need appropriate authority to administer these medicines. See guidance on Patient Group Directions (PGDs)/Patient Specific Directions (PSDs) for more information.

Suggested emergency medicines for GP practices

We have listed some medicines that should be available to staff in an emergency. This list is not exhaustive or mandatory, as we expect practices to use this as a baseline.

Your practice should be able to show how you have considered the risk and local context when deciding which medicines to stock. Any assessment of risk should include the reasons why a particular medicine on the suggested list is not required or a substitute used. This should be kept under review.

This list is based on current practice. It is modified from:

• two Drugs and Therapeutics Bulletins in 2015 (adults volume 53 issue 5 and children volume 53 issue 6)
• stakeholder engagement with medical directors of several GP practices.
• The Faculty of Sexual and Reproductive Healthcare: service standards for resuscitation.

Adrenaline/epinephrine (for injection at 1:1,000)

• Use: For anaphylaxis or acute angio-oedema.
• Important: Must be stocked where vaccines are administered.

Where vaccines are administered, an anaphylaxis pack containing adrenaline must be available. The Resuscitation Council UK recommends that an anaphylaxis kit contains at least:

• 2 ampoules of adrenaline (epinephrine) at 1mg/mL (1:1,000)
• 4x 23G needles and 4 graduated 1mL syringes
• oxygen supply, with face masks suitable for children and adults.

Do not store anaphylaxis packs in locked cupboards or trolleys. Keep them immediately available in each location where you administer vaccines.

Use an ampoule and needle/syringe to give adrenaline rather than auto-injector. Auto-injectors only deliver up to 300 micrograms of adrenaline. Older children and adults need 500 micrograms. You can use an auto-injector for the first dose if speed is important but give subsequent doses by ampoule and needle/syringe.

Antiemetic (for example, cyclizine, ondansetron, metoclopramide or prochlorperazine)

• Use: For nausea or vomiting.

Aspirin soluble tablets

• Use: For suspected myocardial infarction (MI).

Atropine

• Use: For bradycardia or vasovagal syncope.
• Important: Must be stocked where intrauterine devices (coils) are fitted or removed, or where minor surgery is performed.

Benzylpenicillin (for injection)

• Use: For suspected bacterial meningitis (see NICE guidance).

Dexamethasone (5mg/2.5ml oral solution) or Prednisolone (tablets)

• Use: For croup in children.
• Note: Dexamethasone has a short shelf life once opened. Record the date of opening and new expiry date. The use of prednisolone for this indication is off label.

Diclofenac (for intramuscular injection)

• Use: For analgesia.

Glucagon (for example, GlucaGen) and/or Glucogel

• Use: For hypoglycaemia.
• Note: Glucagon ideally requires refrigeration. If stored at room temperature, the expiry date is reduced. Record a new expiry date.

Glyceryl trinitrate (GTN) (spray or sublingual tablets)

• Use: For chest pain of possible cardiac origin.
• Note: GTN sublingual tablets should be kept unopened as they become ineffective shortly after opening.

Ipratropium (nebules)

• Use: For asthma.

See also salbutamol.

Midazolam (buccal) or Diazepam (rectal)

• Use: For seizures.

Naloxone

• Use: For opioid overdose.
• Important: Must be stocked where opiates are administered.

Naloxone is a medicine that can reverse the effects of opiates. If you stock opiates, either in the practice or in a doctor’s bag, you should also stock naloxone. Other practices should risk assess the need to stock naloxone based on their patient group. For example, if you treat patients with addiction or opiate-related problems.

Opiates (for example, diamorphine, morphine, pethidine)

• Use: For severe pain, including heart attacks (myocardial infarction).

Practices may consider stocking opiates to treat severe pain, including heart attacks (myocardial infarction). You must store, manage and oversee opiates appropriately and in line with relevant regulations. This includes any required safe custody or controlled drugs licensing requirements. If you decide not to stock opiates, record this in a risk assessment.

Prednisolone (tablets) or methylprednisolone (intramuscular)

Use: For asthma.

Salbutamol

Available as nebules with nebuliser, or inhaler with volumatic spacer.

• Use: For asthma and chronic obstructive pulmonary disease (COPD).

Sharps box

• Use: For safe disposal of sharps.

Syringes and hypodermic needles

• Use: If emergency medicines are stored in ampoules, stock enough syringes and needles.

Water for injection

• Use: To make up other medicines for injection.

Additional medicines

The above list is not exhaustive. Your practice may need to carry additional medicines based on the needs of the local population and local arrangements for services, for example district nurses, palliative care and substance misuse. This should be risk assessed.

Storage of emergency medicines

Emergency medicines should be readily accessible in an emergency. Do not lock them away. Ideally, store them in a tamper-evident box or container clearly marked ‘for emergency use’.

Emergency medicines, except for those subject to additional storage requirements (for example, safe custody), should not be stored within locked cupboards or rooms as this can cause an unacceptable delay in the event of an emergency.

Oxygen

Staff should be fully trained in the use of oxygen cylinders. This should include managing all related risks, such as risks related to fire, manual handling and storage.

Store oxygen cylinders in a well-ventilated, clean, dry area away from direct sunlight. Keep them away from any sources of combustion or ignition, such as smoking areas, machinery and gas (propane or butane).

Chain or clamp larger cylinders to prevent them falling over. Appropriate signage should be available to inform others about the presence of oxygen cylinders. Consider the size of oxygen cylinders, as larger cylinders may take longer to get to patients.

See the Health and Safety Executive’s guidance on Oxygen use in the workplace and the Medicines and Healthcare products Regulatory Agency’s Top tips on care and handling oxygen cylinders and their regulators.

Home visits

As well as managing medical emergencies in the practice, GPs and healthcare professionals need the knowledge, skills and equipment for managing acute emergencies on home visits.

What medicines to carry depends on the practice and type of visit. For example, a rural practice may need different medicines from an inner-city one.

The choice of medicines depends on:

• the medical conditions likely to be encountered
• how confident practitioners are with specific medicines
• storage requirements and shelf-life
• the extent of ambulance paramedic cover
• distance from the nearest hospital
• whether a 24-hour pharmacy or in-house dispensary is available.

Managing deteriorating patients

Your practice should have appropriate procedures in place to identify, manage and treat patients at risk of deterioration.

This includes recognising deteriorating patients during remote triage or in practice waiting areas.

Oxygen and oximetry

Oxygen must be available and prescribed according to a target saturation range and monitored. Staff should have access to appropriate oxygen masks, cannulae and tubing, including:

• high concentration non-rebreathing masks for adults and children
• venturi or air-entrainment masks.

See NICE guidance for acute exacerbations of asthma and British Thoracic Society guidance for the use of oxygen in healthcare and emergency settings. 

Pulse oximetry is a simple, non-invasive test that is easy to perform. It can quickly detect changes in oxygen levels before a patient becomes unwell. However, it is not an infallible test and requires clinical judgement.

Staff must:

• be trained before using a pulse oximeter
• use it as part of a comprehensive assessment and examination, not in isolation.

Pulse oximetry must be available wherever emergency oxygen is used. However, do not delay oxygen therapy if no pulse oximetry is available. Start monitoring as soon as one becomes available.

Ensure that your practice has an appropriate pulse oximeter for the patients you treat, as some devices may not be suitable for both adults and children.

See guidance on the use and regulation of pulse oximeters by the Medicines and Healthcare products Regulatory Agency and the use of pulse oximetry and monitoring vital signs outside the GP practice setting.

National Early Warning Score

The National Early Warning Score (NEWS), developed by the Royal College of Physicians helps detect and treat acutely unwell patients, including those at risk of clinical deterioration. The system has been endorsed by NHS England. It is now in use in most acute and ambulance settings.

Primary care providers should also use NEWS as a standardised system for assessing acute illness in adults.

You should ensure that clinical staff are trained and have access to the equipment needed to calculate a NEWS. This includes equipment to measure:

• temperature
• blood pressure
• oxygen saturation
• pulse
• respiration rate.

See our guidance on identifying and responding to sepsis.

What we will look at

We use these regulations when we review if your practice is safe, effective, caring, responsive and well-led.

This guidance relates to:

• Regulation 12: Safe care and treatment
• Regulation 15: Premises and equipment
• Regulation 17: Good governance
• Regulation 18: Staffing

We consider how practice staff respond to emergencies and how they recognise and manage patients who are:

• critically ill
• at risk of deterioration
• 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 regularly checked.

We expect to see evidence that an appropriate risk assessment has been carried out. This should include the list of medicines that are not suitable for a practice to stock. There should be a process and system in place to check that drugs are in date and equipment is well maintained.