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Nigel's surgery 1: Resuscitation in GP surgeries
We have updated this Mythbuster to include 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 the Resuscitation Council UK. This confirms the crucial importance of doing CPR for the person in cardiac arrest.
The Resuscitation Council UK has issued:
- statements and resources on Coronavirus (COVID-19), CPR and resuscitation
- statements on COVID-19 (Coronavirus) for primary care settings
- an updated statement on PHE PPE guidance (28 April 2020).
All practices should be able to show they are able to assess and appropriately manage severely ill patients who may present to them with COVID-19.
Resuscitation guidance has been updated by the Resuscitation Council UK due to the need for Personal Protective Equipment for staff. There is also updated guidance from Public Health England, informed by the governmental advisory NERVTAG. There is some dissonance between these different guidelines.
There has also been a statement produced by the Academy of Royal Colleges. They suggest organisations and clinicians should agree on local policy regarding 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, understood, shared and adequately resourced.
All GP practices must be equipped to deal with a medical emergency. All staff should be suitably trained. Online training may be considered acceptable especially given the constraints of the pandemic. They must understand their responsibilities in the event of an emergency. This includes the location of equipment, medicines and how to get help.
Under the safe key question we consider how practices manage patients who are:
- critically ill or
- at risk of deterioration, or
- in cardiac or respiratory arrest.
This relates to key line of enquiry (KLOE) S2: ‘How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?’
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.
The Resuscitation Council UK quality standards for cardiopulmonary resuscitation (CPR) practice and training include:
- 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
- personal protective equipment and sharps boxes available
- reliable system for equipment checks and replacement following manufacturer instructions
- appropriate equipment and medication considered
Nigel’s surgery 88 gives advice on managing sepsis.
Minimum suggested equipment
The Resuscitation Council UK lists minimum suggested equipment to support CPR in primary care settings.
The list is not comprehensive. It should be interpreted 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
- Personal Protective Equipment for staff.
Pulse oximeters are useful for managing a deteriorating patient as well as for chronic respiratory disease.
Equipment for clinicians with enhanced skills
The 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:
- 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 Sp02 level of 94-98%. Do not delay oxygen administration in the absence of pulse oximetry but begin monitoring Sp02 as soon as it is available.
- 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 recommends that pulse oximetry:
- is a useful non invasive investigation that is easily performed and reproducible in primary care. It rapidly detect 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 and 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)
- 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.
- Last updated:
- 11 November 2020