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Nigel's surgery 1: Resuscitation in GP surgeries

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All GP practices must be equipped to deal with a medical emergency and all staff should be suitably trained.

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.

Quality standards

The Resuscitation Council (UK) quality standards for cardiopulmonary resuscitation (CPR) practice and training include:

  • immediate access to appropriate resuscitation equipment and drugs when needed
  • all staff have a means of calling 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 – sepsis in general practice gives advice on managing sepsis.

Resuscitation equipment

Minimum suggested equipment

The Resuscitation Council (UK) lists minimum suggested equipment to support CPR in primary care settings.

The list is not comprehensive and should be interpreted on a place by place basis. Individual practice requirements 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
  • stethoscope
  • absorbent towel – to dry chest if necessary
  • razor – to shave chest to apply pads if necessary

Pulse oximeters can be clearly beneficial 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:

British Thoracic Society (BTS) guidance on oxygen use in adults in healthcare and emergency settings (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.

BTS guideline for the management of acute asthma (2016) recommends:

  • controlled supplementary oxygen for hypoxaemia in acute severe asthma to maintain a target oxygen saturation of 94-98%
  • 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 as it rapidly detect changes in oxygen saturation before the patient is compromised
  • is not an infallible test and 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]:

NICE recommend measuring oxygen saturations in adults and children with potential sepsis. This includes in community settings if equipment is available and 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 training

Resuscitation Council (UK) recommends that all staff, 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 retain documentary evidence of completed and approved resuscitation training.

There is no specific requirement for what training should look like; practices can tailor it to local needs.

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.

NEWS – National Early Warning Score

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.
Last updated:
21 August 2018

 


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