Quality Standards: Acute Care

Healthcare organisations have an obligation to provide a high-quality resuscitation service and to ensure that staff are trained and updated regularly to a level of proficiency appropriate to each professional’s expected role. 

This document provides quality standards for cardiopulmonary resuscitation practice and training in the acute health care setting. Acute care refers to acute hospitals that provide inpatient and/or day-case medical and/or surgical care to adults, children, newborn babies or all. 

Each section of this document contains the quality standards, supporting information and supporting tools for a specific aspect of cardiopulmonary resuscitation in acute care. The appendix provides a list of suggested measures to assess adherence to the standards specified in each section. 

The core standards for the provision of cardiopulmonary resuscitation across all healthcare settings are described in the Introduction and overview page. 

Alongside the quality standards, there is an acute care equipment and drug list.

Standards

1. Healthcare organisations admitting acutely ill patients must have a Resuscitation Committee with clearly defined terms of reference. 

2. The organisation should “ensure that a resuscitation policy is agreed, implemented, and regularly reviewed within the clinical governance framework”. This may be discharged either by having a non-executive director (NED) with responsibility or by the Quality Committee, or equivalent, discharging this role (rather than an individual NED) and including this on the committee work plan, ensuring sign-off from the board.  

3. The Resuscitation Committee must be part of the organisation’s core management structure (e.g. clinical governance, clinical risk, quality improvement, education committees). 

4. The Resuscitation Committee must include representatives from stakeholder groups (e.g. doctors, clinicians, nurses, resuscitation practitioners, pharmacists, management, patient/lay representative) and appropriate specialities (e.g. ambulance service, anaesthesia, cardiology, dentistry, emergency medicine, general practice, intensive care medicine, mental health, neonatology, obstetrics, paediatrics). The exact composition of the committee will depend on local needs and arrangements. 

5. The chair of the Resuscitation Committee must be a senior clinician with an active and credible involvement in resuscitation. This individual would be expected to have the authority to drive and implement change. 

6. The Resuscitation Committee must have administrative support. 

7. The Resuscitation Committee is responsible for implementing operational policies governing cardiopulmonary resuscitation, practice and training. 

8. In the absence of other organisational arrangements, the Resuscitation Committee must also be responsible for implementing operational policies governing the prevention of cardiac arrest. 

9. According to local arrangements, it is recommended that the Resuscitation Committee provides advice to other local healthcare organisations who do not have the necessary expertise in resuscitation issues. In some healthcare communities, this is achieved very effectively by having a Resuscitation Committee that spans all the relevant organisations. 

10. The Resuscitation Committee must determine the level of resuscitation training required by staff members. 

11. At least twice-yearly meetings of the Resuscitation Committee are recommended. 

12. Responsibilities of the Resuscitation Committee include:

    • ensuring implementation and adherence to national resuscitation guidelines and standards,

    • defining the role and composition of the resuscitation team(s),

    • ensuring that resuscitation equipment for clinical use is available and ready for use, 

    • ensuring that appropriate resuscitation drugs (including those for peri-arrest situations) are available and ready for use, 

    • planning the adequate provision of training in resuscitation, determining requirements for and choice of resuscitation training equipment, 

    • preparing and implementing policies relating to resuscitation and treatment of anaphylaxis, 

    • preparing and implementing policies relating to the prevention of cardiac arrest, 

    • preparing and implementing a policy on resuscitation conversations and recommendations or decisions (e.g. Emergency Health Care Plans, ReSPECT or DNACPR decisions), and advanced care planning (this is usually in collaboration with palliative care teams and/or Geriatric Medicine teams), 

    • quality improvement - action plans based on audits (e.g. review of audit data using National Cardiac Arrest Audit data for benchmarking), 

    • recording and reporting of patient safety incidents in relation to resuscitation. 

13. The Resuscitation Committee must ensure that there is defined financial support for the resuscitation service. 

Standards

1. Every organisation must have at least one person, who is responsible for co-ordinating the teaching and training of staff in resuscitation. Throughout the document the term Resuscitation Practitioner (RP) is used for this role, with the understanding that there are many job titles and individual roles agreed locally (including Resuscitation Officer, Resuscitation Specialist, Resuscitation Lead and Resuscitation Services Manager). 
2. This person may have additional important governance responsibilities (e.g. quality improvement, incident review, attending cardiac arrests/medical emergencies, debriefing, risk assessment, procurement, End of Life Care planning) 
3. One whole-time-equivalent RP is recommended for every 750 members of clinical staff - see supporting tools below for further details. Depending on the size and geographical distribution of the organisation, more than one RP may be needed to fulfil training requirements and additional responsibilities relating to resuscitation. 
4. RPs must possess a current provider certificate in the relevant life support course/s, with Instructor qualification/s also desirable. This includes RCUK Advanced Life Support, European Paediatric Advanced Life Support, Newborn Life Support, Advanced Resuscitation of the Newborn Infant or ALSG Advanced Paediatric Life Support courses. 
5. Participating in the Generic Instructor Course, as a member of Faculty is desirable, as this will facilitate the dissemination of best practice resuscitation education.  
6. The RP must have access to a designated training room(s) of adequate size. The room(s) should comfortably accommodate Instructors, Trainees and all the training equipment required for any teaching session. 
7. The RP must have access to suitable electronic teaching aids. There must be adequate space for storing equipment. It is recommended that separate office space, with a desk, computer facilities, and lockable document storage, is available. 
8. The RP must have access to agreed administrative assistance to enable course and clinical  administration. This should be decided locally. 
9. Equipment for training will vary according to local needs. Adult, paediatric and newborn manikins, airway management trainers, an ECG monitor and rhythm simulator, and at least one defibrillator dedicated for training, must be available, if relevant. To ensure appropriate clinical use, equipment for training (especially defibrillators) must be the same model as that used in actual clinical practice. 
10. There must be a defined resuscitation budget made available for the RP to maintain, upgrade and purchase new equipment for patient use and for training. Purchasers of health care need to be made aware of this when contracts are negotiated and adequate provision made. Such financial support for resuscitation services must be taken into account during budget planning by the organisation. 
11. It is recommended that the RP is responsible for ensuring that there are systems in place for maintaining resuscitation equipment in good working order. This will usually mean delegation of routine checking of equipment to ward staff, other members of staff or departments such as medical/clinical engineering.  
12. It is recommended that the RP is involved in data collection and audit of cardiac arrest. It is recommended that this data should be collected as part of the National Cardiac Arrest Audit (NCAA). Interpretation of cardiac arrests/medical emergencies should be sought and discussed within Resuscitation Committee meetings feeding into other internal groups .
13. In order to maintain standards and clinical credibility, it is recommended that responding to and participating in cardiac arrest management is an integral part of the RP’s clinical responsibility on a week-to-week basis. RPs with a clinical role must have appropriate clinical supervision and support. Continuing professional development should be supported both for the RP role and for continuing professional registration. 
14. The RP has a responsibility to maintain their own education in resuscitation alongside the employer who has a duty to allow the individual to maintain their clinical practice. In order to achieve this, teaching on resuscitation courses outside the organisation is recommended. In addition, regular attendance at professional meetings must be supported with a budget for study expenses. 
15. RPs should not be expected to generate income to provide for their own salary. 
16. If the RP is expected to generate income for the organisation it should be agreed in writing with the relevant manager. Any income from RCUK courses must be directed to improving resuscitation services. 

Standards  

1. At induction, staff must either have transferable previous resuscitation training or undergo relevant resuscitation training. Induction must cover any trust or department specifics regarding resuscitation of patients. Training should be repeated at regular intervals thereafter to maintain knowledge and skills.
2. Training must be to a level appropriate for the individual’s expected clinical responsibilities.
3. Training must include the use of an ‘early warning scoring’ system to identify the deteriorating patient, including the use of an escalation protocol to ensure early and effective treatment of patients in order to prevent cardiac arrest. The scoring and escalation system must be the same as used in actual clinical care. The use of the National Early Warning Score 2 (NEWS2) was mandated in acute care in 2018. For children, the use of Paediatric Early Warning Score (PEWS) is recommended. For obstetric practice the National Maternity Early Warning Score (MEWS) is recommended.
4. According to NICE Clinical Guideline 50 (2007), staff caring for patients in any acute hospital setting must have competencies in monitoring, measurement, and interpretation of vital signs. They must have the knowledge to recognise deteriorating health and respond effectively to acutely ill patients, appropriate to the level of care they are providing.
5. It is recommended that training enables clinical staff to possess the competencies defined in the Department of Health document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’ and the National Outreach Forum document ‘Operational Standards and Competencies for Critical Care Outreach Services’. In services caring for children and newborn babies competencies must incorporate recognition of the acutely ill child or infant as described in “Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review”, “Recognition of the acutely ill infant HSIB 2021 and Newborn Early Warning Trigger & Track (NEWTT)”.
6. According to Resuscitation Council UK guidelines, training must be in place to ensure that clinical staff can undertake appropriate cardiopulmonary resuscitation. Training and facilities must ensure that, when cardiorespiratory arrest occurs, as a minimum all clinical staff can:
    
   • recognise cardiorespiratory arrest
   • summon help,
   • start CPR,
   • attempt defibrillation, if appropriate, within 3 minutes of collapse using an automated external defibrillator or manual defibrillator.
7. Clinical staff should have at least annual updates, depending on role.  Those with extant valid qualifications (e.g. ALS etc.) should also be offered annual updates.
8. Training and updates that include an assessment are recommended for clinical staff.
9. The expectation is that non-clinical staff have the resuscitation skills that would be expected from a layperson. If a layperson calls 999 in an emergency, they receive instructions from an ambulance call handler whilst awaiting trained help to arrive. These instructions include starting chest compressions. Telephone guidance does not happen in hospitals unless staff dial 999; hence the expectation that all staff in an acute setting should have some basic knowledge of resuscitation.
   As a minimum, non-clinical staff should be trained to:  
    
   • recognise cardiorespiratory arrest, 
   • summon immediate emergency help in accordance with local protocols, 
   • start CPR using chest compressions,  
   • locate, apply and use an AED  following the device voice prompts. 
10. All staff must know how to summon help and be aware of the use of a standard telephone number within the organisation. We recommend that this should be a common national number 2222, as recommended by the National Patient Safety Agency. 
11. For all staff, a variety of methods to acquire, maintain and assess resuscitation skills and knowledge can be used for annual updates (e.g. life support courses, simulation training, in-house training, mock-drills, ‘rolling refreshers’, training using CPR trainers with feedback, e-learning, video-based training/self-instruction). The appropriate methods must be determined locally. For example, training materials such as Lifesaver (www.life-saver.org.uk), developed by Resuscitation Council UK, or very brief videos aimed at the general public may be appropriate for non-clinical staff. ‘Hands-on’ simulation training and assessment is recommended for clinical staff. 
12. A system must be in place for identifying resuscitation equipment for which staff require special training, such as defibrillators and emergency suction equipment. 
13. Organisations must recognise and make provision for staff to have enough time to train in resuscitation skills as part of their employment. 
14. Specific training for cardiorespiratory arrests in special circumstances (e.g. children, newborn, pregnancy and trauma) must be provided for medical, nursing and other clinical staff in the relevant specialties. 
15. All training must be recorded with a personal record of training available to the individual members of staff (e.g. in the organisation’s training database). 
16. Members of the resuscitation team with a regular involvement in resuscitation, particularly team leaders, may require a level of training beyond that provided by the local RP. These individuals must be encouraged and supported to attend nationally recognised courses such as the Advanced Life Support (ALS) course, the European Paediatric Advanced Life Support (EPALS) course, the Advanced Paediatric Life Support (APLS) course, the Newborn Life Support (NLS) course, the Advanced Resuscitation of the Newborn (ARNI) course, the European Trauma Course (ETC), and the Advanced Trauma Life Support (ATLS) course as appropriate to their role. 

Standards  

1. The use of the 'Chain of Prevention' concept as a basis for the structuring of the organisation’s responses to patient deterioration and the prevention of cardiorespiratory arrest is recommended. 
2. The organisation must have an education programme that is focused on the prevention of patient deterioration, for ward staff and responding clinical personnel. It is recommended that staff attain the competencies identified in the Department of Health document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’ (2009), and the National Outreach Forum document ‘Operational Standards and Competencies for Critical Care Outreach Services’.  
3. The organisation must have a clear policy for the monitoring of patients’ vital signs, based on the guidance in the National Institute for Health and Clinical Excellence clinical guideline 50 [Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital (2007)] and the Royal College of Physicians National Early Warning Score (NEWS2) (2017).  
4. An early warning scoring system must be in place to identify patients who are critically ill and therefore at risk of cardiorespiratory arrest. The use of the National Early Warning Score (NEWS2) for adults, or a paediatric (PEW System) or newborn (NEWTT) early warning score for children is recommended.
5. The organisation must have a patient charting system that facilitates the regular measurement and recording of early warning scores. 
6. The organisation must have a clear, universally known and understood, mandated, unambiguous, graded, activation protocol for escalating monitoring or summoning a response to a deteriorating patient. This should be standardised across the organisation.
7. The use of a standardised method for communicating information about a deteriorating patient (e.g. SBAR, SBARD, RSVP) between staff members is recommended.  
8. A designated outreach service or rapid response team capable of responding to acute clinical crises identified by clinical triggers or other indicators, is recommended. This may include members of the resuscitation team. 
9. The organisation must have a clear and specific policy that requires a clinical response to 'calling criteria' or early warning systems ('track and trigger'). This must include the specific responsibilities of both senior and more junior clinical staff and identify the maximum response times. NCEPOD recommends that when patients continue to deteriorate after non-consultant review there should be escalation of patient care to a more senior doctor with the appropriate skills (e.g. Critical Care). If this is not done, the reasons for non-escalation must be documented clearly in the patient’s health record. 

Standards

1. The Resuscitation Committee must determine the composition of the resuscitation team (may be termed emergency response team).
2. The exact composition of the team will vary between organisations, but overall the team that responds immediately must have the following minimum skills:
    
   • basic airway interventions, including the use of a supraglottic airway in adults,
   • intravenous cannulation, and intraosseous access (essential in children),
   • defibrillation (automated external defibrillation and manual defibrillation),
   • drug administration,
   • skills required for immediate post-resuscitation care,
   • a scribe for more contemporaneous recording of events, and the ability to use prompts and checklists. 
3. NCEPOD recommends that each hospital ensures that there is an agreed plan for airway management during cardiac arrest. This may involve bag-mask ventilation for cardiac arrests of short duration, the use of a supraglottic airway device or tracheal intubation if this is within the competence of members of the team responding to the cardiac arrest.
4. In addition to the resuscitation team, access to individuals with the following skills when needed is recommended:
    
   • tracheal intubation,
   • cardioversion and external pacing,
   • central venous access,
   • focused ultrasound/echocardiography/point-of-care ultrasound.
5. The team should be activated in response to a cardiorespiratory arrest. Certain clinical areas (e.g. emergency departments, intensive care units) have individuals with the necessary resuscitation skills within their own staff and may therefore not always call the hospital resuscitation team/emergency response team.
6. Activation of the team may also be part of the local escalation plan for the deteriorating patient.
7. The resuscitation/emergency response team is responsible for ensuring the appropriate management of relatives (who may or may not wish to be present at a cardiorespiratory arrest), post-resuscitation transfer, and debriefing.
8. Consideration must be given to allowing relatives or significant companions to be present during a resuscitation attempt. An experienced member of staff who can explain what is going on should be delegated to stay with them and liaise with the team on their behalf.
9. Team members often change daily or more frequently, especially when shift working is used. Members may not know each other or the skill mix of the team members. A resuscitation/emergency response team meeting at the beginning of members’ period on duty is recommended to:
    
   • introduce team members to each other; communication is much easier and more effective if people can be referred to by their name,
   • identify everyone’s skills and experience,
   • allocate the team leader role; skill and experience take precedence over seniority,
   • allocate responsibilities; if key skills are lacking (e.g. nobody skilled in tracheal intubation) the team must work out and agree how this deficit can be managed,
   • update the team on any patients who have been identified as ‘at risk’ during the previous duty period.
10. Team debriefings involving resuscitation team members are recommended - the exact mechanism (e.g. end of each event, end of each shift, weekly) must be determined locally; this should be complementary to the local processes to promote resilience. 
11. The resuscitation/emergency response team must be summoned to all cardiorespiratory arrests by the use of a common telephone number. The National Patient Safety Agency has recommended that this number should be 2222.
12. The organisation must ensure that the resuscitation team is activated within 30 seconds of the call for help. This system must be tested daily. Responses to test calls must be monitored and where there is a failure to respond this must be followed up and remedied immediately.
13. The organisation must have a policy for staff and telephone operators for dealing with cardiac arrest calls from remote parts of a hospital site (e.g. car parks, office buildings). In some settings this may include calling an ambulance in addition to the resuscitation team.
14. The role of team leader in a resuscitation team must be undertaken by an individual who is a current Advanced Life Support Provider or has equivalent training. If the patient is a child or newborn, the team leader must have equivalent paediatric or newborn life support qualifications. Although the team leader at a resuscitation attempt will usually be a doctor on the resuscitation/emergency response team, the role must be allocated at each individual event, based on clinical knowledge, skills and experience.
15. The team leader is responsible for:
     
    • directing and co-ordinating the resuscitation attempt,
    • ensuring that current guidelines are followed,
    • ensuring the safety of those present,
    • ending the resuscitation attempt when indicated,
    • documentation (including audit forms),
    • communication with relatives,
    • handover of care to other clinical teams,
    • diagnosis and documentation of death if appropriate. However, certification of death may well be carried out by the responsible clinical team.

    The team leader may decide to delegate some of these tasks but must ensure that they are completed.

16. The organisation must ensure that a complete and detailed record of the cardiorespiratory arrest is retained within the patient’s clinical record. Collection of data for audit at the time of arrest is recommended.

Standards 

1. Most cardiac arrests in children and the newborn are secondary events. Therefore, specific paediatric early warning scoring systems with a ‘Track and Trigger’ should be used to prevent cardiac arrest. 
2. Timely review by appropriately trained clinicians in response to clinical triggers or other indicators reduces mortality in children and newborn. It is recommended that a formal provision be made to provide this response that has early involvement of paediatric experts to reverse potential declines and to escalate to other resources such as anaesthetic teams or advice from local PICU/ retrieval teams in cases of continued deterioration. This may be realised by members of an outreach service, rapid response team or similar service. The nature of this team will vary according to local need and resources and should be determined locally. 
3. When attempting the resuscitation of a child or newborn in cardiorespiratory arrest, as a minimum the team leader must be someone with expertise and training in the resuscitation of children and the newborn. Special knowledge of the equipment, techniques and doses of drugs required for children and the newborn, together with an understanding of the differences in causes and treatment of cardiorespiratory arrest, is essential. 
4. Familiarity with their expected roles and experience in the resuscitation of children and the newborn is recommended for all team members. Ideally, organisations should have a separate paediatric resuscitation team.
5. At least one member of a resuscitation team that may be expected to resuscitate children and/or the newborn must have completed an accredited national paediatric and/or newborn resuscitation course (e.g. EPALS/APLS/NLS/ARNI) successfully. In addition, all staff with regular involvement in paediatric or newborn resuscitation must be encouraged to attend accredited national paediatric resuscitation courses (e.g. EPALS, APLS, NLS, ARNI). 
6. When resuscitating a child or a newborn, particular consideration must be given to allowing the presence of relatives/guardians during the resuscitation attempt. An experienced member of staff who can explain what is going on should be delegated to stay with them and liaise with the team on their behalf. 
7. The use of paediatric and/or newborn resuscitation charts and drug dosing aides is essential. In circumstances where the weight is not known (such as in the emergency department) a method of calculating drug dosages from length or age is useful. 
8. Where appropriate, a separate Emergency Care and Treatment Plan, ReSPECT, DNACPR form and/or Emergency Healthcare Plan (EHP) is recommended for children and the newborn. 
9. The British Association of Perinatal Medicine (www.bapm.org) provides standards for hospitals providing neonatal care. 

    

Standard

1. Organisations must have policies and procedures in place for resuscitation in special circumstances (e.g. trauma, obstetrics, patients with tracheostomies). 
2. In clinical areas where cardiac arrest due to a special circumstance is likely to be more common, specific training of staff to identify early symptoms, treat deterioration and tailor management of any cardiac arrest is encouraged. Where available, national guidance should be followed. 
3. Resuscitation algorithms specific to any likely causes of collapse/cardiac arrest should be displayed in clinical areas. 
4. The management of anaphylaxis should follow current NICE guidelines ‘Assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode’ .

After successful resuscitation, patients may need transfer to another part of the hospital (e.g. cardiac/coronary care unit, intensive care unit, catheter laboratory, theatres) or to another hospital.

Standards

1. Standards for patient transfer must be based on guidance from the Association of Anaesthetists of Great Britain and Ireland, the Intensive Care Society and the Paediatric Intensive Care Society. 
2. Many regions now have critical care transfer teams for babies, children and adults. Local policy/procedures should be followed when a transfer is required. 

Standards

1. It is recommended that hospitals use a local protocol for post-cardiac-arrest care that includes the use of temperature management. This should be based on current guidelines.
2. Guidance on the post-cardiac-arrest care of children and babies can be found in the European Paediatric Life Support / Advanced Paediatric Life Support and Newborn Life Support manuals.
3. Patients may require transport to other units. See Section 8 for Patient Transfer standards.

Standards

Click here to look at the equipment and drug list for an acute care setting.

Standards

1. Healthcare professionals must be familiar with and follow published guidance, including in particular ‘Decisions relating to Cardiopulmonary Resuscitation, a joint statement by the British Medical Association, the Resuscitation Council UK, and the Royal College of Nursing’ and the General Medical Council’s current guidance on ‘Treatment and care towards the end of life: good practice in decision making’. 
2. Healthcare professionals must be familiar with and must comply with the law as it applies to decisions about CPR. There are some differences in the law among countries of the United Kingdom. Healthcare provider organisations must ensure that their staff receive appropriate information and training regarding these laws. 
3. Resuscitation Council UK advises that CPR discussions and recommendations should always be made within the context of overall goals of care. The ReSPECT (Recommended Summary Plan for Emergency Care and Treatment process https://www.resus.org.uk/respect) is one way of doing this. The ReSPECT process facilitates conversations between a person, their families, and their health and care professionals to understand what matters to the patient and what treatments – including CPR – would be of benefit to them, and then records the agreed recommendations on the ReSPECT form.   
4. Healthcare professionals involved in making recommendations about CPR, and/or conducting a ReSPECT conversation must have appropriate training and competency in so doing, and similarly those who undertake the sensitive discussions with patients and those close to patients must have appropriate training and competency in so doing.  Healthcare provider organisations must ensure that they have sufficient staff trained and competent in performing these functions, and that staff have adequate time and facilities to perform them properly. 
5. Resuscitation Council UK has defined standards for recording recommendations about CPR. It is recommended that recommendations about CPR are documented alongside documentation about overall goals of care. It is recommended that these are recorded on a form that is easily recognised and has a standard content and format, to allow healthcare professionals to recognise it and assess its content and validity immediately.  
6. Healthcare organisations must have policies about CPR recommendations and documents that are recognised by the other organisations so that recommendations about CPR continue across organisational and geographic boundaries when patients are transferred from one setting to another. In particular this should include the ambulance service, so that these decisions are respected during transfer. 
7. Healthcare organisations must ensure that healthcare staff have access to appropriate stationery or electronic media for recording, accessing and reviewing recommendations about CPR. As electronic records become more prevalent, individual trusts must implement systems this access is uniformly available to healthcare staff wherever a cardiac arrest occurs.  
8. Healthcare organisations must ensure that patients and those close to patients have ample opportunities to discuss goals of care, resuscitation and recommendations about CPR. Early conversations can occur in many settings  (preoperatively, in out-patients, in primary care and in acute and intensive care). Written information about resuscitation recommendations, or information in other media (e.g. DVD or podcast) should be made readily available for patients and those close to them but should not be used as an attempted substitute for sensitive, face-to-face discussion with a suitably trained and competent healthcare professional. 

Standards

1. NCEPOD recommends that every CPR attempt is reported through the organisation’s patient safety incident reporting system. This information must be reported to the organisation’s Board on a regular basis. 
2. All CPR attempts must be reviewed. When appropriate, a root cause analysis must be undertaken, and the action plan implemented (a suggested guide for reviewing cardiac arrests is available in the appendix). 
3. Taking part in the National Cardiac Arrest Audit (NCAA) is recommended. NCAA is included in the Department of Health’s Quality Accounts as a recognised national audit. 
4. Audit of DNACPR policies is mandatory (Health Services Circular 2000/028). 
5. Organisations must review local audit data regularly against published standards. Where audit identifies deficiencies or unexpected poor performance, a review at a senior organisational level must be undertaken. The Resuscitation Committee must receive appropriate support to achieve this. 

Standards

1. The NHS Constitution highlights the NHS commitment to conduct and use of research to improve the current and future health and care of the population. 
2. Research must be conducted in accordance with the NHS Research Governance Framework. Research involving human participants, their organs, tissue or data require NHS Research and Development approval. Such research may also require approval from a Research Ethics Committee. If in doubt advice should be sought from the local Research and Development Office in the first instance or NHS Research Ethics Advice Service. 
3. Research involving patients who lack capacity must also comply with relevant legislation (e.g. UK Medicines for Human Use [Clinical Trials] Regulations 2004 ; Mental Capacity Act 2005 [England and Wales]; Adults with Incapacity [Scotland] Act 2000); Mental Capacity Act 2016 (Northern Ireland) . 
4. The organisation’s Resuscitation Committee can be a valuable source of advice for those contemplating undertaking clinical research in resuscitation. 

Suggested measures to assess adherence to standards

The numbers listed in the first column correspond to the standards referred to in the corresponding chapter of this document.