Quality Standards: Community hospitals 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 person’s expected role.

This document provides quality standards for cardiopulmonary resuscitation practice and training in settings that deliver community hospital care.

Each section of this document contains the quality standards, supporting information and supporting tools for a specific aspect of cardiopulmonary resuscitation in community hospitals. The appendix provides a list of suggested measures to assess organisations’ 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 a community hospitals care equipment and drug list. Please refer to that by clicking here.

Throughout this document the term Community Hospitals includes inpatients and all services held within those premises (e.g. speech and language therapists, physiotherapists, occupational therapists, podiatrists etc.).

For community hospitals that provide services such as day case surgery with general anaesthesia, standards for Acute Settings may apply.

Resuscitation Council UK recognises that the standards in this document may provide challenges for some community hospitals and the organisations that are responsible for providing them. Intentionally, these standards are aspirational in certain areas. Where appropriate, each section contains links to implementation tools or examples of good practice. Each section also contains guidance on measures to assess adherence to standards.

Terminology:

1. The term ‘MUST’ has been used when the consensus is that the standard promotes normal practice and is obligatory.
2. The term ‘SHOULD’ has been used when the consensus is that the standard promotes normal practice.
3. The term ‘RECOMMENDS’ is used when the consensus is that the standard promotes best practice.

Resuscitation Council UK recommends that each community hospital organisation considers the implications of these standards and makes suitable arrangements to develop the capabilities that are required.

Organisations should consider training some staff selected from within the organisation to a higher standard than is required generally so that they can undertake the actions that are necessary and/or cascade training within their facilities. Additionally, organisations could establish a suitable service level agreement with acute healthcare services that are sufficiently close geographically, ambulance services or external training organisations. Community hospital organisations may require a combination of arrangements.

Many organisations that provide community hospital care do not have a separate Resuscitation Committee within the service. However, they should have a system that incorporates the duties of resuscitation services into their governance and clinical structures. This varies with each organisation and within which jurisdiction patients are cared for and treated in the UK. In addition, Resuscitation Council UK recognises that the structure of the NHS, and community health services within it, is different in England, Northern Ireland, Scotland and Wales. Therefore, this document uses the term Resuscitation Service Structure throughout to avoid repeating Resuscitation Council UK’s recognition of this situation. Readers should apply the standards specified herein into the structural and functional organisational patterns in each of the countries that comprise the UK.

Standards

1. Every community hospital organisation must have an identified Resuscitation Service Structure with clearly defined terms of reference.
2. Every organisation must have an identified executive board member who is responsible for resuscitation services. This was required in England by Health Services Circular 2000/028 which stated that Chief Executives must ensure that ‘a non-executive Director of the Trust is given designated responsibility on behalf of the Trust Board to ensure that a resuscitation policy is agreed, implemented, and regularly reviewed within the clinical governance framework’.
3. The Resuscitation Service Structure must be part of each responsible authority’s management structure (e.g. clinical governance, clinical risk, quality improvement, education service structures).
4. The Resuscitation Service Structure must include local resuscitation experts, representatives from stakeholder groups (e.g. doctors, nurses, resuscitation officers, pharmacists, managers, patient/lay representative(s)), and of appropriate specialties (e.g. ambulance service, anaesthesia, cardiology, dentistry, emergency medicine, general practice, mental health, neonatology, obstetrics, paediatrics). The exact composition of the service structure depends on local needs and arrangements.
5. The lead person who is responsible for the Resuscitation Service Structure must have an active and credible involvement in resuscitation. This person must have the authority to drive and implement change to meet the standards in this document.
6. The Resuscitation Service Structure must have administrative support.
7. The Resuscitation Service Structure is responsible for implementing operational policies governing cardiopulmonary resuscitation, practice and training.
8. In the absence of other organisational arrangements, the Resuscitation Service Structure must also be responsible for implementing operational policies governing prevention of cardiac arrest, including recognition of patients who are deteriorating before they arrest.
9. Clear local arrangements should be negotiated and put in place for the Resuscitation Service Structure to provide advice to other local healthcare organisations that do not have the expertise that is necessary in resuscitation policies, training, clinical practice, monitoring and audit.
10. The Resuscitation Service Structure must determine the level of resuscitation training required by staff members.
11. At least twice-yearly meetings of the Resuscitation Service Structure are recommended.
12. Responsibilities of the Resuscitation Service Structure include:
    • ensuring implementation and adherence to national resuscitation guidelines and standards,
    • defining the roles and composition of the resuscitation team (or the summoning of ambulance service) within the organisation,
    • 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 according to local policy, and ready for use,
    • planning adequate provision of training in resuscitation,
    • determining requirements for, and choice of, resuscitation training equipment,
    • preparing and implementing all policies relating to resuscitation (this may include managing anaphylaxis),
    • preparing and implementing policies relating to prevention of cardiac arrest and recognising patients who are deteriorating,
    • preparing and implementing a policy on resuscitation decisions (e.g. DNACPR decisions and advanced care planning),
    • quality improvement – action plans should be based on audits,
    • recording and reporting of incidents in relation to resuscitation in which patients’ safety may have been at risk.
13. The organisation must ensure that there is defined financial support for the Resuscitation Service Structure.

Standards

1. Every organisation must have at least one person, the resuscitation officer (RO), resuscitation lead, resuscitation services manager, or a person who holds an equivalent role who is responsible for co-ordinating the teaching and training of staff in resuscitation. People in any of these posts are referred to as ROs throughout this document.
2. ROs have additional important responsibilities (e.g. quality improvement, incident review, maintenance of clinical equipment), in conjunction with appropriate clinical governance/risk management structures within the organisation.
3. Depending on the size and geographical distribution of the organisation, more than one RO may be needed to fulfil training requirements and additional responsibilities relating to resuscitation.
4. One whole-time-equivalent RO is required to deliver training for 50% of their working time; this equates to one whole-time RO training no more than 821.5 hours per year – see below for further details. Training may be contracted from outside the organisation, although the organisation holds responsibility for ensuring that training adheres to current RCUK standards and guidelines.
5. Smaller organisations must appoint a resuscitation lead who may have other roles as part of their working commitments.
6. ROs or contracted trainers should possess a current Advanced Life Support (ALS) provider certificate (or equivalent) as a minimum standard; ideally, the ALS Instructor qualification is recommended. Where appropriate, each organisation must ensure that ROs possess certified resuscitation training certificates in other specialist areas (e.g. paediatrics and trauma).
7. ROs 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.
8. ROs must have access to suitable electronic teaching aids and projection facilities. There must be adequate space for storing equipment. It is recommended that separate office space in which there is a desk, computer facilities and filing cabinets, is available.
9. ROs must have adequate access to administrative assistance.
10. The equipment that is required for training varies according to local needs. Adult, paediatric, airway management trainers, an ECG monitor and rhythm simulator, and at least one defibrillator dedicated for training, must be available. The equipment used for training (especially defibrillators) must be the same model as that used in actual clinical practice to ensure appropriate clinical use. All efforts must be made to ensure that duplication of equipment is available to prevent unnecessary moving and handling of equipment, especially if the geographical area covered by an organisation is substantial.
11. There must be a defined capital budget for resuscitation made available for ROs to enable them to maintain, upgrade and purchase new equipment for use with patients and a revenue budget for training. Purchasers and other funders of health care must be made aware of this when contracts, responsibilities and service agreements are negotiated, and adequate provision must be made. The financial support that is necessary for resuscitation services must be taken into account during budget planning by all organisations.
12. ROs must be responsible for ensuring that there are systems in place for maintaining resuscitation equipment in good working order. Often, this requires delegation of routine checking of equipment to other members of staff.
13. ROs must ensure that all cardiorespiratory arrests are documented (by the staff who are involved in the resuscitation attempt) and audited. The results should be sent to the local audit/governance structure.
14. It is recommended that ROs attend cardiorespiratory arrests regularly and/or sustain access to clinical practice in order that they are able to maintain standards and clinical credibility. ROs with a clinical role must have appropriate clinical supervision and support.
15. ROs have a responsibility to maintain their own education in resuscitation. Teaching on resuscitation courses outside the organisation in which they work is recommended in order to achieve this. In addition, attendance at professional meetings must be supported with a budget for study leave and expenses.
16. ROs must not be expected to generate income to provide for their own salaries.
17. If ROs are expected to generate income for the organisation, that commitment should be agreed in writing with the relevant manager. Any income must be directed to improving resuscitation services.

Standards

1. All healthcare staff must undergo training in resuscitation at induction and at regular intervals thereafter to maintain their knowledge and skills.
2. Training must be to a level appropriate for each person’s expected clinical responsibilities.
3. Training must include using an ‘early warning scoring’ system to identify patients who are deteriorating, including using 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 that used in actual clinical care. Use of the National Early Warning Score (NEWS) is recommended for these purposes. For children, the use of paediatric early warning scoring systems is recommended.
4. Training must be in place to ensure that clinical staff possess the competencies defined in the Department of Health document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’.
5. According to Resuscitation Council UK guidelines, training must be in place to ensure that clinical staff can undertake 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 three minutes of collapse using an automated external defibrillator.
6. Clinical staff should have at least annual updates.
7. Training and updates that include an assessment are recommended for clinical staff.
8. The expectation is that non-clinical staff have the resuscitation skills that would be expected from a lay person. As a minimum, non-clinical staff must be trained to:
   • recognise cardiorespiratory arrest,
   • summon help,
   • start CPR using chest compressions.
9. All staff must know how to summon help and be aware of the protocol for the settings in which they work. This could be dialling 999 in some community hospital settings. A variety of methods for all staff 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’, e-learning, video-based training / self-instruction). The methods used must be determined locally. For example, training interventions 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.
10. A system must be in place for identifying resuscitation equipment that requires special training, such as defibrillators and emergency suction equipment.
11. All new members of staff must have training in resuscitation as part of their induction programmes.
12. ROs or resuscitation leads must organise and coordinate resuscitation training for staff. However, ROs may delegate some aspects of training in order to achieve training targets.
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 and patients who have suffered blood loss) must be provided for medical, nursing and other clinical staff in the relevant specialties.
15. All clinical staff must receive training in recognising, monitoring and managing patients whose physical conditions are deteriorating.
16. All training must be recorded (e.g. in the organisation’s training database).
17. Members of resuscitation teams (if available) who are involved in resuscitation regularly, and particularly team leaders, may require a level of training beyond that provided by local ROs. If this is not provided by a local RO, these members of staff should be encouraged and supported to attend a national course such as the Advanced Life Support (ALS) course.

Standards

1. The use of the 'Chain of Prevention' concept is recommended as a basis for structuring each organisation’s responses to situations when patients deteriorate and preventing cardiorespiratory arrest.
2. Every community hospital organisation must have an education programme that is focused on preventing patients’ deterioration that is provided for ward staff and clinical personnel who respond to patients’ needs. It is recommended that staff attain the necessary competences identified in the Department of Health document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’ (2009).
3. Every organisation must have a clear policy for monitoring 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)], National Institute for Health and Clinical Excellence Clinical Guideline 25 (2007), NPSA Rapid Response Report (2008/RRR010) and the Royal College of Physicians National Early Warning Score (NEWS) (2012).
4. An early warning scoring system must be in place to identify patients who are critically ill and who are, therefore, at risk of cardiorespiratory arrest. The use of the National Early Warning Score (NEWS) or equivalent, or a paediatric early warning score for children is recommended.
5. Every organisation must have a patient charting system that facilitates regular measurement and recording of early warning scores.
6. Every organisation must have a clear, universally known and understood, mandated, unambiguous, graded activation protocol for escalating monitoring or summoning responses to deteriorating patients. Its use should be standardised across each organisation.
7. The use of a standardised method for communicating information about deteriorating patients (e.g. SBAR, RSVP) between staff members is essential.
8. When acute clinical crises are identified by clinical triggers or other indicators, a 999 ambulance must be called if there is no designated resuscitation team.
9. Every 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 onsite/on call doctors and nursing staff and include when and how to call for an out of hours or ambulance service. The reasons for non-escalation must be documented clearly in the case notes if this practice is not followed.

Standards

1. Unless the organisation that delivers community hospital care is situated on the same site as an acute hospital which provides a resuscitation team that is specifically contracted to deliver an on call service, a 999 ambulance should be called immediately for any patient who collapses. In the interval before an ambulance arrives, staff should be capable of deploying the skills that are identified in paragraph 4 below.
2. The Resuscitation Service Structure must determine the composition of the resuscitation team/responding personnel. This is likely to vary depending on location and clinical need. All clinical facilities must have access to an outside telephone line to summon the 999 ambulance service. A 999 ambulance must be called for any cardiorespiratory arrest unless there is a local resuscitation team available.
3. The RO must be informed of all cardiorespiratory arrests.
4. The staff who respond immediately must have the following minimum skills:
   • CPR,
   • defibrillation (automated external defibrillation),
   • basic airway interventions including bag-mask ventilation and/or supraglottic airway,
   • skills required for immediate post- resuscitation care.
   • The following skills are recommended, and their need should be determined locally:
     • intravenous cannulation,
     • intraosseous access,
     • drug administration.
5. The designated responding personnel must be summoned in response to every cardiorespiratory arrest or when patients collapse.
6. Activation of the designated responding personnel must also be part of the local escalation plan for patients whose conditions deteriorate.
7. Each community hospital organisation must ensure that the designated responding personnel are activated within 30 seconds of the call for help. 
8. The team leader is responsible for:
   • directing and co-ordinating each resuscitation attempt,
   • ensuring that current guidelines are followed,
   • ensuring the safety of those present, 
   • ending resuscitation attempts when indicated (if applicable to the individual’s clinical role and training),
   • documenting each attempt to resuscitate (including ensuring that audit and incident report are completed in a timely way and submitted),
   • communication with relatives,
   • handover of care to other clinical teams,
   • diagnosis and documentation of death if appropriate.
9. Some of these responsibilities may require delegation to other team members (e.g. death certification by a registered doctor).
10. Each organisation should have a policy on providing support for relatives during resuscitation attempts. The designated responding personnel are responsible for ensuring compliance with that policy.
11. The designated responding personnel should arrange patients’ transfer after their resuscitation.
12. Team debriefings of designated personnel are recommended. The exact mechanism (e.g. end of each event, end of each shift, weekly) must be determined locally.
13. Every organisation that delivers community hospital care must ensure that a complete and detailed record of each cardiorespiratory arrest is retained within relevant patient’s clinical records. Collection of data at the time of arrest is recommended for audit.

Standards

1. Unless organisations that deliver community hospital care are situated on the same site as an acute hospital, a 999 ambulance should be called immediately to each child who collapses or deteriorates (see section on the resuscitation of children in standards for acute care)
2. Organisations have a duty to ensure that staff who work with children are trained accordingly.
3. The designated responding personnel must have knowledge about the equipment and doses of drugs (the availability of which should be determined by local policy) that children require. They must understand the differences in causes of, and treatment required by cardiorespiratory arrest in children as compared with adults.
4. The designated responding personnel must be familiar with their expected roles and should be trained specifically in paediatric resuscitation.
5. When resuscitating children, particular consideration must be given to allowing relatives or caretakers to be present during resuscitation attempts. 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.
6. The use of paediatric 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.
7. Where appropriate, a separate DNACPR form and/or Emergency Healthcare Plan (EHP) is recommended for children.

Standards

1. Organisations that deliver community hospital care must have policies and procedures in place for resuscitation in special circumstances such as care of the patient who is pregnant

Supporting information

1. Maternal Collapse in Pregnancy and the Puerperium (Green-top 56). Royal College of Obstetricians and Gynaecologists. 2011.
2. National Tracheostomy Safety Project. www.tracheostomy.org.uk
3. Regional Networks for Major Trauma NHS Clinical Advisory Groups Report. September 2010.
4. Truhlář A, Deakin CD, Soar J, Khalifa GE, Alfonzo A, Bierens JJ, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP; Cardiac arrest in special circumstances section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015 Oct;95:148-201.

After successful resuscitation, patients must be transferred to acute hospitals for more specialised care. Transfers must be carried out by the 999 ambulance service, a retrieval team, or by local arrangements. All transfers should follow the appropriate national guidance.

In all cases, organisations should have systems in place to ensure handover of care and safe transfer.

Supporting information

1. Association of Anaesthetists of Great Britain and Ireland (AAGBI) Safety Guideline – Interhospital Transfer. 2009. www.aagbi.org/
2. Intensive Care Society. Guidelines for the transport of the critically ill adult (3rd Edition 2011). www.ics.ac.uk/
3. Paediatric Intensive Care Society. Standards for the care of critically ill children. 4th Edition, version 2. June 2010. https://picsociety.uk/wp-content/uploads/2015/10/PICS_standards_2010.pdf
    

Community hospital organisations must transfer to acute inpatient units all patients who have been resuscitated after a cardiorespiratory arrest for further post resuscitation care. Post cardiac arrest care must be based upon the current standards produced by the Intensive Care Society.

 Supporting information

Resuscitation Guidelines 2015. Resuscitation Council UK. 

Standards

Click here to view the equipment and drug list for cardiopulmonary resuscitation in community hospitals care.

Supporting tools

1. Resuscitation equipment checks in Raising the Standard: A compendium of audit recipes for continuous quality improvement in anaesthesia. https://www.rcoa.ac.uk/sites/default/files/documents/2019-09/CSQ-ARB-2012_0.pdf

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, 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. Healthcare professionals involved in making decisions about CPR must have appropriate training (determined by local policy) and competency in so doing, and similarly those who undertake the sensitive discussions with patients and staff who are 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.
4. Resuscitation Council UK has defined standards for recording decisions about CPR. It is recommended that decisions about CPR 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.
5. Healthcare organisations must have policies about CPR decisions and documents that are recognised by the other organisations so that decisions about CPR continue across organisational and geographic boundaries when patients are transferred from one setting to another. This must include the ambulance service, in particular, so that these decisions are respected during transfer.
6. Healthcare organisations must ensure that healthcare staff have access to appropriate stationery or electronic media for recording, accessing and reviewing decisions about CPR.
7. Healthcare organisations must ensure that patients and staff who are close to patients have ample opportunities to discuss resuscitation and decisions about CPR should they wish to, but that such discussions are not forced upon people who do not want them. Written information about resuscitation decisions, or information in other media (e.g. DVD or podcast) should be made readily available for patients and people who are close to them, but should not be used as an attempted substitute for sensitive, face-to-face discussions with suitably trained and competent healthcare professionals.

Standards

1. NCEPOD recommends that every CPR attempt is reported through healthcare organisations’ patient safety incident reporting systems. 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 supporting tools below.
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 (this is only appropriate if a community hospital organisation has access to a resuscitation team summoned by the use of 2222).
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 an appropriate level must be undertaken. The Resuscitation Service Structure must receive appropriate support to achieve this.

Standards

1. 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.
2. 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.
3. The organisation’s Resuscitation Service Structure can be a valuable source of advice for staff who are contemplating undertaking clinical research in resuscitation.

Supporting information

1. National Research Ethics Service. https://www.hra.nhs.uk/about-us/committees-and-services/res-and-recs/
2. National Research Ethics Service - Does my project require review by a Research Ethics Service Structure? https://www.hra.nhs.uk/approvals-amendments/
3. NHS Constitution for England 2015. www.gov.uk/government/publications/the-nhs-constitution-for-england

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.