New standards for cardiopulmonary resuscitation
http://www.100md.com
《英国医生杂志》
Represent a milestone in resuscitation practice and training
A joint statement, Cardiopulmonary Resuscitation—Standards for Clinical Practice and Training, has been issued by the Royal College of Anaesthetists, Royal College of Physicians of London, the Intensive Care Society, and the Resuscitation Council (UK).1 This was endorsed by a further nine healthcare organisations including the National Patient Safety Agency and defines minimum standards for the delivery of resuscitation related services in healthcare institutions. Perhaps the only major omissions from this list are the Royal College of General Practitioners and the Royal College of Obstetricians. This is surprising given that most cardiac arrests occur out of hospital and that cardiac arrest of mothers has a potentially catastrophic outcome. However, the endorsement of these guidelines by so many national professional organisations is a milestone, and their implementation marks an advance in resuscitation practice and patient safety.
Since the first major report from the United Kingdom on resuscitation was introduced in 1987, considerable changes have taken place in the science and practice of resuscitation.2 These include founding of the United Kingdom and European resuscitation councils, development of evidence based clinical guidelines, the introduction of resuscitation related courses, and the establishment of resuscitation officers as an independent discipline. The new statement integrates these advances to produce patient focused guidance for those responsible for planning and delivering resuscitation services. Although the document focuses primarily on resuscitation in hospitals admitting acutely ill patients, its recommendations are relevant to other healthcare institutions that may be involved with resuscitation such as general practice surgeries, minor injury units, maternity hospitals, ambulance trusts, mental health units, and the military.
The main recommendations of the document form the basis for integrated resuscitation related practice (box). A local resuscitation committee should be responsible for the delivery of an effective audited response to a cardiac arrest. The committee should determine the level of resuscitation training required by staff, which must be in accordance with national guidelines and standards. Although the document could be criticised for not specifying the individual staff members or specialties that should comprise a cardiac arrest team, it takes a more modern, competency based approach to this contentious area. Evidence that formal structured resuscitation teams improve survival to discharge is limited, but organised cardiac arrest teams improve the rates of return of spontaneous circulation at cardiac arrest and are regarded as best practice.3 4 Resuscitation committees need to consider best methods of delivering these resuscitation skills on the background of changes such as the European Working Time Directive and "Hospital at Night" projects, which will limit the availability of appropriate clinical staff.5-7
Main recommendations
Healthcare institutions should have a resuscitation committee or be represented on one
Every institution should have at least one resuscitation officer, who is responsible for teaching and conducting training
Staff who come in contact with patients should be given regular resuscitation training appropriate to their expected abilities and roles
Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for its prevention
Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times
Clear guidelines should be available, indicating how and when to call for the resuscitation team
Cardiopulmonary arrest should be managed according to current national guidelines
Equipment for resuscitation should be available throughout the institution for clinical use and for training
The practice of resuscitation should be audited to maintain and improve standards of care
A "do not attempt resuscitation" policy should be compiled, communicated to relevant members of staff, used, and audited regularly
Funding must be provided to support an effective resuscitation service
Adequate funding, particularly of resuscitation officers, is vital to the effective implementation of these standards and is likely to require more investment, particularly in trusts, which already fail to meet current standards on resuscitation set by the Clinical Negligence Scheme for Trusts—a mutual financial pooling arrangement for NHS trusts.8 With the reduction in junior doctors' hours, the need for regular resuscitation training is likely to exacerbate the workload of trainers further.
The remit of this document extends beyond acute resuscitation procedures. Several retrospective studies have shown that cardiac arrests that occur in hospitals are rarely unheralded and are usually preceded by a physiological deterioration.9 10 The main causes of sub-optimal care are failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. 11 These failings have been dealt with in some hospitals by the introduction of medical emergency teams or outreach teams that have been shown to reduce morbidity, mortality, and rates of unexpected cardiac arrest.11 12 Recommendations to develop outreach teams should not be viewed as a substitute for adequate clinical teaching and training of junior doctors and nurses who have direct responsibility for the care of patients.
At the other end of the spectrum, recommendations for the appropriate management of patients for whom cardiopulmonary resuscitation is inappropriate or has been declined after prior discussion with the patient, are made. Guidance on this issue has already been issued and a "do not attempt resuscitation" policy should already be in place for patients where appropriate.13
Trusts' managers will need to ensure integration of these guidelines into action plans for clinical governance. Attainment of the standards has important implications for acute trusts, as they are likely to form part of future assessments by the clinical negligence scheme for trusts. Implementation of these guidelines will inevitably have cost implications, particularly in relation to equipment and staff training. Some of these costs will be offset by the ensuing reduction in premiums to the clinical negligence scheme, but training of staff is likely to require additional funding, which many trusts will struggle to meet in the current financial climate.
Hopefully these guidelines will improve early identification of patients who may progress to cardiac arrest and the provision of care for patients in whom resuscitation is attempted.
Charles D Deakin, consultant anaesthetist
Shackleton Department of Anaesthetics, Southampton University Hospital NHS Trust, Southampton SO16 6YD (charlesdeakin@doctors.org.uk)
Competing interests: CD is a member of the executive committee of the Resuscitation Council (UK).
References
Cardiopulmonary resuscitation—standards for clinical practice and training. London: Resuscitation Council (UK), 2004.
Resuscitation from cardiopulmonary arrest. Training and organization. A report of the Royal College of Physicians. J R Coll Physicians Lond 1987;21: 175-82.
Weng TI, Huang CH, Ma MH, Chang WT, Liu SC, Wang TD, et al. Improving the rate of return of spontaneous circulation for out-of-hospital cardiac arrests with a formal, structured emergency resuscitation team. Resuscitation 2004;60: 137-42.
Henderson SO, Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest? Resuscitation 2001;48: 111-6.
Catto G. Education and training within the European working time directive. BMJ 2002;325(suppl):s69. http://careerfocus.bmjjournals.com/cgi/content/full/325/7362/S69
Paice E, Reid W. Can training and service survive the European working time directive? Med Educ 2004;38: 336-8.
NHS Modernisation Agency. Hospital at night. www.modern.nhs.uk/scripts/default.asp?site_id=50&id=17048 (accessed 21 Feb 2005).
NHS Clinical Negligence Scheme for Trusts. www.nhsla.com/Claims/Schemes/CNST (accessed 1 March 2005).
Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 2002;54: 115-23.
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316: 1853-8.
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002;324: 387-90.
DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004;13: 251-4.
Decisions relating to cardiopulmonary resuscitation: a joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. J Med Ethics 2001;27: 310-6.
A joint statement, Cardiopulmonary Resuscitation—Standards for Clinical Practice and Training, has been issued by the Royal College of Anaesthetists, Royal College of Physicians of London, the Intensive Care Society, and the Resuscitation Council (UK).1 This was endorsed by a further nine healthcare organisations including the National Patient Safety Agency and defines minimum standards for the delivery of resuscitation related services in healthcare institutions. Perhaps the only major omissions from this list are the Royal College of General Practitioners and the Royal College of Obstetricians. This is surprising given that most cardiac arrests occur out of hospital and that cardiac arrest of mothers has a potentially catastrophic outcome. However, the endorsement of these guidelines by so many national professional organisations is a milestone, and their implementation marks an advance in resuscitation practice and patient safety.
Since the first major report from the United Kingdom on resuscitation was introduced in 1987, considerable changes have taken place in the science and practice of resuscitation.2 These include founding of the United Kingdom and European resuscitation councils, development of evidence based clinical guidelines, the introduction of resuscitation related courses, and the establishment of resuscitation officers as an independent discipline. The new statement integrates these advances to produce patient focused guidance for those responsible for planning and delivering resuscitation services. Although the document focuses primarily on resuscitation in hospitals admitting acutely ill patients, its recommendations are relevant to other healthcare institutions that may be involved with resuscitation such as general practice surgeries, minor injury units, maternity hospitals, ambulance trusts, mental health units, and the military.
The main recommendations of the document form the basis for integrated resuscitation related practice (box). A local resuscitation committee should be responsible for the delivery of an effective audited response to a cardiac arrest. The committee should determine the level of resuscitation training required by staff, which must be in accordance with national guidelines and standards. Although the document could be criticised for not specifying the individual staff members or specialties that should comprise a cardiac arrest team, it takes a more modern, competency based approach to this contentious area. Evidence that formal structured resuscitation teams improve survival to discharge is limited, but organised cardiac arrest teams improve the rates of return of spontaneous circulation at cardiac arrest and are regarded as best practice.3 4 Resuscitation committees need to consider best methods of delivering these resuscitation skills on the background of changes such as the European Working Time Directive and "Hospital at Night" projects, which will limit the availability of appropriate clinical staff.5-7
Main recommendations
Healthcare institutions should have a resuscitation committee or be represented on one
Every institution should have at least one resuscitation officer, who is responsible for teaching and conducting training
Staff who come in contact with patients should be given regular resuscitation training appropriate to their expected abilities and roles
Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for its prevention
Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times
Clear guidelines should be available, indicating how and when to call for the resuscitation team
Cardiopulmonary arrest should be managed according to current national guidelines
Equipment for resuscitation should be available throughout the institution for clinical use and for training
The practice of resuscitation should be audited to maintain and improve standards of care
A "do not attempt resuscitation" policy should be compiled, communicated to relevant members of staff, used, and audited regularly
Funding must be provided to support an effective resuscitation service
Adequate funding, particularly of resuscitation officers, is vital to the effective implementation of these standards and is likely to require more investment, particularly in trusts, which already fail to meet current standards on resuscitation set by the Clinical Negligence Scheme for Trusts—a mutual financial pooling arrangement for NHS trusts.8 With the reduction in junior doctors' hours, the need for regular resuscitation training is likely to exacerbate the workload of trainers further.
The remit of this document extends beyond acute resuscitation procedures. Several retrospective studies have shown that cardiac arrests that occur in hospitals are rarely unheralded and are usually preceded by a physiological deterioration.9 10 The main causes of sub-optimal care are failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. 11 These failings have been dealt with in some hospitals by the introduction of medical emergency teams or outreach teams that have been shown to reduce morbidity, mortality, and rates of unexpected cardiac arrest.11 12 Recommendations to develop outreach teams should not be viewed as a substitute for adequate clinical teaching and training of junior doctors and nurses who have direct responsibility for the care of patients.
At the other end of the spectrum, recommendations for the appropriate management of patients for whom cardiopulmonary resuscitation is inappropriate or has been declined after prior discussion with the patient, are made. Guidance on this issue has already been issued and a "do not attempt resuscitation" policy should already be in place for patients where appropriate.13
Trusts' managers will need to ensure integration of these guidelines into action plans for clinical governance. Attainment of the standards has important implications for acute trusts, as they are likely to form part of future assessments by the clinical negligence scheme for trusts. Implementation of these guidelines will inevitably have cost implications, particularly in relation to equipment and staff training. Some of these costs will be offset by the ensuing reduction in premiums to the clinical negligence scheme, but training of staff is likely to require additional funding, which many trusts will struggle to meet in the current financial climate.
Hopefully these guidelines will improve early identification of patients who may progress to cardiac arrest and the provision of care for patients in whom resuscitation is attempted.
Charles D Deakin, consultant anaesthetist
Shackleton Department of Anaesthetics, Southampton University Hospital NHS Trust, Southampton SO16 6YD (charlesdeakin@doctors.org.uk)
Competing interests: CD is a member of the executive committee of the Resuscitation Council (UK).
References
Cardiopulmonary resuscitation—standards for clinical practice and training. London: Resuscitation Council (UK), 2004.
Resuscitation from cardiopulmonary arrest. Training and organization. A report of the Royal College of Physicians. J R Coll Physicians Lond 1987;21: 175-82.
Weng TI, Huang CH, Ma MH, Chang WT, Liu SC, Wang TD, et al. Improving the rate of return of spontaneous circulation for out-of-hospital cardiac arrests with a formal, structured emergency resuscitation team. Resuscitation 2004;60: 137-42.
Henderson SO, Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest? Resuscitation 2001;48: 111-6.
Catto G. Education and training within the European working time directive. BMJ 2002;325(suppl):s69. http://careerfocus.bmjjournals.com/cgi/content/full/325/7362/S69
Paice E, Reid W. Can training and service survive the European working time directive? Med Educ 2004;38: 336-8.
NHS Modernisation Agency. Hospital at night. www.modern.nhs.uk/scripts/default.asp?site_id=50&id=17048 (accessed 21 Feb 2005).
NHS Clinical Negligence Scheme for Trusts. www.nhsla.com/Claims/Schemes/CNST (accessed 1 March 2005).
Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 2002;54: 115-23.
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316: 1853-8.
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002;324: 387-90.
DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004;13: 251-4.
Decisions relating to cardiopulmonary resuscitation: a joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. J Med Ethics 2001;27: 310-6.