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Showing results for tags 'Resuscitation'.
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EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. For every 1000 babies born, 1-2 need assistance (2-10% of these need intubation). In this webinar we will explore learnings following a review of hypoxic ischaemic injuries (HIE) or early neonatal deaths (ENND). Register for the webinar
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Content ArticleResuscitation Council UK’s Guidelines guarantee that health and care professionals across the UK share the same knowledge base surrounding teamwork and practice. The 2021 Guidelines contain detailed information about basic and advanced life support for adults, paediatrics and newborns, as well as information on the use of Automated External Defibrillators and other topics. Executive summary of the main changes since the 2015 GuidelinesGuidelines ProcessEducationEpidemiology of cardiac arrestEthicsSystems saving livesAdult basic life supportAdult advanced life supportSpecial circumstancesPost-resuscitation carePaediatric basic life supportPaediatric advanced life supportNewborn resuscitation and support of transition of infants at birthContributors and Conflict of InterestReferences
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Content Article
Obstetric Cardiac Arrest quick reference guide
Mark Hughes posted an article in Maternity
Do all your staff receive training for the management of anaphylaxis as part of their mandatory training? Do you have a specific maternal cardiac arrest emergency call to include obstetricians and neonatologists? Do all resuscitation trolleys in your trust have a scalpel and umbilical cord clamps as an essential kit requirement? Are you aware of the obstetric cardiac arrest quick reference guide from the Resus Council, OAA and MBRRACE? Obstetric cardiac arrest is rare but devastating. This quick reference guidance, produced by Resuscitation Council UK and Obstetric Anaesthetists’ Association (and endorsed by MBRRACE), has been developed to aid Advanced Life Support providers response to this. It aims to help structure the team response, with reminders of modifications required for the pregnant patient and causes of cardiac arrest to consider. -
Content ArticleThis narrative review aimed to investigate adverse events in trauma resuscitation, evaluate contributing factors and assess methods, such as trauma video review (TVR), to mitigate adverse events. The authors found that, when integrated with standardised tools, TVR shows promise for identifying adverse events. They suggest that future research should prioritise linking trauma team performance to patient outcomes and developing sustainable TVR programs to enhance patient safety.
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News Article
Concerns over ‘essential’ newborn breathing equipment at one in five hospitals
Mark Hughes posted a news article in News
One in five recent inspections of maternity services have raised concerns over “essential” breathing equipment for newborn babies, HSJ has found. Care Quality Commission (CQC) inspectors have flagged fears over shortages and overdue maintenance of resuscitaire, a device commonly used by midwives if babies require additional support with breathing. Experts say the equipment should be immediately available to ensure safe resuscitation. The CQC itself said the lack of such equipment was impacting patient safety at some hospitals. Read the full story (paywalled) Source: HSJ, 31 May 2024 -
Content ArticleThis video shows CCTV footage of Bob being treated for a cardiac arrest on his way to watch a football match at the AMEX stadium in Brighton. The video could be used as a training tool to show how to start cardiopulmonary resuscitation (CPR) and how to use an automated external defibrillator (AED). The video highlights what the AED is analysing and then shocking, showing what happened to the electrical rhythm as it converts ventricular fibrillation (VF) to sinus rhythm. It also features the voice prompts from the cardiac arrest. Bob survived with a completely normal quality of life and was the seventh person (out of seven) at the AMEX stadium to have a cardiac arrest and survive with a normal quality of life. The video shows great team work and human factors interactions between the St John Ambulance volunteers who saved Bob's life, the stewarding team and paramedics.
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Content ArticleThis article in the journal Patient Safety describes a state-wide, population-based study into tracheostomy- and laryngectomy-related airway safety events. The Pennsylvania-based study aimed to assess the relationship of these events with associated factors, interventions and outcomes, to identify potential areas for improvement. The authors queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between 1 January 2018, and 31 December 2020. The authors found that the four most frequent tracheostomy-related complications were: unplanned decannulations, 71.4% uncontrolled bleeding/hemorrhage, 9.2% partial/total occlusion, 6.9% mucus plug/thick secretions, 6.9%. They concluded that in order to manage patient airways safely, staff need to be knowledgeable, confident and equipped with appropriate skills and equipment to respond promptly when there are complications. They discuss potential safety strategies to reduce the risk of complications and issues related to equipment, knowledge and communication.
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News Article
Betsi Cadwaladr did not discuss resuscitation decision with family
Patient Safety Learning posted a news article in News
A health board has apologised to the family of a patient after medical staff failed to consult with them over a decision not to resuscitate her. While the decision was clinically justified, the public services ombudsman for Wales said Betsi Cadwaladr health board did not discuss it with the patient and her family. The ombudsman, Michelle Morris, also upheld a complaint by the patient's daughter, identified only as Miss A, that her mother's discharge from Ysbyty Gwynedd in Bangor was "inappropriate" and that insufficient steps were taken to ensure her needs could be safely met at home. The final complaint, which was also upheld, was that medics failed to communicate with the family about the deteriorating condition of the patient, identified as Mrs B, which meant a family visit was not arranged before she died. In her report she said the Covid pandemic had contributed to the failings, but added "this was a serious injustice to the family". As well as apologising to the family, she asked that all medical staff at Ysbyty Gwynedd and Ysbyty Penrhos Stanley be reminded of the importance of following the proper procedure when deciding when a patient should not be resuscitated. Read full story Source: BBC News, 6 February 2023 -
News Article
Closing baby unit considered over safety concerns
Patient Safety Learning posted a news article in News
Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023 -
News Article
Do not resuscitate: Man choked to death after paramedics stood down
Patient Safety Learning posted a news article in News
Experts are calling for "do not resuscitate" orders to be scrapped, saying they are being misused and putting people's lives at risk. One woman told BBC News that her elderly father might still be alive if the DNR in his medical file had been properly checked. When Robert Murray began choking on a piece of fruit at breakfast, staff at his care home called 999. He'd stopped breathing and the ambulance service operator immediately sent paramedics to attend. But seconds later, the care home told the dispatcher that the 80-year-old had a do not resuscitate form (DNR) in his medical records. The paramedics were stood down. Mr Murray died minutes later. However, it was all a terrible mistake. It hadn't been made clear to the ambulance service that Mr Murray was choking - the DNR was only meant to apply should he have a cardiac arrest. Mr Murray's death, at a nursing home in Eastbourne in June 2021, is an example of what experts call "mission creep" in the use of DNR - also known as DNACPR (Do Not Attempt Cardiac Pulmonary Resuscitation) - decisions. Researchers from Essex University say some care home residents are "being inappropriately denied transfer to hospital or access to certain medicines" due to the recommendations. Read full story Source: BBC News, 16 May 2023 -
Content ArticleThese Quality Standards have been developed by the Resuscitation Council UK. They enable healthcare organisations provide a high-quality resuscitation service, with guidance tailored for different settings including acute care, primary care, dental care, mental health units, community hospitals and in the community.
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Content ArticleThis research explores how the COVID-19 pandemic has changed the ways doctors make end-of-life decisions, particularly around Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR), treatment escalation and doctors’ views on the legalisation of euthanasia and physician-assisted suicide. This research from Benjamin Kah Wai Chang and Pia Matthews was conducted between May and August 2021, during which COVID-19 hospital cases were relatively low and pressures on NHS resources were near normal levels. Data were collected via online survey sent to doctors of all levels and specialties, who have worked in the NHS during the pandemic. In total, 231 participants completed the survey. The research found that over half of participants reported making more patients DNACPR than prepandemic, and this was due, at least in part, to an increased focus on factors including patient age, Clinical Frailty Scores and resource limitations. In addition, a sizeable minority of participants reported that they now had a higher threshold for escalating patients to ITU and a lower threshold for palliating patients, with many attributing these changes to formative experiences gained during the pandemic. The study found that there has not been a statistically significant change in the views of clinicians on the legalisation of euthanasia or physician-assisted suicide since the start of the pandemic. The authors concluded that the COVID-19 pandemic appears to have altered several aspects of end-of-life decision making, and many of these changes have remained even as COVID-19 hospital cases have declined.
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News ArticleDoctors are less likely to resuscitate the most seriously ill patients in the wake of the pandemic, a survey suggests. Covid-19 may have changed doctors’ decision-making regarding end of life, making them more willing not to resuscitate very sick or frail patients and raising the threshold for referral to intensive care, according to the results of the research published in the Journal of Medical Ethics. However, the pandemic has not changed their views on euthanasia and doctor-assisted dying, with about a third of respondents still strongly opposed to these policies, the survey responses reveal. The Covid-19 pandemic transformed many aspects of clinical medicine, including end-of-life care, prompted by millions more patients than usual requiring it around the world, say the researchers. In respect of DNACPR, the decision not to attempt to restart a patient’s heart when it or breathing stops, more than half the respondents were more willing to do this than they had been previously. Asked about the contributory factors, the most frequently cited were: “likely futility of CPR” (88% pre-pandemic, 91% now); coexisting conditions (89% both pre-pandemic and now); and patient wishes (83.5% pre-pandemic, 80.5% now). Advance care plans and “quality of life” after resuscitation were also commonly cited. Read full story Source: The Guardian, 25 July 2022
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News ArticleWhen Susan Sullivan died from Covid-19, her parents’ world fell quiet. But as John and Ida Sullivan battled the pain of losing their eldest, they were comforted by doctors’ assurance that they had done all they could. It was not until more than a year later, when they received her medical records, that the family made a crushing discovery. These suggested that, despite Susan being in good health and responding well to initial treatments, doctors at Barnet hospital had concluded she wouldn’t pull through. When Susan was first admitted on 27 March 2020, a doctor had written in her treatment plan: “ITU (Intensive therapy unit) review if not improving”, indicating he believed she might benefit from a higher level of care. But as her oxygen levels fell and her condition deteriorated, the 56-year-old was not admitted to the intensive unit. Instead she died in her bed on the ward without access to potentially life-saving treatment others received. In the hospital records, seen by the Observer, the reason Susan was excluded is spelled out: “ITU declined in view of Down’s syndrome and cardiac comorbidities.” A treatment plan stating she was not to be resuscitated also cites her disability. For John, 79, a retired builder, that realisation was “like Susan dying all over again”. “The reality is that doctors gave her a bed to die in because she had Down’s syndrome,” he said. “To me it couldn’t be clearer: they didn’t even try.” Susan is one of thousands of disabled people in Britain killed by Covid-19. Last year, a report by the Learning Disabilities Mortality Review Programme found that almost half those who died from Covid-19 did not receive good enough treatment, including problems accessing care. Of those who died from Covid-19, 81% had a do-not-resuscitate decision, compared with 72% of those who died from other causes. Read full story Source: The Guardian, 10 July 2022
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old. Findings Findings of this investigation included: The administration of a blood transfusion as part of resuscitation requires a number of preparatory steps, including collecting the blood and undertaking various checks before using it. Inclusion in resuscitation training of a prompt for clinicians to consider the need for a transfusion, and to prepare for it if appropriate, may help reduce any delay. Involving members of neonatal teams (staff who specialise in the care of newborn babies) in multidisciplinary training in maternity units is not routine. Standardising their inclusion in such training would promote a shared understanding of relevant clinical information and ways of working. Recommendations The report makes the following safety recommendations: HSIB recommends that NHS Resolution, working with relevant specialities through the clinical advisory group, amends the maternity incentive scheme guidance for year five to include the neonatal team as one of the professions required to attend multi-professional training. HSIB recommends that the Resuscitation Council (UK)’s Newborn Life Support training course highlights that neonatal resuscitation teams should consider fetal blood loss in the event of neonatal resuscitation that includes chest compressions. In addition, this consideration should be included in the guidance to support the newborn life support algorithm.
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Content ArticleNon-traumatic cardiac arrest is a critical condition, and errors and safety incidents during resuscitation reduce patient survival rates. Systematic investigations of patient safety incidents during resuscitation are limited. This systematic review examines the characteristics and nature of patient safety incidents during real and simulated resuscitation. This review identified a range of types of patient safety incidents that occur during non-traumatic cardiac arrest resuscitation which can be categorised thematically to support work to address the potential for latent safety issues effecting resuscitation.
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Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. Latest case studies: Urgent/emergency care Delayed oxygenation of neonate during resuscitation when oxygen not ‘flicked’ on Equipment falling onto critically ill patients during intrahospital transfers Misapplication of spinal collars resulting in harm from unsecured spinal injury Ensuring compatibility between defibrillators and associated defibrillator pads Ensuring pregnant women with COVID-19 symptoms access appropriate care General medicine Harm from catheterisation in patients with implanted artificial urinary sphincters Confusion between different strength preparations of alfentanil Ensuring compatibility between defibrillators and associated defibrillator pads Distinguishing between haemofilters and plasma filters to reduce mis-selection Variation in use of cardiac telemetry Ceftazidime as a 24-hour infusion Tacrolimus – risk of overdose when converting from oral to intravenous route Haloperidol prescribing for confused/agitated/delirious patients Ensuring oxygen delivery when using two step humification systems Intensive care Ventilator left in standby mode Equipment falling onto critically ill patients during intrahospital transfers Ensuring compatibility between defibrillators and associated defibrillator pads Distinguishing between haemofilters and plasma filters to reduce mis-selection Sudden patient deterioration due to secretions blocking heat and moisture exchanger filters Anaesthetic machines used as ventilators: issues with circuit set up Importance of ‘tug test’ for checking oxygen hose when transferring a patient to a portable ventilator Ensuring oxygen delivery when using two step humification systems Obstetrics and gynaecology/midwifery Harm from prescribing and administering Syntometrine when contraindicated to woman with significantly raised BP Delayed oxygenation of neonate during resuscitation when oxygen not ‘flicked’ on Unnecessary caesarean section for breech presentation if not scanned on the day HIV prophylaxis in women and new-borns Ensuring compatibility between defibrillators and associated defibrillator pads Ensuring the safe use of plastic cord clamps at caesarean section Warning on the use of ethyl chloride during fetal blood sampling Ensuring pregnant women with COVID-19 symptoms access appropriate care Risk of babies becoming unwell following move to virtual home midwifery visits Paediatrics and child health Ensuring compatibility between defibrillators and associated defibrillator pads Risk of babies becoming unwell following move to virtual home midwifery visits Unintentional perforation of oesophagus in neonates from invasive procedures Chemical burn to a neonate from use of chlorhexidine Other Ensuring compatibility between defibrillators and associated defibrillator pads Infrared temperature screening to detect COVID-19
