‘APP ADMINISTRATIVE POLICY AND PROCEDURE ‘Applies To: VOR Department Ne an en TO ALL HEALTH CARE SS ———_ Been SEVIS | PROVIDERS AND OTHER SSS CONCERNED CARDIO PULMONARY RESUSCITATION DEPARTMENTS IN NGH Policy No: Replace Policy No: Pages: NAJRAN GENERAL o1 NEW - i HOSPITAL [Date Issued: Effective Dat Review Date: 08-11-1436H 08-12-1436H 08-12-1438H 1. PURPOSE: 41.1. To establish criteria for the initiation and termination of cardiopulmonary resuscitation (CPR) 1.2, To identify resources available to assist patient visitors/staff experiencing cardiopulmonary arrest. 1.3. To set forth the function and composition of the Hospital CPR team, and define coverage areas within the Hospital. 1.4. To ensure the efficiency and effective response to code blue call 2, DEFINITION: 2.1. Cardiopulmonary Resuscitation (CPR) - is an emergency medical procedure for a victim of cardiac and pulmonary arrest. 2.2. Code Blue - is the name given to an alert call for immediate assistance to save life of @ person who is found to be unresponsive with cardio pulmonary arrest. 2.3. Cardiac Arrest - is the sudden and complete loss of cardiac function. It may be due to ventricular fibrilation, asystole or electromechanical dissociation, 2.4, Respiratory Arrest - is the sudden and complete cessation of breathing. 2.8. Adult Code Blue - applies to all adults over 14 years old anywhere in the hospital 2.8. Pediatric Code Blue - applies to all children less than 14 years of age anywhere in the hospital inchiding Neonatal Intensive Care Unit (NICU) 2.7. Neonatal Resuscitation Program - an educational program that focuses on basic resuscitation skills for newly bom infants. 2.8, Basic Cardiac Life Support (BCLS) - This comprises: initial assessment, chest compression, airway maintenance, expired air ventilation (rescue breathing). Basic life Support implies that no equipment and no drugs are employed. 2.9. Advanced Cardiac Life Support (ACLS) - This comprises, in addition to Basic Life Support (BLS), usage of drugs and equipments during CPR including endotracheal tube, monitoring and DC shock 2.10. Witnessed Arrest - is one that is seen or heard by another person or an arrest that is monitored, 2.11. Assisted Ventilation - the act of inflating a patient's lungs by rescue breathing with or without a bag- mask device or any other mechanical device 2.12.Chest Compression (CC) - are performed by an individual during CPR in attempt to restore spontaneous circulation. 2.13, Drugs - refer to the delivery of any medication (by intravenous cannula, intraosseous needle, or tracheal tube) during the resuscitation event. 2.14, First Monitored Rhythm - is the first cardiac rhythm present when a monitor or defibrillator is attached toa patient after a cardiac arrest. [CPR POLICY MS-029 Page 1 of 11]VR... Department Name: TO ALL HEALTH CARE SEA sites CONCERNED PP ADMINISTRATIVE POI ‘APP ADMINISTRATIVE POLICY AND PROCEDURE ‘Applies To: MEDICAL SERVICES PROVIDERS AND OTHER CARDIO PULMONARY RESUSCITATION DEPARTMENTS IN NGH Policy No: Replace Policy No: Pages: NAJRAN GENERAL or ew 7 HOSPITAL Date Issue Effective Date: Review Date: 08-11-1436H 08-12-1436H 08-12-1438H 2.18.Return of Spontaneous Circulation (ROSC) - includes breathing (more than an occasional gasp), ‘coughing, or movement; may include evidence of palpable pulse or a measurable blood pressure. For the purposes of quality report - successful resuscitation or ROSC is defined as the restoration of a ‘spontaneous perfusing rhythm that results in more than an occasional gasp, fleeting palpated pulse, or arterial waveform, 2.16. Shockable/Non-shockable Rhythm - refers to the first monitored rhythm, which when analyzed by the Person interpreting the monitor/defibrillator, was found to be treatable by atternpted defibrillation ‘Shockable - Ventricular Fibrillation (VF) & pulseless ventricular tachycardia (VT); non-shockable either asystole or PEA 2.17.EMD - Electro Mechanical Dissociation: A condition at which there is cardiac rhythm seen on the monitor but no apical pulse could be felt and no heart sounds could be auscultated. It is also called as PEA. Pulseless electrical activity 2.18.Sustained ROSC - deemed to have occurred when chest compressions are not required for 20 Consecutive minutes and signs of circulation persist 2.18, MRP - Most Responsible Physician RESPONSIBILITY: 3.1. CPR Committee 3.2, Heads of Medical Staff Department 3.3, Medical Director POLICY: 4.1, The Hospital CPR Committee oversees all aspects of CPR, 4.2. The Medical Director works closely with the Nursing Director and other department head for CPR Team that will provide coverage for resuscitation at all imes (twenty-four hours round the clock). 4.3. CPR Is attempted on all persons experiencing cardiopulmonary arrest unless there is a valid “Physician's order to limit cardiopulmonary resuscitation’ in the medical record or a ‘Do Not ion" (DNR) decision has been made by the MRP in consultation with other staff and the Resusci patient/family and documented in the patient record, 4.4. All hospital staff should possess valid BCLS certificate to be able to take part in CPR. 4.5. Equipment should be available and operable at all imes to manage clinical emergencies requiring CPR. 4.6. The CPR Record should be kept in a designated location preferably on the top of the crash cart, so it ‘can be quickly found at the very beginning of resuscitation. [CPR POLICY MS-029) Page 2 of 14]N LIGY AND PROCEDURE ‘Applies 7 sh fa ee TO ALL HEALTH CARE = |_____ MEDICAL SERVICES| pROVIDERS AND OTHER SeaeesA [Titer CONCERNED CARDIO PULMONARY RESUSCITATION DEPARTMENTS IN NGH Policy No: Replace Policy No: Pages: NAJRAN GENERAL O1 Hew - 44 HOSPITAL Date Issued: Effective Dati Review Date: | 08-11-1436H 08-12-1436H 08-12-1438H 4.7. CPR Teams: 4.7.4, Adult CPR Team: 4.7.1.1. Team Leader: Medical Specialist on duty will assume overall responsibilty for the direction of the code. (Certified with ACLS) 47.1.2. Members 47.41.24. Physician On Duty In Charge Of The Patient, 471.22. ICU Resident On Duty 47.1.2.3, Anesthesiologist On Call 47.1.2.4, Staff Nurse Assigned To The Patient 47.1.2.5. Head Nurse! Charge Nurse 4.7.1.2.6. ICU Nurse, If Possible 47.1.2.7. Nursing Supervisor On Duty 4.7.2. Pediatric CPR Team: 47.2.1. Team Leader: Pediatric Specialist On CalliDuty (Certified in PALS) 47.22. Members: 47.221. Pediatric Resident On Duty 4.1.2.2.2. Staff Nurse Assigned To The Patient 472.23. Head Nurse/Charge Nurse Of The Department 47.224, NICU Nurse, If Possible 47.225. _Nutsing Supervisor On Duty 4.8. Coverage Areas: 4.8.1, Adult CPR Team is responsible for responding to Female Ward, Male Ward, ER, Delivery Room, Operating Room, OB Gyne Ward, OPD (except Pedia) and ICU. 4.8.2. Pediatric CPR Team is responsible for responding to Pedia Ward, Nursery, NICU, Pedia ER, ‘Operating Room and Pedia OPD. 4.9. CPR Initiation and Termination of Resuscitation: 4.9.1. When a patient's condition warrants, CPR is initiated by a physician, nurse, or other qualified paramedical personnel (BCLS certified). 4.9.2, Resuscitation efforts are terminated after successful restoration of circulation and ventilation 4.9.3. In the event CPR efforts are unsuccessful, CPR is terminated after concurrence that the patient is unresponsive to all therapeutic efforts by the CPR Team. (Cer POLICY MS-025. Page Sof 11]