What’s Documentation Got To Do With Cardiac Arrest Management?

• If the patient is breathing spontaneously and an SGA is not insitu deliver high flow oxygen via a non-rebreather oxygen mask (NRB) with 15 litres per minute of oxygen. As a rule, if the patient remains unconscious and requires airway care and supportive ventilation, use the BVM resuscitator. If the patient is conscious and does not need ventilation support or an airway device, use the NRB or medium concentration mask.

Circulation

With a return of pulse, wound sites and lacerations may start to bleed again. Consider external bleeding control measures may be required. For potential pelvic fractures, consider the SAM Pelvic splint/binder. For long bone fracture e.g. femur, consider the use of the CT-6 traction splint.

Disability and or exposure

• Consider if sufficient resources are available to conduct a secondary survey (including exposure and checking of the whole body). This is very important if the patient has a trauma mechanism. • Consider if manual spinal immobilisation, a cervical collar or a vacuum mattress is required. This is very important if the patient has a trauma mechanism. • Take and record a blood glucose level (BGL). If the patient is hypoglycemic consult with EOC Clinician. • Record other vital signs e.g. blood pressure (palpatory method as a minimum), pulse, respiration rate, pupil response to light and temperature (use tympanic thermometer stored in the Defibrillator case). • If trained, record ECG - Lead I, II, III with monitor (print 10-second strip of each). • Do not over warm the patient. It is not uncommon for patients post ROSC to be combative and agitated. This is normally due to the period of hypoxia during cardiac arrest. Continue with high flow oxygenation. At all times, be prepared for the patient’s condition to change and cardiac arrest to occur again. If the patient is unresponsive, stops breathing normally and shows no other signs of life, recommence cardiac arrest clinical practice protocol again (CPR and defibrillation). Do not rely on the presenting ECG on the monitor. Constantly reassess for signs of life.

Real-life resuscitation ROSC and care - London Ambulance [04:30 minutes] https://player.vimeo.com/video/295086583

It’s our ‘missing piece’.

Cardiac Arrest PCRs can be complex, with a lot of information to record, including treatment, reasoning, timings, mandatory data or declarations, and more. Trying to make sense of a PCR at a later time can sometimes feel like working on a jigsaw puzzle, and then finding you don’t have everything you need to complete the picture.

How do we measure our outcomes and modify our equipment, training and care if we don’t have an accurate picture of how we are performing? The information that’s written on a Patient Care Record is used to:

• Identify trends • Change practice • Drive research • Improve cardiac arrest survival. There is a diverse range of completion standards for cardiac arrest PCRs. While it is fair to recognise that there will be variations in structure or writing styles between clinicians, there is a clear need to set a standard and highlight common omissions.

While how you write your PCR will be up to you, some things are not negotiable and are required by policies, procedures, guidelines or legislation, or otherwise prevent meaningful review or invalidate research if left out.

Correct Patient Identification

National Safety and Quality Health Service Standards V2

Australian Commission on Safety and Quality in Health Care – NSQHS Standards – Communicating for Safety Standard – Correct identification and procedure matching – Action 6.05

https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/ correct-identification-and-procedure-matching/action-605

Correct patient identification is important not only for standards compliance and record-keeping, but has significant implications when applying Advance Care Directives, or to aid in establishing relevant history, e.g. information that might lead to identifying a reversible cause. Make sure you provide as much patient identification information as possible. Patient identification is an important part of clinical care. It is confirmation that clinical information on the case card matches the patient and that you have attended the right person. Best practice requires at least 3 approved patient identifiers – because we transfer care to other facilities/HCPs, we will strive for 4 approved patient identifiers. The approved patient identifiers we use in SAAS are: 1. Patient name (family and given name) 2. Date of birth 3. Gender

4. Address (including postcode). If unable to identify the patient – write ‘unknown’ in the name/address/dob fields. In these situations, as much detail as possible should be recorded on the PCR. Useful information for this is: • The location that the person was picked up from (recorded in the ‘from’ section). • The time the person was picked up (recorded in the ‘arrived scene/patient’ time). • The SAAS dispatch/event number, day and date. • Physical description of the person (in the clinical documentation section). Proper recording of patient identifiers is a requirement of NSQHS Standard 6 Communicating for Safety - Action 6.5

What has been missing or incomplete?

Some of the key areas on the front of the PCR are often missed or incomplete.

1. ID/Patient Information - Be sure to complete this every time.

While you’re here – always record patient weight (known or estimated). It’s not only a statistical tool but helpful for case reviews where weight-based drug doses are used – remember your PCR needs to a useful, reviewable document. 2. Event Number - Last 5 digits of the “1” number (underlined on MDT dispatch information); easy to search through EPAS system for patient management and follow up. This is in addition to the Dispatch “D” number. 3. Codes - The preferred option is to mark all codes with either a number or ‘00’. - What is it used for? o The first code (A) determines the type of bill a patient gets / if they get a bill. o The remaining codes, while time-consuming is important for any clinical auditing. A number or ‘00’ (not applicable) should be entered for all active codes rather than left blank. Non-active codes can be left blank or crossed out. - Examples of why these codes are useful: o If we think we need a new cardiac drug, the audit team will review all cardiac D coded cases (01-12) – it is currently the most effective way to ‘search’. o If SA Health wants to know how much violence and aggression SAAS operational staff encounter, the search will be for all K codes (01-04). o If we want to review the safety and suitability of doing trauma bypass, perhaps with the view of expanding the scope of practice (hypothetical example only), then the H code needs to be completed. No data = no evidence to support change in clinical practice. 4. Treatment Summary - Completing these makes the review of cases much easier when looking for trends or instances of drug administration or other treatment e.g. the easiest way to see if a patient required suction, or was given adrenaline, without needing to read PCR. 5. Cardiac Arrest box – Lack of compliance makes data collected less useful. If Bystander CPR or AED occurred before SAAS arrival, be sure to complete the relevant section.

Declaration of Life Extinct - We always plan for ROSC but sometimes we can’t always beat death and resuscitation will be terminated on site. A Declaration of Life Extinct may be added to the PCR by a Paramedic or ICP. If no ALS staff are onsite and you are instructed to terminate CPR by the EOC Clinician, you should document “CPR ceased at (insert time) as per instruction of EOC Clinician (insert name)”. You are however not declaring life extinct. The declaration must be personally completed and signed by the clinician making the declaration e.g. the Paramedic/ICP who does the examination, writes the declaration and sign it themselves. “…Declaration of life extinct is a significant legal responsibility and can only be completed and signed by a clinician who is present with the deceased and authorised to do so following their CPGs. This task cannot be delegated to a clinician who does not hold this authority. The EOC Clinician, State Duty Manager or Medical Officers are not able to “authorise” this by telephone consult or at the scene…”

Clinical Communications –Scope of practice and consult authorization [CLC-17-023]

Readability

Tell the whole story and make it legible. During cardiac arrest case reviews, PCR standards have varied enormously. It’s often hard to understand what was done, and why. They may as well have been written in another language. Some are very brief; some are long and detailed. Many are missing important details and because they are missing, make the PCR difficult or impossible to review in a meaningful way. Sometimes the missing information is annoying, or frustrating, other times it creates an impression of clinical error or omission. Some missing information makes statistical reporting impossible. Some of the information recorded on PCRs is required for medico-legal reasons, including a declaration of life extinct, controlled substance recording or coronial and court cases.

Who writes the PCR?

You’ve just worked as a team to manage a complex case, now who writes the paperwork? The PCR is a collaborative document but is much easier to understand or review if only one person writes it. Ideally, the senior or experienced clinical person involved in the case should write the notes, in consultation with others present. Regardless of who writes the PCR, the senior or most experienced clinician is always responsible for the overall management of the case, so should sign the PCR anyway. It is preferred that two signatures appear on the PCR; it helps to demonstrate collaboration and agreement. Be thorough, check you have included all relevant information and completed all of the relevant sections. This is another reason to have someone else check or read your PCR. If you fill up all 6 places on the RDR observation chart, use a second PCR, NOT a Clinical Notes Supplement. This allows continued monitoring of trends as well as ensuring compliance with Policy and Procedures. If you have performed a complex skill, or a significant event has occurred, document it thoroughly. Ensure to number PCR “1/2, 2/2” etc. ensuring others know there are multiple PCRs for the case. Be sure to attach your ECG code summary to all copies of the PCR and mark it with the patient identifiers, date and dispatch number. This is what makes it possible to review and understand your PCR at a later time. A reviewable document can be used to discover trends and develop improved systems. If you need more room, use Clinical Notes Supplements. If you record more than 6 sets of observations, you MUST use another PCR to allow them to be recorded on the RDR chart. • If you considered something, write it down. • If you did something, write it down. • If you did or did not get a result, write it down. • If you have made a decision, write it down and state why you made it.

We got a ROSC!!!!

Record the time you notice ROSC on your PCR • Either within your free text

Or

• In the Drugs or Intervention section

This data is being gathered and at this stage, there is no specific place to record it. We only ask that you write it somewhere. This means that if you have correctly filled out the Cardiac Arrest research box, and ROSC is ticked, the time will be looked for on review of the PCR.

Take away points

• Quality documentation can help to identify trends to improve practice and patient care • Your PCR is the only record of what you did, will it make sense years from now? • Remember to comply with policies, procedures and legal requirements • If it isn’t recorded, it didn’t happen All PCRs from cardiac arrest cases are returned in the orange cardiac arrest DX postage bag.