Guidelines: In-hospital resuscitation

Authors
Carl Gwinnutt
Robin Davies
Jasmeet Soar

1. The guideline process

The process used to produce the Resuscitation Council UK Guidelines 2015 has
been accredited by the National Institute for Health and Care Excellence. The
guidelines process includes:

Systematic reviews with grading of the quality of evidence and strength of

recommendations. This led to the 2015 International Liaison Committee on
Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science with Treatment Recommendations.
1,2

The involvement of stakeholders from around the world including members

of the public and cardiac arrest survivors.
Details of the guidelines development process can be found in the
Resuscitation Council UK Guidelines Development Process Manual. 
These Resuscitation Council UK Guidelines have been peer reviewed by the
Executive Committee of Resuscitation Council UK, which comprises 25
individuals and includes lay representation and representation of the key
stakeholder groups.

2. Summary of changes since 2010 Guidelines

The 2015 Guidelines do not include any major changes to core in-hospital
resuscitation interventions since the previous guidelines published in 2010. 
The key changes since 2010 are:

Continuing emphasis on the use of rapid response systems for care of the
deteriorating patient and prevention of in-hospital cardiac arrest.
Continued emphasis on providing minimally interrupted high-quality chest
compressions throughout CPR: chest compressions are paused briefly only
to enable specific interventions. This includes minimising interruptions in
chest compressions to attempt defibrillation.

3. Introduction

These Guidelines are aimed primarily at healthcare professionals who are first to
respond to an in-hospital cardiac arrest and may also be applicable to healthcare
professionals working in other clinical settings. Resuscitation Council UK has
produced Quality Standards for cardiopulmonary resuscitation and training to
support the implementation of this guideline.

The use of rapid response systems for care of the deteriorating patient and
prevention of in-hospital cardiac arrest is specifically addressed in Prevention of
cardiac arrest and decisions about CPR. After in-hospital cardiac arrest the
division between basic life support (BLS) and advanced life support (ALS) is
arbitrary; in practice, the resuscitation process is a continuum. For all in-hospital
cardiac arrests, ensure that:

cardiorespiratory arrest is recognised immediately

help is summoned using a standard telephone number (e.g. 2222)3
CPR is started immediately and, if indicated, defibrillation is attempted as
soon as possible (within 3 min)

All in-hospital cardiac arrests should be reviewed as part of an audit and quality
improvement process. Details should be recorded after each event. The National
Cardiac Arrest Audit (NCAA) enables hospitals to collect standardised data and
monitor changes in cardiac arrest activity.

4. Sequence for a collapsed patient in hospital

An algorithm for the initial management of in-hospital cardiac arrest is shown in

Figure 1.

Figure 1. In-hospital cardiac arrest algorithm

1. Ensure personal safety

 There are very few reports of harm to rescuers during resuscitation.4        
Your personal safety and that of resuscitation team members is the first
priority during any resuscitation attempt.
Check that the patient’s surroundings are safe.
Put on gloves as soon as possible. Other personal protective equipment
(PPE) (eye protection, face masks, aprons, gowns) may be necessary
especially when the patient has a serious infection such as tuberculosis.
Follow local infection control measures to minimise risks.
Be careful with sharps; a sharps box must be available. Use safe handling
techniques for moving victims during resuscitation. Resuscitation Council UK
has produced Guidance for safer handling during cardiopulmonary
resuscitation in healthcare settings.

2. Check the patient for a response

If you see a patient collapse or find a patient apparently unconscious assess

if they are responsive (shake and shout). Gently shake their shoulders and
ask loudly: “Are you all right?”
If other members of staff are nearby it will be possible to undertake several
actions simultaneously.

3A. If the patient responds

Urgent medical assessment is required. Call for help according to local

protocols. This may include calling a resuscitation team (e.g. medical
emergency team (MET)).
While waiting for the team, assess the patient using the ABCDE (Airway,
Breathing, Circulation, Disability, Exposure) approach.
Give the patient oxygen. Use a pulse oximeter to guide oxygen therapy.5
Attach monitoring: a minimum of pulse oximetry, ECG and blood pressure.
Record vital signs observations and calculate the early warning score.
Obtain venous access and take blood samples for investigation.
Prepare for handover using SBAR (Situation, Background, Assessment,
Recommendation) or RSVP (Reason, Story, Vital signs, Plan).6,7

3B. If the patient does not respond

 Shout for help (if not done already).
Turn the patient on to their back.
Open the airway using head tilt and chin lift.
If there is a risk of cervical spine injury, establish a clear upper airway by
using jaw thrust or chin lift in combination with manual in-line stabilisation
(MILS) of the head and neck by an assistant (if enough people are
available). If life-threatening airway obstruction persists despite effective
application of jaw thrust or chin lift, add head tilt a small amount at a time
until the airway is open; establishing a patent airway, oxygenation and
ventilation takes priority over concerns about a potential cervical spine
injury.
Keeping the airway open, look, listen, and feel to determine if the victim is
breathing normally. This is a rapid check and should take less than 10
seconds:
Look for chest movement (breathing or coughing)
Look for any other movement or signs of life
Listen at the victim’s mouth for breath sounds
Feel for air on your cheek
If trained and experienced in the assessment of sick patients, check for
breathing and assess the carotid pulse at the same time. The assessment
should take less than 10 seconds whether you do a pulse check or not.
Agonal breathing (occasional, irregular gasps) is common in the early stages
of cardiac arrest and is a sign of cardiac arrest and should not be mistaken
for a sign of life. Agonal breathing and limb movement can also occur during
chest compressions as cerebral perfusion improves, but is not indicative of a
return of spontaneous circulation (ROSC).
Changes in skin colour (e.g. pallor, cyanosis) in isolation are not diagnostic
of cardiac arrest.8
If the patient is already attached to monitoring in a critical care area this will
add to rather than replace the assessment for signs of life.

4A. If there are signs of life or a pulse

Urgent medical assessment is required. Depending on the local protocols,

this may take the form of a resuscitation team.
While awaiting the team, assess and treat the patient using the ABCDE
approach.
Follow the steps in 3A whilst waiting for the team.
 The patient is at high risk of further deterioration and cardiac arrest and
needs continued observation until help arrives.

4B. If there are no signs of life and no pulse

Start CPR and get a colleague to call the resuscitation team and collect the
resuscitation equipment and a defibrillator.
If alone, leave the patient to get help and equipment.
Chest compressions in a patient whose heart is still beating are unlikely to
cause harm. However, delays in diagnosing cardiac arrest and starting CPR
will adversely affect chances of survival and must be avoided, so if there is
any doubt proceed as if there are no signs of life and no pulse.
Give 30 chest compressions followed by 2 ventilations.
The correct hand position for chest compression is the middle of the lower
half of the sternum.
This hand position can be found quickly if you have been taught to ‘place
the heel of one hand in the centre of the chest with the other hand on top’
and your teaching included a demonstration of placing hands in the middle
of the lower half of the sternum.
Ensure high quality chest compressions:
Depth of 5–6 cm
Rate of 100–120 compressions min-1   
Allow the chest to recoil completely after each compression
Take approximately the same amount of time for compression and
relaxation
Minimise any interruptions to chest compression (hands-off time)
If available, use a prompt and/or feedback device to help ensure high
quality chest compressions. The use of these devices should be part of a
hospital-wide quality improvement program that includes formal debriefing.9
Do not rely on palpating carotid or femoral pulses to assess the
effectiveness of chest compressions.10
Resume compressions without any delay; place your hands back on the
centre of the patient's chest.
If there are enough team members, the person doing chest compressions
should change about every 2 min or sooner if they are unable to maintain
high quality chest compressions. This change should be done with minimal
interruption to compressions. This should be done during planned pauses in
chest compression such as during rhythm assessment.
Use whatever equipment is available immediately for airway and ventilation
(e.g. a self-inflating bag-mask, or a supraglottic airway device and bag
according to local policy).
Use an inspiratory time of about 1 second and give enough volume to
produce a visible rise of the chest wall. Avoid rapid or forceful breaths.
Add supplemental oxygen as soon as possible.
There are usually good clinical reasons to avoid mouth-to-mouth ventilation
in clinical settings, and it is therefore not commonly used, but there will be
situations where giving mouth-to-mouth breaths could be life-saving (e.g. in
non-clinical settings). If there are clinical reasons to avoid mouth-to-mouth
contact, or you are unable to do this, do chest compressions until help or
airway equipment arrives. A pocket mask or bag-mask should be
immediately available in all clinical areas.
Tracheal intubation should be attempted only by those who are trained,
competent and experienced in this skill, and can insert the tracheal tube
with minimal interruption (less than 5 seconds) to chest compressions.
Waveform capnography must be used routinely for confirming that a
tracheal tube is in the patient’s airway and subsequent monitoring during
CPR. Waveform capnography can also be used to monitor the quality of CPR,
as an indicator of a ROSC and to help with determining prognosis during
CPR.
Once the patient’s trachea has been intubated, continue chest
compressions uninterrupted (except for defibrillation or rhythm checks when
indicated), at a rate of 100–120 min-1, and ventilate the lungs at
approximately 10 breaths min-1 (i.e. do not stop chest compressions for
ventilation). If a supraglottic airway (e.g. LMA) device has been inserted it
may also be possible to ventilate the patient without stopping chest
compressions.
As soon as a defibrillator arrives, apply the self-adhesive pads to the
patient's chest whilst chest compressions are ongoing. The use of adhesive
electrode pads will enable rapid assessment of heart rhythm compared with
the use of ECG electrodes.4
Once the pads are applied, pause briefly for a rapid rhythm check – aim for
a pause in chest compressions of less than 5 seconds.
If the rhythm is ventricular fibrillation/pulseless ventricular tachycardia
(VF/pVT), restart chest compressions. All other team members must now be
informed to stand clear of the patient whilst the defibrillator is charged and
a safety check performed. Once the defibrillator is charged and the safety
check completed, stop chest compressions, deliver the shock and restart
chest compressions immediately.
Do not delay restarting chest compressions to check the cardiac rhythm.
 Using a manual defibrillator, it is possible to reduce the pause between
stopping and restarting of chest compressions to less than 5 seconds.
If staff cannot use a manual defibrillator, use an automated external
defibrillator (AED). Switch on the AED and follow the audio-visual prompts.
Rescuers must not compromise on safety. All actions should be planned by
the team before pausing chest compressions. If there are delays caused by
difficulties in rhythm analysis or if individuals are still in contact with the
patient, chest compressions are restarted whilst a decision is made what to
do when compressions are next paused.
Continue resuscitation until the resuscitation team arrives or the patient
shows signs of life. Follow the Advanced life support algorithm.
Once resuscitation is underway, and if there are sufficient staff present,
prepare intravenous cannulae and drugs likely to be used by the
resuscitation team (e.g. adrenaline).
Use a watch or clock for timing between rhythm checks. Any interruption to
CPR should be planned. Assess the cardiac rhythm about every 2 minutes.
Identify one person to be responsible for handover to the resuscitation team
leader. Use a structured communication tool for handover (e.g. SBAR, RSVP).
Locate the patient’s records and ensure that they are available immediately
when the resuscitation team arrives.

4C. If the patient is not breathing and has a pulse

(respiratory arrest)

Ventilate the patient’s lungs (as described above) and check for a pulse
every 10 breaths (about every minute).
This diagnosis can be made only if you are confident in assessing breathing
and pulse or the patient has other signs of life (e.g. warm and well-perfused,
normal capillary refill).
If there are any doubts about the presence of a pulse, start chest
compressions and continue ventilations until more experienced help arrives.
All patients in respiratory arrest will develop cardiac arrest if the respiratory
arrest is not treated rapidly and effectively.

5. If the patient has a monitored and witnessed cardiac

arrest
If a patient has a monitored and witnessed cardiac arrest in the catheter
laboratory, coronary care unit, a critical care area, or whilst monitored after
cardiac surgery, and a manual defibrillator is rap-idly available:

Confirm cardiac arrest and shout for help.

If the initial rhythm is VF/pVT, give up to three quick successive (stacked)
shocks.
Rapidly check for a rhythm change and, if appropriate check for a pulse and
other signs of ROSC af-ter each defibrillation attempt.
Start chest compressions and continue CPR for 2 min if the third shock is
unsuccessful. These initial three stacked shocks are considered as giving
the first shock in the ALS algorithm.
This three-shock strategy may also be considered for an initial, witnessed
VF/pVT cardiac arrest if the patient is already connected to a manual
defibrillator – these circumstances are rare.
A precordial thump works only rarely.10 Delivery of a precordial thump must
not delay calling for help or accessing a defibrillator. Consider a precordial
thump only when it can be used without delay whilst awaiting the arrival of
a defibrillator in a monitored VF/pVT arrest. Using the ulnar edge of a tightly
clenched fist, deliver a sharp impact to the lower half of the sternum from a
height of about 20 cm, then retract the fist immediately to create an
impulse-like stimulus.

5. Background notes

Hospital and staff factors

The exact sequence of actions after in-hospital cardiac arrest depends on several
factors including:

location (clinical or non-clinical area; monitored or unmonitored patients)

skills of staff who respond
number of responders
equipment available
hospital system for response to cardiac arrest and medical emergencies
(e.g. MET, cardiac arrest team).
Location

Monitored cardiac arrests are usually diagnosed rapidly. Ward patients may have
had a period of deterioration and an unwitnessed arrest.11-19 Ideally, all patients
who are at high risk of cardiac arrest should be cared for in a monitored area
where facilities for immediate resuscitation are available. Patients, visitors, or
staff may also have a cardiac arrest in non-clinical areas (e.g. car parks,
corridors).

Delay in attempting defibrillation can occur when patients sustain cardiac arrest
in unmonitored hospital beds and in outpatient departments.20 In these areas
several minutes may elapse before a resuscitation team arrives with a
defibrillator and delivers a shock. Automated external defibrillation should be
considered to facilitate early defibrillation (aiming for shock delivery within 3 min
of collapse) in areas where staff have no rhythm recognition skills or use
defibrillators infrequently. However, an automated external defibrillator (AED)
should not be used in preference to a manual defibrillator when staff are present
who have rhythm recognition and manual defibrillation skills.

Skills of staff who respond

All healthcare professionals should be able to recognise cardiac arrest, call for
help, and start resuscitation. Staff should do what they have been trained to do.
For example, staff in critical care and emergency medicine may have more
advanced resuscitation skills than staff who are not involved regularly in
resuscitation in their normal clinical role. Hospital staff who attend a cardiac
arrest may have different competencies in managing the airway, breathing, and
circulation. Rescuers should use those resuscitation skills in which they have
been trained.

Resuscitation Council UK’s Immediate Life Support (ILS) course is aimed at the
majority of healthcare professionals who attend cardiac arrests rarely but have
the potential to be first responders or resuscitation team members.21 
Resuscitation Council UK’s Advanced Life Support (ALS) course is aimed at
doctors and senior nurses working in acute areas of the hospital and those who
may be resuscitation team leaders and members.22 The course is also suitable
for senior paramedics and some hospital technicians.

During training and clinical practice there should be a greater emphasis on non-
technical skills (NTS).23 These consist of situational awareness, decision making,
team working, team leadership, task management and communication. Tools
such as SBAR or RSVP should be used to ensure rapid effective communication
and handovers.

Number of responders

The single responder must ensure that help is on its way. If other staff are
nearby, several actions can be undertaken simultaneously. Numbers of hospital
staff tend to be fewer during the night and at weekends. This may influence
patient monitoring, recognition, treatment and outcomes. Data from the US
shows that survival rates from in-hospital cardiac arrest are lower during nights
and weekends.24 Several studies show that increased nurse staffing is
associated with lower rates of failure-to-rescue, and reductions in incidence of
cardiac arrest, pneumonia, shock and death.16,25

Equipment available

The equipment used for CPR (including defibrillators) and the layout of
equipment and drugs should be standardised throughout the hospital. A review
by Resuscitation Council UK of serious patient safety incidents associated with
CPR and patient deterioration reported to the National Patient Safety Agency
showed that equipment problems are a common contributing cause. All
resuscitation equipment must be checked regularly to ensure it is ready for use.
Specially designed trolleys or sealed tray systems improve speed of access to
equipment and reduce adverse incidents.26,27

Hospitals and teams must have monitoring and equipment for transferring
patients after they have been resuscitated. This includes portable monitors with
a minimum capability of pulse oximetry, ECG, and non-invasive blood pressure
measurement. In addition waveform capnography must be used for all patients
after tracheal intubation. For further information, refer to the Intensive Care
Society’s Guidelines for the Transport of the Critically ill Adult.

Resuscitation team

The resuscitation team may take the form of a traditional cardiac arrest team,
which is called only when cardiac arrest is recognised. Alternatively, hospitals
may have strategies to recognise patients at risk of cardiac arrest and summon a
team (e.g. MET) before cardiac arrest occurs. The term ‘resuscitation team’
reflects the range of response teams. In-hospital cardiac arrests are rarely
sudden or unexpected. A strategy of recognising patients at risk of cardiac arrest
may enable some of these arrests to be prevented, or may prevent futile
resuscitation attempts in those patients who are unlikely to benefit from CPR
(See Prevention of in-hospital cardiac arrest and decisions about CPR).

Surveys show that resuscitation teams rarely have formal briefings and/or
debriefings.28 Resuscitation team members should meet for introductions and
plan roles and responsibilities before they attend actual events. Team members
should also debrief after each event based on events during the resuscitation.
The aim should be to discuss problems and concerns openly and allow learning
and improvement in a constructive manner. Ideally this should be based on data
collected during the event.9

Diagnosis of cardiac arrest

Trained healthcare staff cannot assess the breathing and pulse sufficiently
reliably to confirm cardiac arrest.29-38 Agonal breathing (infrequent and irregular
gasps) is a pre-terminal event and common in the early stages of cardiac arrest.
It should not be confused as a sign of life/circulation.39-42 Agonal breathing can
also occur during chest compressions as cerebral perfusion improves, but is not
indicative of a ROSC. In addition, immediately after cardiac arrest the sudden
cessation of cerebral blood flow can cause an initial short seizure-like episode
that can be confused with epilepsy.8,43

Delivering chest compressions to a patient with a beating heart is unlikely to

cause harm. However, delays in diagnosis of cardiac arrest and starting CPR will
adversely effect survival and must be avoided.

High quality CPR

The quality of chest compressions during in-hospital CPR is frequently sub-
optimal and interruptions are often prolonged.44 Even short interruptions tochest
compressions can adversely impact on outcome and every effort must bemade
to ensure that continuous, effective chest compression is maintainedthroughout
the resuscitation attempt. Chest compressions should commence atthe
beginning of a resuscitation attempt and continue uninterrupted apart from a
brief pause for a specific intervention (e.g. rhythm check). Most interventions can
be performed without interruptions to chest compressions. The team leader
should monitor the quality of CPR, change the person providing chest
compressions every 2 minutes (during rhythm assessment) or sooner if the
quality of CPR is poor.

Defibrillation strategy

The length of the pre-shock pause (i.e. the interval between stopping chest
compressions and delivering a shock) is inversely related to the chance of
successful defibrillation. Every five-second increase in the duration of the pre-
shock pause almost halves the chance of successful defibrillation, therefore it is
critical to minimise the pause.45-48 The traditional lengthy ‘top-to-toe’ safety
check (e.g. “head, middle, bottom, self, oxygen away”) performed after the
defibrillator has charged and before shock delivery, will therefore diminish
significantly the chances of successful defibrillation. The pre-shock pause can be
substantially reduced by continuing compressions during charging of the
defibrillator and by having an efficient team coordinated by a leader who
communicates effectively. The safety check to avoid rescuer contact with the
patient at the moment of defibrillation should be undertaken rapidly but
efficiently. The post shock pause is minimised by resuming chest compressions
immediately after shock delivery. The process of shock delivery should be
achievable with less than a 5 second interruption to chest compressions.

Rescuers must not compromise on safety. Roles should be agreed by the team
members before attending a cardiac arrest. Always plan actions before stopping
chest compressions. If there are delays caused by difficulties in rhythm analysis
or if individuals are still in contact with the patient as the shock is about to be
delivered, restart chest compressions whilst plans are made to decide what to do
when compressions are next stopped. Rescuers should wear gloves during CPR
attempts but do not delay starting CPR if gloves are not immediately available.

Although there are no data supporting a three-shock strategy, it is unlikely that

chest compressions will improve the already very high chance of ROSC when
defibrillation occurs immediately after onset of VF/pVT. In circumstances where
rapid early defibrillation is feasible (e.g. cardiac catheter laboratory, in monitored
cardiac surgery patients, patients who have a witnessed and monitored VF/VT
and are already connected to a defibrillator) three rapid defibrillation attempts in
quick succession, may achieve ROSC without the need for chest compressions.

National Cardiac Arrest Audit

All in-hospital cardiac arrests should be reviewed and audited. The National
Cardiac Arrest Audit (NCAA) is a UK-wide database of in-hospital cardiac arrests
and is supported by Resuscitation Council UK and the Intensive Care National
Audit & Research Centre (ICNARC). NCAA monitors and reports on the incidence
of, and outcome from, in-hospital cardiac arrests in order to inform practice and
policy. It aims to identify and foster improvements in the prevention, care
delivery and outcomes from cardiac arrest. Participating in NCAA enables
hospitals to collect and contribute to national, standardised data on cardiac
arrest, enabling local and national improvements in patient care.49-53

6. Accreditation of the 2015 Guidelines

NICE has accredited the process used by Resuscitation Council UK to produce its
Guidelines development Process Manual. Accreditation is valid for 5 years from
March 2015. More information on accreditation can be viewed at
https://www.nice.org.uk/about/what-we-do/accreditation

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