Resuscitation Committee Research Articles

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey.

Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown. Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher exact test. Internet-based survey. U.S. PICU representatives (one per institution) involved in resuscitation systems of care. None. Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children's hospitals or dedicated children's hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%), and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 respondents (94%) report using patient weight, 23 (34%) patient age, and five (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to less than 60 kg, 17 (27%) at 60 to less than 80 kg, five (8%) at 80 to less than 100 kg, and eight (12%) at greater than or equal to 100 kg. Among those reporting using age, four (17%) switch at 14 to less than 16 years, five (22%) at 16 to less than 18, and six (26%) at greater than or equal to 18. Twenty-nine respondents (43%) report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require Advanced Cardiac Life Support (ACLS) certification for some/all code team responders compared with institutions that do not require ACLS certification (52% vs 22%; p = 0.02). The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.

Abstract 13163: Use of a QR Code Accessed Debrief Tool is Associated With Higher Rates of Debrief After In-Hospital Cardiac Arrest

Introduction: In-hospital cardiac arrest (IHCA) affects over 200 000 patients in the US annually. Approximately 20% will survive to hospital discharge, although outcomes vary between hospitals. Debriefing has been shown to improve resuscitation quality and teamwork and has been associated with improved IHCA outcomes. All IHCA at NYU Langone Health are attended by the ALERT team, a dedicated team of critical care nurses who perform active patient surveillance and respond to acute in-hospital emergencies. IHCA debriefs at NYU Langone Health have historically been performed on paper forms but were limited by low rates of compliance. As part of an ongoing quality improvement (QI) initiative, we designed and implemented an electronic debriefing tool for use after IHCA (eDebrief). Methods: The eDebrief tool was developed by the NYU Interdisciplinary Resuscitation Committee. The tool captures cardiopulmonary resuscitation (CPR) quality metrics, teamwork and leadership, use of resuscitation equipment (mechanical CPR, advanced airway adjuncts, and ultrasound), and outcomes. ALERT team nurses received an educational session and ad hoc refresher sessions if required. Data were collected at the conclusion of the event using an electronic device (iPhone, Apple, Cupertino CA). The tool is accessible using a QR code located on every code cart. Rates of IHCA debrief post-implementation (2/13/20-06/10/21) were compared to prior years (01/01/19 - 12/31/19 and 01/01/18-12/31/19). Results: The eDebrief tool was implemented on 2/13/20. During the post-implementation phase, there were 254 IHCA at NYU Langone Health. The eDebrief form was used in 175 events (69%). The debrief rate from previous calendar years were 38% and 42% for 2019 and 2018 respectively. Use of the eDebrief form has identified three targets for ongoing quality improvement and research projects: room overcrowding (identified in 64/175 IHCAs, 37%); ultrasound use (39/175 IHCAs, 22%); and optimization of mechanical CPR. Conclusions: Use of electronic debriefing is feasible at a large academic medical center and has been associated with increased uptake of IHCA debrief. Regular debriefs at our center have identified several targets for further quality improvement and research initiatives.

Abstract 326: Practice Variation in the Transition from Weight-based to Flat Dosing of Epinephrine During Cardiopulmonary Resuscitation in Pediatric Intensive Care Units

Introduction: Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations (0.01 mg/kg with a maximum dose of 1mg), but do not specify the age or weight at which adult (flat) dosing should be provided. Hypothesis: We hypothesized that there would be considerable practice variation in the transition from weight-based to flat dosing of epinephrine in pediatric ICUs (PICUs) and that more providers would prioritize weight than age in making this decision. Methods: We performed an IRB-exempt, multi-institution, internet-based survey. Recipients were U.S. PICU attending physicians (one per institution) involved in resuscitation system oversight. Proportions across categories were compared using Chi-square testing. Results: Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are children’s hospitals (free-standing or dedicated pediatric hospitals within combined hospitals) (67; 99%) and academic (55; 81%); 41 (60%) have PICU fellowship programs. Thirteen (19%) respondents are PICU medical directors, 16 (24%) are resuscitation committee members and 21 (31%) are PICU attendings with an interest in resuscitation. When choosing between weight-based and flat dosing, a significantly higher proportion of providers consider weight (64/68; 94%) vs. age (23/68; 34%) (p <0.01). Among those using age, there were no significant differences in the proportion of providers transitioning at 12 to <14 years of age (0, 0%), 14 to <16 (4, 17%), 16 to <18 (5, 22%) or ≥18 (6, 26%; p=0.82). Among those prioritizing weight, there was a significant difference between the proportion of providers transitioning at 50 to <60kg (28, 44%), 60 to <80kg (17, 27%), 80 to <100kg (5, 8%) or ≥100kg (8, 13%; p< 0.01). Twenty-nine (43%) institutions use an ideal body weight that is less than the patient’s actual weight when dosing epinephrine in obese patients. Conclusions: There is considerable practice variation in the transition from weight-based to flat epinephrine dosing during CPR in PICUs with most institutions using patient weight. Given the potential for large variation in amount of epinephrine delivered to these patients, prospective study is warranted to inform PALS guidelines.

Yenidoğanın Doğum Odasında Aspirasyon İlkelerinde Güncel Yaklaşımlar; Ebelerin Rol ve Sorumlulukları

Neonatatal mortalite istatistikleri incelendiğinde, önemli bir bölümünün yaşamın ilk günü meydana geldiği görülmektedir. Bu durum yenidoğanın doğum odasındaki bakım ve izleminin ne kadar önemli olduğunu ortaya koymaktadır. Doğum odasında yenidoğanlara yapılan uygulamalar arasında yer alan aspirasyon işlemi yaygın olarak kullanılmaktadır. Aspirasyon işlemine bağlı solunum ve dolaşım sisteminin çalışmasını olumsuz etkileyen birçok komplikasyon gelişebilmektedir. Bu açıdan yenidoğanda dikkatli uygulanması gereken bir girişimdir. Yıllar içerisinde yenidoğanlara doğum odasında yaklaşım uygulamaları değişiklik göstermiştir. Yenidoğan bakımına yön veren Dünya Sağlık Örgütü, Türk Neonatoloji Derneği, Amerikan Kalp Derneği ve Uluslararası Resüsitasyon Komitesi’nin güncel önerileri incelendiğinde, yenidoğanlara rutin aspirasyon işlemi önerilmemektedir. Ebelerin görev ve sorumlulukları arasında yenidoğanın ilk bakım ve muayenesi ve gerektiğinde acil resüsitasyon gerçekleştirmesi de yer almaktadır. Bu durum ebelerin yenidoğanın aspirasyon işleminde anahtar role sahip olduğunu göstermektedir. Bu açıdan ebelerin yenidoğanda aspirasyon ilkeleri hakkında ayrıntılı bilgi sahibi olması ve konuyla ilgili güncel yaklaşımları bilmesi önemli bir konudur. Aspirasyon yenidoğanlara doğum odasında oro-nazofarenks, endotrakeal ve mide içeriği aspirasyonu yöntemlerinde uygulanmakta ve ebelik bakımında önemli yer tutmaktadır. Bu makalede, yenidoğanın doğum odasında aspirasyon ilkelerinde güncel yaklaşımlar ve ebelerin rol ve sorumlulukları literatür bilgisi kapsamında derlenmiştir.

Saudi Heart Association, National Heart Center and National Cardiopulmonary Resuscitation Committee taskforce statement on CPR and resuscitation during COVID-19 pandemic.

Corona virus disease 2019 is a global pandemic, which affects around 2million individuals with a high death rate that exceeds 90,000 death cases across the globe. The Saudi Heart Association and the national cardiopulmonary resuscitation committee developed a taskforce to discuss the magnitude of clinical situation and CPR management on COVID-19 patients in a prehospital and in-hospital settings. Meanwhile, the taskforce aims to develop a nation-wide clinical guidance to be used by health care workers and untrained laypersons to resuscitate COVID-19 suspected and diagnosed patients.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department.

Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

Differences in implementation strategies of the European Resuscitation Council Guidelines 2015 in Danish hospitals - a nationwide study.

IntroductionGuideline implementation is essential to improve survival following cardiac arrest. This study aimed to investigate awareness, expected time frame, and strategy for implementation of the European Resuscitation Council (ERC) Guidelines 2015 in Danish hospitals.MethodsAll public, somatic hospitals with a cardiac arrest team in Denmark were included. A questionnaire was sent to hospital resuscitation committees one week after guideline publication. The questionnaire included questions on awareness of ERC Guidelines 2015 and time frame and strategy for implementation.ResultsIn total, 41 hospitals replied (response rate: 87%) between October 22 and December 22, 2015. Overall, 37% hospital resuscitation committees (n=15) were unaware of the guideline content. Most hospitals (80%, n=33) expected completion of guideline implementation within 6 months and 93% hospitals (n=38) expected the staff to act according to the ERC Guidelines 2015 within 6 months. In contrast, 78% hospitals (n=32) expected it would take between 6 months to 3 years for all staff to have completed a resuscitation course based on ERC Guidelines 2015. Overall, 29% hospitals (n=12) planned to have a strategy for implementation later than a month after guideline publication and 10% (n=4) hospitals did not plan to make a strategy.ConclusionThere are major differences in guideline implementation strategies among Danish hospitals. Many hospital resuscitation committees were unaware of guideline content. Most hospitals expected hospital staff to follow ERC Guidelines 2015 within six months after the publication even though they did not offer information or skill training to all staff members within that time frame.

Korean Cardiac Arrest Research Consortium (KoCARC): rationale, development, and implementation.

ObjectiveThis study aimed to describe the conceptualization, development, and implementation processes of the newly established Korean Cardiac Arrest Resuscitation Consortium (KoCARC) to improve out-of-hospital cardiac arrest (OHCA) outcomes.MethodsThe KoCARC was established in 2014 by recruiting hospitals willing to participate voluntarily. To enhance professionalism in research, seven research committees, the Epidemiology and Preventive Research Committee, Community Resuscitation Research Committee, Emergency Medical System Resuscitation Research Committee, Hospital Resuscitation Research Committee, Hypothermia and Postresuscitation Care Research Committee, Cardiac Care Resuscitation Committee, and Pediatric Resuscitation Research Committee, were organized under a steering committee. The KoCARC registry was developed with variables incorporated in the currently existing regional OHCA registries and Utstein templates and were collected via a web-based electronic database system. The KoCARC study population comprises patients visiting the participating hospitals who had been treated by the emergency medical system for OHCA presumed to have a cardiac etiology.ResultsA total of 62 hospitals volunteered to participate in the KoCARC, which captures 33.0% of the study population in Korea. Web-based data collection started in October 2015, and to date (December 2016), there were 3,187 cases compiled in the registry collected from 32 hospitals.ConclusionThe KoCARC is a self-funded, voluntary, hospital-based collaborative research network providing high level evidence in the field of OHCA and resuscitation. This paper will serve as a reference for subsequent KoCARC manuscripts and for data elements collected in the study.

Emergency response team: Quality of care and improvement

Background: As a part of a general quality-of-care improvement program at our institution, an Emergency Response Team (ERT) permanently on-call was launched since September 2012. The team is composed by two in-house on-call physicians, one cardiologist and one anesthetist, both trained in ACLS. Once ERT is activated, they join and support the residents in their resuscitation efforts. Resuscitation-trustee nurses belonging to each department support the ERT efforts and are responsible for maintaining medical records. All staff members fulfilled course requirements and participate in bi-annual refresher courses. An institutional Resuscitation Committee composed of senior ACLS instructors was named in order to protocolize, follow-up and improve the ERT implementation, organize ACLS and PALS courses to nurses and physicians from each hospital ward.

Survival trends and health care cost following out-of-hospital cardiac arrest in the United States: 1995–2013

Background: The international resuscitation committees have put forward multiple strategies to optimize health-care delivery and expenditure following cardiac arrest. We sought to identify national trends in survival and healthcare cost post out-of-hospital cardiac arrest (OHCA).

Part 7. Neonatal resuscitation: 2015 Korean Guidelines for Cardiopulmonary Resuscitation.

The following is a summary of the 2015 Korean Neonatal Resuscitation Guidelines. An extensive review of scientific evidence by experts of Neonatal Resuscitation Committee for the 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care including neonatologists, nurse, obstetrician, perinatologist, and anesthesiologist was performed to update the 2011 Korean Neonatal Resuscitation Guidelines.

G574(P) Improving patient care through paediatric simulation and multi-disciplinary resuscitation training based upon previous serious incidents at a district general hospital

Context The quality improvement project was undertaken at a District General Hospital and included staff who care for seriously sick or injured children including doctors and nurses working in general paediatrics, accident and emergency and anaesthetics. The appropriate initial assessment and resuscitation of serious ill and injured children together with on-going reassessment and emergency management are essential for reducing morbidity and mortality. Problem There was no integrated multi-disciplinary team (MDT) paediatric resuscitation training and several paediatric serious incidents had involved more than one department. Simulation training increases the acquisition of skills and provides a platform to review performance and make errors without compromising patient safety. Both the Department of Health and RCPCH recognise the importance of simulation training in improving patient safety through reducing human and system errors. High fidelity manikins can be monitored which significantly adds to their realism. Assessment of problem and analysis of its causes A retrospective review was undertaken by a paediatric trainee of all the paediatric serious incidents during a ten year period to identify common themes and key recommendations. The development of MDT resuscitation training was one of the principle recommendations to improve the emergency assessment and care provided to children. Intervention MDT paediatric resuscitation training sessions involving healthcare assistants, nurses, doctors and other allied healthcare professionals from general paediatrics, accident and emergency and anaesthetics were planned several months in advance through a consultation process. Dates and times were chosen to maximise trainee availability and minimise disruption to routine services. For MDT training in accident and emergency, strategies were implemented to ensure patient safety at all times. Resuscitation officers provided support and resuscitation equipment. The hospital switch board was notified so a simulated paediatric crash call could be initiated through the hospital paging system. Scenarios were developed based upon previous paediatric serious incidents to review whether key recommendations had been successfully implemented and sustained. The focus was on familiarisation with paediatric resuscitation equipment, drugs and guidelines in real time as well as teamwork, communication and leadership skills and dynamics between and within the different specialties. A pilot paediatric simulation MDT training session was also undertaken in the Education Centre. Strategy for change MDT paediatric resuscitation training was coordinated through the paediatric and emergency departments as well as the hospital resuscitation committee. Anonymous feedback through questionnaires was collected from participants. Measurement of improvement The MDT paediatric resuscitation and simulation training received very positive feedback: Excellent scenario, felt more real than other simulated scenarios I have attended. Participants found the MDT simulation training much more realistic than weekly departmental resuscitation training with 79% strongly recommending the simulation training compared with just 33% for the weekly departmental training. Effects of changes MDT paediatric resuscitation training was successfully implemented. A business case was developed for the purchase of a paediatric simulation manikin to improve the reality of the training. Lessons learnt MDT paediatric resuscitation training is a very valuable tool for improving teamwork and paediatric resuscitation skills. Paediatric high fidelity simulation training can enhance this further through providing a more realistic experience. Message for others MDT resuscitation training should be routine practice in district general hospitals. Basing scenarios on previous serious incidents is a useful way to review previous key recommendations. A business case can be developed by demonstrating improved experience through a pilot high fidelity simulation trainer.

Therapeutic hypothermia post-cardiac arrest: a clinical nurse specialist initiative in Pakistan.

The purpose of this project was to assess the feasibility of an evidence-based therapeutic hypothermia protocol in adult post-cardiac arrest (CA) patients in a university hospital in Pakistan. Cardiac arrest has a deleterious effect on neurological function, and survival is associated with significant morbidity. The International Liaison Committee of Cardiopulmonary Resuscitation and the American Heart Association recommend the use of mild hypothermia in post-CA victims to mitigate brain injury caused by anoxia. In Pakistan, the survival rate in CA victims is poor. At present, there are no hospitals in the country that use the evidence-based hypothermia intervention in adult post-CA victims. This pilot project of therapeutic hypothermia in adult post-CA patients was implemented in a university hospital in Pakistan by a clinical nurse specialist in collaboration with the cardiopulmonary resuscitation committee and the nursing leadership of the hospital. Various clinical nurse specialist competencies and roles were used to address the 3 spheres of influence: patient, nurses, and system, while executing an evidence-based hypothermia protocol. Process and outcome indicators were monitored to evaluate the effectiveness and feasibility of hypothermia intervention in this setting. The hypothermia protocol was successfully implemented in 3 adult post-CA patients using cost-effective measures. All 3 patients were extubated within 72 hours after CA, and 2 patients were discharged home with good neurological outcome. Adoption of an evidence-based hypothermia protocol for adult CA patients is feasible in the intensive care setting of a university hospital in Pakistan. The process used in the project can serve as a road map to other hospitals in resource-limited countries such as Pakistan that are motivated to improve post-CA outcomes. This experience reveals that advanced practice nurses can be instrumental in translation of evidence into practice in a healthcare system in Pakistan.

Implementation of resuscitation committees in Canary Islands Health Service (Canary Islands, Spain)

Implementation of resuscitation committees in Canary Islands Health Service (Canary Islands, Spain)

Hospital cardiac arrest resuscitation practice in the United States: A nationally representative survey

In-hospital cardiac arrest (IHCA) outcomes vary widely between hospitals, even after adjusting for patient characteristics, suggesting variations in practice as a potential etiology. However, little is known about the standards of IHCA resuscitation practice among US hospitals. To describe current US hospital practices with regard to resuscitation care. A nationally representative mail survey. A random sample of 1000 hospitals from the American Hospital Association database, stratified into 9 categories by hospital volume tertile and teaching status (major teaching, minor teaching, and nonteaching). Surveys were addressed to each hospital's cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer. A 27-item questionnaire. Responses were received from 439 hospitals with a similar distribution of admission volume and teaching status as the sample population (P = 0.50). Of the 270 (66%) hospitals with a CPR committee, 23 (10%) were chaired by a hospitalist. High frequency practices included having a rapid response team (91%) and standardizing defibrillators (88%). Low frequency practices included therapeutic hypothermia and use of CPR assist technology. Other practices such as debriefing (34%) and simulation training (62%) were more variable and correlated with the presence of a CPR committee and/or dedicated personnel for resuscitation quality improvement. The majority of hospitals (79%) reported at least 1 barrier to quality improvement, of which the lack of a resuscitation champion and inadequate training were the most common. There is wide variability among hospitals and within practices for resuscitation care in the United States with opportunities for improvement.

Assessing Safety Attitudes among Healthcare Providers after a Hospital-Wide High-Risk Patient Care Program

PurposeCardiopulmonary resuscitation (CPR) is commonly performed in high-risk, high intensity situations and is therefore a good procedure around which to develop and implement safety culture strategies in the hospital. The purpose of this study was to evaluate the impact of a hospital-wide quality improvement program on the management of sudden cardiac arrests by assessing healthcare providers' attitudes towards patient safety.Materials and MethodsThis study was designed as a prospective cohort study at a single academic medical center. The comprehensive hospital-based safety program included steps to identify areas of hazard, partner units with the Resuscitation Committee, and to conduct a Safety Attitudes Questionnaire (SAQ). The SAQ evaluated 35 questions in seven domains to assess changes in patient safety culture by comparing the results before and after the hospital-wide high risk patient care improvement program.ResultsThe response rates of the pre- and post-SAQ survey were 489 out of 1121 (43.6%) and 575 out of 1270 (45.3%), respectively. SAQ survey responses revealed significant improvement in all seven domains of the questionnaire (p-values of 0.006 and lower). In a subgroup analysis, doctors and nurses showed improvement in five domains. Both doctors and nurses did not show improvement in the "sharing information" domain.ConclusionA hospital-wide quality improvement program for high-risk, high reliability patient care involving CPR care was shown to be associated with a change in healthcare providers' attitudes towards patient safety. Through an immersive and active program on CPR care, change in healthcare providers' attitudes towards patient safety was initiated.

Advance care planning documentation adopted county-wide

IntroductionThe process of advance care planning is a vital and integral part of our practice. A need was identified for documentation to be developed locally to enable written records of...

Adult basic life support

Prompt and skilful resuscitation during cardiac arrest can make a significant difference between life and death. There have been important advances in the science of resuscitation and various international resuscitation committees have formulated evidence-based recommendations for the performance of basic life support. The revised guidelines published in the year 2005 have been designed to simplify cardiopulmonary resuscitation. In this article, we have summarized basic life support guidelines for adult victims.

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post-resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact 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 the prevention of cardiopulmonary arrest. 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. Resuscitation equipment 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 (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact 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 the prevention of cardiopulmonary arrest. 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. Resuscitation equipment 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 (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.