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Saving lives safely during COVID-19: CPR flowcharts explained

22 October, 2020
CPR in healthcare setting during COVID-19

Why were the flowcharts developed?

The Taskforce received feedback from hospital and community representatives citing a hesitation to commence resuscitation of people in cardiac arrest during the COVID-19 pandemic, stemming from concerns about infection risk for responders. There was a clear need to provide healthcare providers, healthcare workers and members of the community with clear, national consensus guidance on resuscitation principles during the COVID-19 pandemic and key changes in the management of cardiac arrest.

Who are they designed for?

Healthcare setting flowcharts

The flowcharts are intended to guide healthcare providers and healthcare workers so that they feel confident, supported and are prepared for the situation where a person with COVID-19 arrests in a hospital, primary care clinic or aged care facility. The guidance in the flowcharts will ultimately impact patients who are likely to have better outcomes if resuscitation efforts are not delayed.

Community flowchart

The flowchart is intended for members of the public who are trained first responders so that they feel confident to commence resuscitation on people who arrest at home or in the community during the COVID-19 pandemic.
People who arrest are likely to have better outcomes if resuscitation efforts are not delayed.

How were they developed?

In collaboration with the Infection Control Expert Group (ICEG), the Taskforce established a dedicated Cardiac Arrest Working Group with membership spanning Australian experts in emergency care, intensive care, anaesthetics, infectious diseases and retrieval. The working group drew on the infectious diseases and infection prevention and control expertise provided by ICEG.

A series of video conferences were held with the Working Group from June to September 2020 to consider existing guidance on CPR during the COVID-19 pandemic (national and international) and to develop an agreed set of national recommendations.

The Taskforce consulted broadly to ensure that the national guidance would be acceptable to all Taskforce member organisations while remaining consistent with national guidance on the use of Personal Protective Equipment (PPE) during the pandemic.

What are the key points of each chart?

Preparedness for CPR during the COVID-19 pandemic

  • This flowchart outlines overarching principles that apply to cardiopulmonary resuscitation (CPR) for adults with confirmed COVID-19.
  • This advice has been developed for use in hospitals, but can be applied where appropriate, in other settings such as primary care and allied health clinics, quarantine hotels, and aged care facilities.
  • Preparedness for CPR delivery in a time of COVID-19 is key to facilitating a rapid response whilst protecting staff from the risk of infection.
  • Standard infection prevention control precautions apply to all patients at all times.

CPR of adults with COVID-19 in healthcare setting

  • This guidance applies to adults with confirmed COVID-19.
  • The guidance for first responders is for healthcare workers trained in Basic Life Support, in healthcare settings including hospitals, primary care clinics, and aged care facilities.
  • The guidance for ongoing resuscitation is for healthcare workers trained in Advanced Life Support.
  • Maximise staff safety and commence chest compressions as soon as possible, except where resuscitation is likely to be futile or there is a documented DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) for the patient.
  • Undertake resuscitation procedures according to the level of PPE worn by responders.
  • For CPR in settings such as quarantine hotels or a person’s own home, refer to BASIC LIFE SUPPORT FOR ADULTS IN THE COMMUNITY DURING THE COVID-19 PANDEMIC flowchart.

Basic life support for adults in the community during the COVID-19 pandemic

This guidance is for members of the public who are trained first responders. It was developed in collaboration with the Australian Resuscitation Council.

Key messages:

  • delayed resuscitation is associated with poorer outcomes for the person in cardiac arrest
  • any attempt at resuscitation is better than no attempt.

If you’ve done Basic Life Support (BLS) training and are willing to jump in to help save a life, then don’t hesitate. Our advice is to call for help, start chest compressions if you’re willing to do so, and get someone to fetch a defibrillator if one is handy.

The same DRSABCD principles apply during the COVID-19 pandemic with only a couple of modifications if you are concerned about getting COVID-19 from the person in arrest.

Points of difference if the person may have COVID-19:

  • D – Dangers? If you have a mask, make sure you are wearing it correctly before you start.
  • B – Normal Breathing? Look for breathing (chest movements) but do not place your face or hand near the person’s mouth or nose to listen or feel for breathing.
  • C – Start CPR. Perform chest compressions only (no rescue breaths)

What needs to be done differently in healthcare settings?

The key message is to maximise staff safety but do not delay resuscitation.

Ongoing resuscitation involves aerosol-generating procedures and therefore contact, droplet & airborne precautions are required. Any first responders who do not have appropriate PPE must leave the area before any additional resuscitation techniques commence.

Preparedness of health care providers is critical. This means ensuring that the wishes of patients and their family in terms of treatment plans and advanced care directives are documented, understood and communicated; health care workers receive life support training incorporating PPE use; and resuscitation equipment is readily available together with appropriate PPE.

What do these flowcharts add to CPR advice developed early in the pandemic?

The Taskforce flowcharts contain consensus recommendations from resuscitation experts across Australia, representing metropolitan, regional, rural and remote settings. The guidance was developed with broad consultation, incorporating input from government, consumers and healthcare workers in hospitals, primary care and aged care facilities and all member organisations of the Taskforce. The flowcharts were developed in partnership with ICEG and are consistent with national advice regarding PPE.

The flowcharts have been developed with end users in mind, and are printable in A3 (healthcare setting flowcharts) and A4 (community flowchart) formats.

Unlike other guidelines, the Taskforce undertakes weekly surveillance for new evidence relating to areas of contention (such as whether chest compressions pose a risk with regard to disease transmission) and is committed to regular flowchart updates that reflect current knowledge.

Which organisations were key contributors to the development of the flowcharts?

Membership of the Working Group included experts in emergency, intensive care, anaesthetics and retrieval, representing metropolitan, regional, rural and remote settings across Australia. The flowcharts were developed in partnership with the Infection Control Expert Group (ICEG) providing specialist infectious diseases and infection prevention and control expertise, and have also drawn heavily from the basic and advanced life support guidance issued by the Australian Resuscitation Council.

In addition, existing CPR and infection control guidance from each of the following bodies was discussed by the Working Group and taken into consideration when developing the flowcharts:

These flowcharts are only for adults, why haven’t they been developed for children?

There is currently very little experience in Australia of CPR for paediatric patients with COVID-19.

Guidance is different for children where, often, a parent or carer is the first responder and will have been exposed to the infected child already and will be more willing to resuscitate without hesitation. Whereas early defibrillation and compression-only CPR is advised for adults with confirmed COVID-19, defibrillation is rarely indicated for children and rescue breaths are essential.