Resuscitation of those with COVID-19 in health care settings – Summary of recommendations.

Overarching principles

1. All workers in health and disability roles and settings should be vaccinated against COVID-19 as required by The COVID-19 Public Health Response (Vaccinations) Order 2021.
2. Ensure early conversations and decision making regarding goals of care and resuscitation plans. An age limit for resuscitation is not recommended, but co-morbidities, futility and patient wishes should be considered for each patient.
3. Those with COVID-19 like symptoms, who are at risk of acute deterioration or cardiac arrest, should be identified as soon as possible. Management steps should include prevention of cardiac arrest and avoidance of resuscitation without Personal Protective Equipment (PPE).
4. Anyone who is known or suspected of having COVID-19 should be cared for by those wearing PPE as outlined in the NZ Ministry of Health Infection Prevention and Control (MoH IPC) requirements. All clinicians should wear contact and airborne precaution PPE before entering the room of a COVID-19 positive patient. This includes a P2/N95 particulate respirator mask, eye protection, a long sleeve fluid resistant gown and gloves. Those who are required to wear a P2/N95 particulate respirator mask should have undertaken the requisite fit testing and be trained in fit checking.
5. Patients without COVID-19 infection, who have an in-hospital cardiac arrest (IHCA), have a much better chance of survival if standard resuscitation procedures are followed (early CPR, early defibrillation, good quality CPR, good teamwork). The standard NZ Resuscitation Council Advanced Life Support algorithm and guideline should be used.

Resuscitation management

• Wearing contact and airborne precaution PPE, assess the collapsed person for response and normal breathing, without placing ear and cheek close to the person’s mouth and nose. If unresponsive and normal breathing is absent, call for help.

• If a defibrillator is immediately available do not delay early defibrillation of shockable rhythms. Shocks may be delivered prior to starting chest compressions.

• Good quality chest compressions should be commenced. If an oxygen mask is on the person’s face, leave this in place until help arrives. Consider covering this with a surgical mask. If a view of the mouth and nose is obscured, regularly check the patient’s airway for vomit or secretions.

• Restrict the number of rescuers in the room with the collapsed person. A gatekeeper should be allocated to do this.

• Ventilations with a bag-mask device should be performed by two rescuers where possible – one rescuer using two hands to hold the mask and ensure a tight mask seal, and the second rescuer alternating between doing compressions and squeezing the bag.

• An appropriate heat and moisture exchanging (HME) viral filter must be connected to any positive pressure oxygen delivery device, as close to the patient as possible. Ensure that all connections are secure.

• Prolonged bag-mask ventilation should be avoided. A supraglottic airway (SGA) should be considered if an experienced person is available to insert it.

• For ventilation with a bag-mask or supraglottic airway, pause chest compressions for ventilation using a 30:2 compression to ventilation ratio in adults and a 15:2 ratio in infants and children. 

• A tracheal tube may be less likely to generate additional respiratory particles than a supraglottic airway or bag-mask ventilation. Airway and ventilation interventions should be performed by the most skilled provider to ensure a high first attempt insertion success rate, and minimize aerosol generation. Consider methods that enable providers to remain further from the patient’s mouth, such as video laryngoscopy. Ensure an adequate cuff pressure to prevent leaks.

• Mechanical CPR devices may be useful to reduce the number of health care workers present during resuscitation. They should only be used when staff are adequately trained in their use.

• Apply the NZ Resuscitation Council Advanced Life Support algorithm throughout the resuscitation. When no reversible cause of cardiac arrest can be identified and treated, the appropriateness of ongoing resuscitation and the termination of resuscitation should be considered. 

• Clean or dispose of equipment as required by MoH IPC measures. Remove all PPE safely to avoid self-contamination and thoroughly wash hands.

• All clinicians involved in the resuscitation should have their names and contact details recorded to facilitate appropriate MoH IPC follow up if needed.

• MoH IPC requirements for the management of deceased patients must be adhered to.

• Post resuscitation debrief is encouraged.

NZ Resuscitation Council, December 2021

Sources

Couper K,Taylor-Phillips S et al (ILCOR), COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Resuscitation. 2020;151:59-66.

ILCOR – International Liaison Committee on Resuscitation: COVID-19 consensus on science, treatment

recommendations and task force insights. Resuscitation. 2020;151:145-147.

RCUK – Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in acute hospital

settings. (Reviewed August 2021).

National COVID-19 Clinical Evidence Taskforce/ICEG Australia – Cardiopulmonary Resuscitation Of Adults With Covid-19 In Healthcare Settings V2.1

NZ Ministry of Health, COVID-19: Infection prevention and control recommendations for health and disability care workers, December 2021

Update - What does the COVID-19 Protection Framework mean for Resuscitation and First Aid Training and Practice

Please note: The information below does not supersede advice from the government or your organisational protocol. As the COVID-19 response evolves, our recommendations may change. Please consider this when reviewing the following statement.

As New Zealand moves to the next stage of our COVID-19 response, the Protection Framework (traffic lights), high rates of vaccination are New Zealand’s key tools in protecting people and minimising the spread of COVID-19. It continues to remain important that those that respond to cardiac arrest and learners on training courses understand that providing early defibrillation and a combination of chest compressions and rescue breaths gives the best chance of survival to someone in cardiac arrest. Early intervention continues to be strongly recommended. 

In many cases of out-of-hospital collapse the person in cardiac arrest will be a loved one or known to the rescuer. In that situation the rescuer may be willing to give mouth-to-mouth breaths. This continues to give the best chance of survival, particularly for children. Those responding in an in-hospital setting should have access to appropriate personal protective equipment and airway and ventilation adjuncts.

The NZ Resuscitation Council’s advice to all training providers is that:

• A risk assessment should be completed for all courses and providers should ensure they comply with their local health service, regional and national infection control requirements 
• Record keeping and the use of QR codes and the tracer app scanning should be required
• The COVID-19 Public Health Response (Vaccinations) Order 2021 requires workers in health and disability roles and settings to be vaccinated against COVID-19. The order extends to many education settings. While providers are required to make their own risk assessments, resuscitation and first aid training requires close-proximity interactions. The Council strongly recommends every instructor and learner is vaccinated regardless of their employment and vaccination passes should be required
• Strict hygiene practice is important before, during and following provider courses to protect against all infections
• Anyone who is sick, waiting for COVID-19 test results or has been asked to self-isolate should stay home, and not go to educational facilities.

In addition:

At Red 

• Classroom and workshop activities should be managed to ensure the requirements of physical distancing. Capacity limits are based on the maximum number of people who could occupy the space if each person was 1 metre apart (learners do not have to keep 1 metre apart). This may require small classes and workshops of 10 people or less
• Face coverings should be required - including in teaching and learning spaces
• Workplace-based learning and scenarios that are on-site or face-to-face must be managed within the COVID-19 related restrictions being applied to that workplace. 

At Orange and Green

• Classroom and workshop activities should be managed to ensure capacity limits taking into account the community transmission and vaccination rates in the area and other public health requirements that may be imposed (for example physical distancing, face coverings, ventilation and vaccination)
• Face coverings should be encouraged
• Workplace-based learning and scenarios that are on-site or face-to-face must be managed within the COVID-19 related restrictions being applied to that workplace.

For NZ Resuscitation Council CORE Advanced Instructors we reaffirm our previous advice:

• For the demonstration and assessment of adult and childhood collapse management we acknowledge that, even with disposable masks and good hygiene practices, a learner may still feel uncomfortable demonstrating expired air ventilations into a manikin. Our experience is that this is rare but this concern may be exaggerated as the virus becomes endemic
• To gain NZ Resuscitation Council CORE Advanced or CORE Immediate certification, those learners who cannot bring themselves to demonstrate expired air ventilation when demonstrating and being assessed on adult and childhood collapse management may simulate breaths. All learners must demonstrate the correct sequencing of a DRSABCD approach and correctly position the airway of the manikin at the time when ventilation would be given
• Demonstrating compressions is a requirement. If a learner is unwilling or unable to demonstrate chest compressions a NZ Resuscitation Council CORE Skills Confirmation of Attendance may be provided
• This flexibility continues to remain in place until further notice. 

Specific questions may be addressed to info@nzrc.org.nz

COVID-19: Accessing New Zealand Resuscitation Council Courses and Services

Our highest priority has always been to provide a safe environment for our team, customers, suppliers, contractors and visitors. We have undertaken a health and safety risk assessment to determine what our response will be to help protect our people and workplace from the negative impacts of COVID-19. We are introducing a Vaccination Policy.

From Monday 6 December we have implemented the following measures:

Visits to our offices on the Terrace, Wellington

Only fully vaccinated visitors are permitted to visit our premises. On arrival visitors will be required to:

• Sign in
• Present proof of vaccination
• Follow all applicable COVID-19 protocols

For all Council Instructor Training Courses, ECI Assessments and other events held at other sites 

Under the COVID-19 Public Health Response (Vaccination) Order 2021 (the Order), health & disability workers are required to be fully vaccinated against COVID-19.    

The scope of the Order is broad and covers not only employees of health & disability providers but also contractors, service providers, volunteers and others, including learners who provide services in a setting where healthcare is provided (”affected persons”).  

This means that anyone who provides or receives services on behalf of the NZ Resuscitation Council on District Health Board or other health care sites, must  have had their first dose of the COVID-19 vaccine by 15 November 2021 and their second dose by 1 January 2022.  

Where our services are provided on health care sites, we are required to confirm that any of our contractors, volunteers, or learners coming onto a site will be required to be vaccinated to the same requirements as if they were an employee on that site.  

We may require our contractors, volunteers, or learners to verify that they are vaccinated in accordance with the requirements and timeframes in the Order and agree that, if asked, will provide us with information of an affected person: including their full legal name, date of birth, contact details, and vaccination details.    

We acknowledge that the risks associated with COVID-19, and the measures that can be taken to mitigate or eliminate these risks, may change. To adapt and remain proactive we will review these measures regularly to ensure they reflect any new controls which become available in the future.

Please note, the NZ Resuscitation Council takes the protection of personal information seriously.  Any health information that we receive as part of this process will be stored securely, held and managed in accordance with the Privacy Act 2020 and the Health Information Privacy Code 2020.  

Thank you for your support and understanding as we implement these measures.

Kevin Nation

Chief Executive 

COVID-19 Vaccination Statement – implications for resuscitation and first aid training

The New Zealand Resuscitation Council firmly believes that vaccination is a critical part of Aotearoa New Zealand’s response to the COVID-19 pandemic. 

Vaccination not only helps protect yourself, your learners, and your community, but also supports your colleagues – especially those caring for the people who contract the virus.

We strongly recommend that every instructor takes up the opportunity to be vaccinated, regardless of their employment.

We respect an individual’s right to have their own opinions, but it is the Council’s view that there is no place for anti-vaccination messages, nor any promotion of anti-vaccination claims including on social media and advertising.