My TCU CPR policy

umcRN, BSN, RN · May 2, 2012

well I work in an ICU...so I would say definitely not common in an ICU setting. In my pedi cardiac icu we also make sure that each patient not only had a code status but also has an ecmo candidate status (one can be a full code but not an ecmo candidate and if you are an ecmo candidate then you are obviously full code). We do CPR until the pt stabilizes or until we can get them on ecmo (with the goal of arrest to ecmo in under 30 minutes).

Kind of a strange policy...although I don't know, I've never worked out of an ICU. What rhythms to you do CPR for? (and what do you mean by response to stimulus? certainly if a person was responding they wouldn't need cpr?)

Zookeeper3 · May 2, 2012

I know of a few nursing homes that don't do CPR, they call 911. Is this what you mean?

Perpetual Student · May 2, 2012

That's a mighty strange policy. I would seek to clarify and likely revise that if I were you. The only similar thing I can think of off the top of my head is that a lot of EMS protocols have exclusions for CPR for people who're obviously not coming back (e.g. decapitated). Not attempting to resuscitate a full code patient would likely not be a very defensible even if it were in accordance with facility policy.

I know of a few nursing homes that don't do CPR, they call 911. Is this what you mean?

You're kidding. That's horrible. What is the point of calling 911 if they're not going to start CPR so the person has even a modest chance at a good outcome? Is that their policy, or ignorance on the part of the staff? Seems to me that even if it were policy, it'd be quite risky from liability and licensure perspectives to abide.

Do-over, ASN, RN · May 2, 2012

The TCU protocol qualification for being dead is no pulse and no response to stimulus.

Strange, as this is also the general qualifications for beginning CPR...

That is a policy I would look into very carefully. If a patient is a "full code" I am coding them until we call it as a team, or the doc says stop.

unsaint77 · May 2, 2012

woops

unsaint77 · May 2, 2012

I am going to type this written policy for you here. I saved the copy just in case.

"****** C.P.R policy and procedure

CPR will not be performed on any resident (regardless of code status) who is assessed as clinically expired by the folowing criteria, as determined by a licensed professional:

1. Absence of respiration

2. Absence of blood pressure

3. Absence of pulse

4. Absence of response to painful stimulus

a. Sternal rub - knuckle of fingers rubbed hard into sternum.

5. All above criteria must be present to determine resident is clinically expired.

"******

Essentially, my facility prohibits me from doing CPR on a full code pt if they have no pulse.

I understand that in a normal setting, the only time chest compression is needed is in the scenario described in #4. And this policy prohibits that and directs me to call 911 instead. At best scenario, according to this policy, I can do rescue breathing if the pulse is present. But if the pulse stops in the middle of my rescue breathing, I am supposed to stop.

It sounds like my facility is not the only longterm care place doing this. (My whole building of over 100 residents and have not a single AED.) I suspect this is done because they have no financial gain from performing CPR, but potential legal problem. I know it is sad, but let's not dwell on ethics for now. By the samarithan law, I am supposed to apply my CPR skill to save people with no pulse. So, if I didn't do chest compression on a full code pt with no pulse, following the facility procedure, would my license be in jeopardy?

Thanks.

sapphire18 · May 2, 2012

In a "normal" setting, compressions are started at the absence of a pulse. I don't know about your license, but any layperson on the street can start CPR on someone, so why would a nurse in a nursing home not? I don't understand. (btw, what is "TCU"?)

unsaint77 · May 2, 2012

sapphire18, I am an RN. I am as puzzled as you are about this policy. I just started working at this nursing home with TCU. Did you read zookeeper's comment? "a few nursing homes don't do CPR, they call 911." That is exactly what I mean. So, my facility is not the only place with this horrifying policy.

Again I think the reason is there is no reimbursement for the nursing home although I still don't understand how this would be okay for the state.

So, for now, I want to know what other experienced nurses think as far as the safety of my license if I followed the policy and not performed CPR on a full code pt with no pulse (and no MD or NP had decided on the pt status). I know I sound bad worrying about my license over the life of the pt.

CompleteUnknown · May 2, 2012

I can't answer your question about your licence because I'm not in the US but your policy says CPR will not be performed on a resident who is dead, as determined by the absence of all of the signs that are listed. It doesn't say don't do CPR on someone who is dying.

We have a rather similar policy except that the criteria for obvious death includes things like fixed pupils and absence of heart sounds when listening through a stethoscope for a full minute.

Our policy means that when you walk into a room and it's obvious the resident is dead, we don't do CPR. It's not going to work anyway and will only be distressing for everyone involved.

I think I will be in the minority here, but I don't see this as a bad thing at all.

If I were you I'd be clarifying your policy next time you work though, just so you're sure that you're reading it correctly and understand what is expected by the facility. If you still have concerns, address them with management straight away so you have some certainty about your own obligations versus the facility's expectations and will be able to make a decision on what you see as the correct course of action should someone die on your shift - nothing worse than having that sort of worry and uncertainty on your mind all shift.

Guest219794 · May 2, 2012

I am going to type this written policy for you here. I saved the copy just in case.
"****** C.P.R policy and procedure
CPR will not be performed on any resident (regardless of code status) who is assessed as clinically expired by the folowing criteria, as determined by a licensed professional:
1. Absence of respiration
2. Absence of blood pressure
3. Absence of pulse
4. Absence of response to painful stimulus
a. Sternal rub - knuckle of fingers rubbed hard into sternum.
5. All above criteria must be present to determine resident is clinically expired.
"******
Essentially, my facility prohibits me from doing CPR on a full code pt if they have no pulse.
I understand that in a normal setting, the only time chest compression is needed is in the scenario described in #4. And this policy prohibits that and directs me to call 911 instead. At best scenario, according to this policy, I can do rescue breathing if the pulse is present. But if the pulse stops in the middle of my rescue breathing, I am supposed to stop.
It sounds like my facility is not the only longterm care place doing this. (My whole building of over 100 residents and have not a single AED.) I suspect this is done because they have no financial gain from performing CPR, but potential legal problem. I know it is sad, but let's not dwell on ethics for now. By the samarithan law, I am supposed to apply my CPR skill to save people with no pulse. So, if I didn't do chest compression on a full code pt with no pulse, following the facility procedure, would my license be in jeopardy?
Thanks.

Maybe I am missing something, but I am pretty sure you got that wrong.

By your policy, no pulseless people get cpr. Anybody without a pulse will have no bp, respirations, response to pain, etc, therefore no CPR.

Under that policy, what patient would get compressions?

What on earth is the point of calling 911? They are going to attempt to resuscitate a patient that is far less viable because your staff was prohibited against providing the Standard of Care. The patient would have a better chance of surviving a pulseless arrest at a ball game.

I think this policy was written by somebody who doesn't really understand this stuff. One clue is having both criteria 4 and 5. A sternal rub IS painful stimlus. That's why it is done.

Maybe if you witness a pulseless arrest, you could get a family member to do compressions while you call 911. What a crappy position your employer has put you in.

psu_213, BSN, RN · May 2, 2012

I really don't understand. If an individual is a full code, they don't have a pulse, you do CPR--the same thing you would do if you saw someone go down in the mall. Are the RNs (and other staff) CPR certified? If so, there is no reason they cannot and should not do CPR.

Are the residents and their family aware of this facility policy?