Resuscitation Policy - Royal United Hospital Bath NHS Trust

10. Monitoring and Audit10.1 Cardiac arrest audit data will be collected with an audit form being completedafter each resuscitation attempt. The completed form should be left in theresuscitation store outside ICU. Data from this form will be extracted for entryinto the National Cardiac Arrest Audit (NCAA). The RUH NCAA data will bereviewed by the Resuscitation Committee at least annually and comparedwith national NCAA data. Any areas of risk will be assessed by theResuscitation Committee.10.2 DNAR documentation will be audited every two years and results reviewed bythe Resuscitation Committee, in order to identify compliance with the DNARpolicy.10.3 Resuscitation Trolley equipment will be audited by the ResuscitationDepartment annually and results reviewed by the Resuscitation Committee, inorder to identify areas of non-compliance and assist wards/departments toimprove practice.10.4 Training records will be reviewed at least annually by the ResuscitationCommittee, in order to respond to and prioritise supply and demand foraccess to training and determine key areas of risk through non-attendance.10.5 Information on reported incidents relating to resuscitation will be reported tothe Resuscitation/Clinical Skills Training Manager, in order to identify areas ofrisk/non-compliance, informing the development of training programmes andpolicy development.10.6 The Resuscitation/Clinical Skills Training Manager will report to eachresuscitation committee, detailing information on compliance with this policy,audit reports, incident reporting and areas of risk identified including actionstaken.10.7 Information on the analysis of audit data, benchmarking and the identificationof areas of risk will form part of the resuscitation committee reports to theOperational Governance Committee.Document name: Resuscitation Ref.: 774Issue date: 7 February 2013Status: ApprovedAuthor: Jerry Nolan Page 10 of 25