Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest

Dear Editor
The News on CPR in COVID-19 (BMJ 2020;368:m1282) is the latest example of the state of confusion, denial and unpreparedness in which the NHS, the national health authorities and the politicians are facing the pandemic.[1] Actions taken are allegedly justified by scientific evidence provided by top scientific advisers. Indeed, such evidence is either challenged on scientific grounds,[2] or is not made available,[3] or is absent. In the specific, the World Health Organization lists CPR as an aerosol generating procedure (AGP)[4], a procedure for which there is general consensus that full PPE (gown, gloves, FFP3 mask and facial protection) should be used. However, the Department of Health and Social Care and other public health bodies across the four nations do not consider CPR as AGP and they suggest that emergency staff can carry out CPR whilst awaiting further support.[5] To add to the confusion, one regional NHS recommends to refrain from starting CPR in suspected or diagnosed COVID-19 patients, unless in ED, and staff wearing full PPE, assuming CPR is an AGP. For an experienced intensive care physician, with full PPE availability and well-trained support staff, it would take between 3 and 5 min to be in full PPE, making CPR after cardiac arrest almost uninfluential. Furthermore, appropriate PPE is not available across the whole of the NHS, and testing for COVID-19 is still limited in the UK and unlikely to become widespread, despite official reassurances. We can only guess from other countries’ statistics that the proportion of people infected are very high.
It is therefore prudent to consider most patients seen in the NHS as infected.
Is University Hospitals Birmingham NHS Foundation Trust’s policy too restrictive to protect NHS staff at the expense of more disadvantaged patients or are patients, health workers and the public knowingly been put at risk? Both scenarios are equally worrying. Emerging reports suggest that myocardial injury and ensuing cardiac dysfunction are significantly associated with excess mortality from COVID-19.[6-7] Delaying CPR due to the revised criteria may lead to avoidable fatalities.
The present state-of-affair shows a national system in disarray, unprepared, slow, confused, and not listening to the tsunami of comments from NHS staff and volunteers, that are applauded for their dedication to the profession and their solidarity, but are not equipped with the PPE they need to be able to work.[8] Our clinical staff does not need ‘empowerment to make individualised, context dependent judgements’, but adequate means to provide the best level of care, under decisive guidance and in a safe environment.

References

1. Horton R. Offline: COVID-19 and the NHS – “a national scandal”. Lancet 2020;395:1022
2. Ferguson NM et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. 2020; March, 16.
https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020...
3. Alwan NA, et al. Evidence informing the UK’s COVID-19 public health response must be transparent. Lancet 2020;395:1036-7
4. World Health Organization. Modes of transmission of virus causing COVID-19 : implications for IPC precaution recommendations. 2020.
5. Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland, Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings. March 2020.
6. Guo T et al. Cardiovascular implications of fatal outcomes of patients with Coronavirus Disease 2019 (COVID-19). JAMA Cardiol 2020; on-line March 27; doi: 10.1001/jamacardio.2020.1017
7. Madjid M et al. Potential effects of Coronaviruses on the cardiovascular system. A review. JAMA Cardiol 2020; on-line March 27; doi: 10.1001/jamacardio.2020.1286
8. https://www.theguardian.com/society/2020/apr/03/coronavirus-deaths-of-tw...