Checking Emergency Equipment Protocol - V4.0 - CG482

Checking Maternity Emergency
equipment protocol (CG482)
Approval and Authorisation
Approved by Job Title Date

Maternity Clinical Governance Chair, Maternity Clinical 5th January
Committee Governance Committee 2018
Change History
Version Date Author Reason

1.0 April 2011 J Tuckey, M Whitfield, L Cox, Trust requirement
J Sangha
2.0 October J Tuckey, M Whitfield, L Cox, Review required
2013 J Sangha, N Benns
3.0 November J Tuckey, S Bailey, L Cox, J Reviewed
2015 Sangha, N Benns
4.0 November R Smith, M Redfearn, L Cox, Reviewed
2017 J Sangha, N Benns Pg 8 – 4.1 section updated
Pg 9 – Table 1 updated
Author: Rebecca Smith, Milica Redfearn, Lindsay Cox, Jean Sangha, Nicky Date: January 2018
Benns
Job Title: Delivery Suite Manager, Marsh Ward Manager, Iffley Ward Manager, Review Date: January 2020
Matron for Community & MLU, Clinical Risk Manager
Policy Lead: Group Director Urgent Care Version: 4.0 ratified 5th Jan 2018
Mat CG mtg
Location: Policy hub/ Clinical/ Maternity/ Professional guidelines/ CG482
This document is valid only on date last printed Page 1 of 10
Checking Maternity Emergency Equipment protocol (CG482) January 2018
Contents
1.0 Introduction ................................................................................................... 3
2.0 Purpose .......................................................................................................... 3
3.0 Responsibilities ............................................................................................. 4
3.1 The Maternity Clinical Governance Committee (MCGC) ............................ 4
3.2 Director of Midwifery (DOM) ......................................................................... 4
3.3 Maternity Matrons ......................................................................................... 4
3.4 Ward and departmental managers .............................................................. 5
3.5 Shift coordinators ......................................................................................... 5
3.6 Individual members of staff .......................................................................... 5
3.7 Professional Development Team ................................................................. 5
3.8 Consultant Obstetricians.............................................................................. 6
3.9 Audit and Quality Midwife ............................................................................ 6
3.10 Clinical Engineering ...................................................................................... 6
3.11 Facilities Management .................................................................................. 6
4.0 Equipment checking process ...................................................................... 7
4.1 Community equipment ................................................................................. 7
4.2 Emergency Department ................................................................................ 8
5.0 Monitoring .................................................................................................... 10
6.0 References ................................................................................................... 10
Other relevant corporate or procedural documents:

This document must be read in conjunction with:
 The Trust Risk Management Strategy (CG027)
 The Maternity Clinical Risk Management Strategy (CG347)
 Neonatal resuscitation guideline (GL443)
 Basic Newborn Life support - see page 5 of GL433 above
 Trust Mandatory Training Policy (CG065)
 Medical Device Training Procedure (CG554), Feb 2016 onwards
 Medical Gases Policy (CG197)
Author: Rebecca Smith, Milica Redfearn, Lindsay Cox, Jean Sangha, Date: January 2018
Nicky Benns
Job Title: Delivery Suite Manager, Marsh Ward Manager, Iffley Ward Review January 2020
Manager, Matron for Community & MLU, Clinical Risk Manager Date:
th
Policy Lead: Group Director Urgent Care Version: 4.0 ratified 5 Jan
2018 Mat CG mtg
1.0 Introduction
The Royal Berkshire NHS Foundation Trust (RBFT) is committed to achieving excellence in
respect of the services it provides and strives to work together to provide excellent health
care for the local community and beyond. It is the aim of the RBFT that all employees
should maintain their knowledge, skill and expertise in order to operate in a safe and
competent manner and that the RBFT should equip the employees with the necessary
resources to provide this level of service.
Successful resuscitation requires immediate access to resuscitation drugs and equipment.
Each clinical area should have as a minimum equipment to facilitate basic life support for
both adults and newborn infants. More specialised equipment is required in areas of high
risk such as delivery suite and the birth centre. Where possible, resuscitation equipment
should be single use and latex free.
The choice of resuscitation equipment used for basic life support and supplies is defined by
the RBFT Resuscitation Committee. Newborn life support equipment is defined by the
neonatal consultants.
A risk assessment should be undertaken to determine what additional resources may be
required depending on the circumstances.
2.0 Purpose
The purpose of this protocol is to ensure that emergency equipment required for basic and
newborn life support is available, appropriate, and in good working order in all care settings
and that all clinical staff are familiar with its functionality, checking and maintenance by
observing the following:
 All clinical staff providing maternity care both in the hospital and in the community
are required to attend and be certified in basic and newborn life support annually.
 Emergency equipment should be stored together and readily accessible in a
specified location
 All clinical staff working in maternity and the community are responsible for knowing
the location of emergency equipment, drugs and oxygen supplies within their
working environment
 All clinical staff should have received training in the use of the equipment and the
required documentation
 All clinical staff should know how often to check, clean and restock equipment
 All staff should know how to requisition repairs
 All drugs used for resuscitation should be in-date, sealed and replaced after use
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 All clinical staff should attend medical gas training every 3 years
 Clinical Engineering department undertake routine maintenance checks and to
respond to requests to check and repair equipment in a timely way
 All staff must be familiar with the ‘Emergency Calls in Maternity’ procedure
 Six monthly audit of auditable standards
3.0 Responsibilities
3.1 The Maternity Clinical Governance Committee (MCGC)
The MCGC are responsible for ensuring compliance with this protocol and taking
action if deficiencies are identified either in the training of staff or failures in checking
or maintenance and availability of the equipment.
Where new or replacement emergency equipment is required the MCGC are
responsible for ensuring that timely action is taken to replace the equipment through
the usual risk assessment process. Where there is a potential risk to the mothers’
and babies’ this should be added to the Maternity Risk register so that the risk is
escalated to the Urgent Care Board - see Trust and Maternity Risk Management
Strategies.
3.2 Director of Midwifery (DOM)
The DOM is responsible for managing the effective implementation and application
of the protocol.
3.3 Maternity Matrons
The maternity matrons are responsible for ensuring
 Compliance with this protocol in all clinical areas. Where deficiencies and/or
associated risks are identified the matron will delegate responsibility to
ward/departmental managers to ensure appropriate and timely action is taken to
eliminate or reduce these deficiencies and/or risks.
 Deficiencies or associated risks are reported to the Clinical Director for the
Maternity and Children’s Directorate and the Director of Midwifery
 Managing the purchase of emergency equipment as required or in the case of
replacing expensive equipment that a risk assessment is undertaken and
quotations obtained for replacement under the medical equipment funding
scheme or other sources as appropriate.
 Action is taken on receipt of Medical safety alerts relating to emergency
equipment and the measures taken to reduce or eliminate the risk.
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3.4 Ward and departmental managers

Ward/department managers are responsible for ensuring:
 All staff are aware of this protocol and its contents
 All new staff are familiar with the location of emergency equipment and
emergency drug boxes
 All clinical staff working in the wards/departments are trained in the use of
emergency equipment in that area
 Routine checking and cleaning of emergency equipment is performed as detailed
in the checking schedule (Table 1)
 Availability of supplies and equipment
 For ensuring that all emergency equipment undergoes routine maintenance
 All faulty equipment is removed from use immediately and labeled accordingly
 Timely requisition of repairs
 Escalates concerns regarding deficiencies in the emergency equipment
3.5 Shift coordinators

Shift coordinators are responsible for ensuring:
 routine checking of equipment and replacement of stock is undertaken in accord
with the checking schedule in table 1
 Checklists are completed and a record made on the ward activity logs as
appropriate
3.6 Individual members of staff

All staff working in maternity is responsible for ensuring:
 Attendance in basic and newborn life support training annually in accord with the
Trust and Maternity Mandatory Training policy.
 They are familiar with the location, function and checking of emergency
equipment
 Location of portable oxygen cylinders.
In addition community based staff are responsible for:

 complying with the safe transport of medical gases used for basic and newborn
life support
 familiarising themselves with the location and use of emergency equipment at
individual GP practices, Children’s Centres and community bases
3.7 Professional Development Team

3.7.1 Practice Development Midwife
Is responsible for:
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 organising the provision of basic and newborn life support training for all clinical
staff (midwives, nurses, doctors and support staff) working in maternity in accord
with the Trust Mandatory Training Policy.
 maintaining a training database and producing quarterly reports which are
presented to the MCGC and Midwifery Services Committee on basic and
Newborn life support. If compliance falls below 80% for any particular staff group
an action plan will be agreed to improve attendance as detailed in the maternity
training needs analysis
3.7.2 The Skills Facilitator is responsible for ensuring all clinical staff:
 receive training and updating in the use of emergency equipment.
 comply with the Trust Medical Device training policy
 update the medical device training record 6 monthly
3.7.3 The Practice Educator is responsible for ensuring all midwifery students have:
 received training in basic and newborn life support
 are aware of the location of emergency equipment in their allocated workplace.
3.8 Consultant Obstetricians

Consultant obstetricians are responsible for ensuring:
 All obstetric medical staff receive basic and newborn life support training on
induction and in accord with the Trust and Maternity Training Policy
 All obstetric medical staff receives training in the use of emergency equipment on
induction and when new equipment is introduced to the clinical areas.
3.9 Audit and Quality Midwife

The audit and quality midwife is responsible for ensuring audit of this protocol twice
annually and an action plan if compliance falls below 75%.
3.10 Clinical Engineering
The clinical engineering department are responsible for:
 The routine maintenance and timely repair of emergency equipment as required
 Report to the departmental/ward manager any deficiencies or faults in the
emergency equipment.
 Source replacement of spares or equipment as required
 To remove faulty or broken equipment from use
3.11 Facilities Management

 The head of portering services is responsible for ensuring that porters are trained
in the safe handling and replacement of medical gases
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 Porters are required to change medical gas cylinders as requested and to sign,
date and time the ‘Replace Gas Cylinder’ requisition sheets
4.0 Equipment checking process

 All emergency equipment should be kept in the designated place at all times
unless in use and should be checked in accord with the schedule for checking
emergency equipment as seen in table 1.
 Emergency equipment checklists should be completed, dated and signed at each
check by the designated person (replacement checklists are available on the
stationary section on the maternity website). The checklists should be stored next
to the emergency equipment at all times
 Where stock levels are incomplete replacements should be sourced. If items are
unavailable this should be reported to the clinical coordinator for immediate
action.
 Emergency drugs/IV fluids should be in date and sealed with the appropriate
security tag. Out of date drugs/IV fluids should be removed and replaced. Gas
cylinders should be checked for sufficient gas and that there are no leaks.
Replacements are requested from the Portering Services. Porters are to sign the
resus checklist to say they have changed and turned on the gases (date and
time) when replaced.
 Requisitions should be recorded in log attached to the equipment or in the case
of community in the folder outside the call centre. The person requesting the
change of cylinder is responsible for ensuring that the cylinder has been changed
or ensuring that this responsibility is delegated to a colleague.
 Checklists should be stored next to the equipment for a period of one month.
Thereafter the checklists will be stored for one year in a secure place for future
reference.
 The equipment should be clean and dust free
 Resuscitaires should be stripped and cleaned thoroughly weekly
4.1 Community equipment

Community homebirth equipment is stored in the 2 designated homebirth bags in the
room next to the Band 7 community office on the postnatal clinic corridor. The
community emergency equipment is located within these bags, with the exception of
the suction units which are located in the same room but should be plugged in and
charging when not in use. In Newbury, the homebirth kit is stored at West Berkshire
Community Hospital, first door on the right as you enter the main entrance- a key
can be obtained from security out of hours.
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All community Midwives and MSWs should be made familiar with the location and
contents of each kit and how to set up emergency equipment in the home setting.
The coordinating community midwife is responsible for checking:
 Emergency equipment used for home birth in accordance with table 1.
 Stock against checklist and restocked as required.
 Room temperature equipment is stored in- to be recorded, and reported if
exceeds maximum or minimum temperatures and appropriate action taken
 Emergency drug boxes and intravenous fluids kept in homebirth bag for expiry
dates and out of fridge dates.
 Diamorphine supplies used for home birth which are located on Rushey in the
drug cupboard. This should be transported in the cash box for security and
safety. Unused drugs to be returned, checked and controlled drugs register
signed
 Oxygen/Entonox cylinders have sufficient gas and no leaks. Additional gas
cylinders to be safely stored in locked black gas cupboard outside community
office.
 When transporting gas cylinders in a car they must be transported in the
designated BOC gas transport bag and secured in the boot using bungee cords.
Before taking to the home setting ensure gas cylinders are full. Fire extinguisher
to be carried in passenger side in front of car where it can be easily accessed by
driver.
 Homebirth Equipment (see table 1)
 Equipment to be signed out on log when in use. When returned to base, is
checked, re-stocked, cleaned and in good working order by person returning the
equipment. Equipment must be signed back in on log and signed to confirm that
checking and restocking has been completed on return of the equipment
 Green tape used to seal homebirth kit following checking with date and time
check completed
 Suction equipment – units should have batteries replaced 3 yearly and
appropriate Yanker suckers available for both neonate and adult.
 All midwives to carry in their day to day kit: BVM (or one way valve and filter),
neonatal mask, adult mask, grey Guedal, tongue depressor and drugs pot
(containing Syntometrine, Oxytocin, ergometrine, vitamin K). Midwives to ensure
maintenance of all equipment and individual checking of expiry dates and out of
fridge dates for drugs that they carry in own kit.
4.2 Emergency Department

The emergency department are responsible for checking the neonatal resuscitaire
daily and in accordance with their own policies and procedures.
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Table 1: Schedule for routine checking of emergency equipment in all clinical areas
related to maternity.
Clinical Area Equipment Frequency Location By Whom
Top daily
Adult trolley Whole trolley Outside report room Midwife/Nurse
weekly
Delivery Suite
1 rooms 4-5
Neonatal Twice daily on
1 rooms 6-7 Midwife/MCA
resuscitiares x 3 each shift
1 room 8-9
Adult trolley Daily Recovery Nurse
Maternity
Neonatal
Theatre Once daily Theatre 17 & 18 Midwife/MCA
resuscitaires x 2
Top daily
Located outside summer
Adult Trolley Whole trolley Midwife
delivery room
Birth centre/ weekly
Midwife Led Each birthing room and
Unit Neonatal outside triage in store
Twice daily Midwife/MCA
recuscitaries cupboard located near
entrance to Rushey
Top daily
Adult trolley Whole trolley Behind work station Midwife/MCA
Iffley once weekly
Neonatal
Twice daily Nursery Midwife/MCA/nurse
resuscitaire
Top of trolley
Adult
daily
resuscitation At work station Midwife/nurse/MCA
Whole trolley
Marsh trolley
weekly
Neonatal
Twice daily Opposite work station Midwife/MCA
resuscitaire
ANC Adult trolley Daily Opposite counselling room Midwife/MCA
Oxygen
DAU Daily Midwife/MCA
cylinders
Daily - check to
ensure kit
sealed and in
date.
Weekly - Every
Monday kit
should be fully In room next to band 7
Adult and checked and re office on level 2 in
Neonatal sealed and postnatal clinic corridor.
Resuscitation, stock and Equipment is also
Community plus contents of expiry dates available in Newbury Midwife/MSW
homebirth kit in documented (West Berks Community
accordance against Hospital)- new staff to be
with checklist. checklist. familiar with location and
how to access out of hours
After each use
- kit should be
checked,
cleaned,
restocked and
sealed ready
for next use
Daily. Must be
plugged in and
Community Suction Units As above Midwife/MSW
charging when
not in use.
Emergency Neonatal
Daily Resuscitation area Paediatric & ED nurses
Department resuscitaire
Note: all emergency equipment should be cleaned, restocked and in good working order
after each use
This document is valid only on date last printed (Jan 2018) Page 9 of 10
5.0 Monitoring
Responsibility for ensuring compliance with this protocol lies with the Maternity
Clinical Governance Committee who will receive quarterly basic and newborn life
support training reports from the Professional Development Midwife and six monthly
audit reports and action plans from the audit and quality midwife. Where
deficiencies are identified action will be taken to rectify these deficiencies.
6.0 References
1. Department of Health. (2004). Maternity Standard, National Service Framework for
Children, Young People and Maternity Services. London: COI. Available at:
www.dh.gov.uk
2. King’s Fund. (2008). Safe Births: Everybody’s Business - Independent Inquiry into the
Safety of Maternity Services in England. London: King’s Fund. Available at:
www.kingsfund.org.uk
3. National Institute for Health and Clinical Excellence (NICE). (Feb 2017). Intrapartum
Care: Care Of Healthy Women And Their Babies during Childbirth CG190. London:
NICE. Available at: www.nice.org.uk
4. National Patient Safety Agency. (2010). Neonatal Resuscitation - Signal. Available at:
www.npsa.org.uk
5. Nursing and Midwifery Council, (2015). The Code. London: NMC. Available at:
www.nmc-uk.org
6. Nursing and Midwifery Council, (2010). Standards for Medicines Management.
London: NMC. Available at: www.nmc-uk.org
7. Resuscitation Council (UK). (2010). Resuscitation Guidelines. London: Resuscitation
Council (UK). Available at: www.resus.org.uk
8. Resuscitation Council (UK). (2011). Newborn Life Support (Nls) Provider Course
Regulations 2011. London: Resuscitation Council (UK). Available at: www.resus.org.uk
9. Royal College of Anaesthetists, Royal College of Midwives, Royal College of
Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health.
(2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care
in Labour. London: RCOG Press. Available at: www.rcog.org.uk
10. Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists,
Royal College of Midwives, Royal College of Paediatrics and Child Health. (2008).
Standards for Maternity Care: Report of a Working Party. London: RCOG Press.
Available at: www.rcog.org.uk
11. Royal College of Paediatrics and Child Health, Royal College of Obstetricians and
Gynaecologists, Royal College of Midwives. (2006) Joint Statement On Training And
Maintenance Of Skills For Professionals Responsible For Resuscitation Of Babies At
Birth. London: Joint Standing Committee RCPCH/RCOG/RCM. Available at:
www.rcog.org.uk
Nicky Benns
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Checking Maternity Emergency

equipment protocol (CG482)

Approval and Authorisation

Approved by Job Title Date

Version Date Author Reason

Other relevant corporate or procedural documents:

3.4 Ward and departmental managers

3.5 Shift coordinators

3.6 Individual members of staff

In addition community based staff are responsible for:

3.7 Professional Development Team

3.8 Consultant Obstetricians

3.9 Audit and Quality Midwife

3.11 Facilities Management

4.0 Equipment checking process

4.1 Community equipment

4.2 Emergency Department

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