Rashida Sultana

Emergency Medical Response Policy 
including Management of Resuscitation  

Policy author 

Lead Resuscitation Officer and Associate Deputy 
Chief Nurse MMUH 

Accountable Executive Lead  Chelf Medical Officer 
Approving body 
Policy reference 

EQG 

ESSENTIAL READING FOR THE FOLLOWING STAFF 
GROUPS: 

1: 
2: 
3: 

All Group Triumvirates  
On call Team Members 
All Clinical Members of the Multidisciplinary 
Team – Medical and Non-Medical  

STAFF GROUPS WHICH SHOULD BE AWARE OF THE 
POLICY FOR REFERENCE PURPOSES:  

1: 
2: 
3: 

Senior Clinical Executives  
Risk Management  
Clinical Governance Teams 

POLICY APPROVAL 
DATE: 
March 2025 

POLICY 
IMPLEMENTATION 
DATE: 
March 2025 

DATE POLICY TO  
BE REVIEWED: 
March 2027 

DOCUMENT CONTROL AND HISTORY 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 1> of < 27>  

 
 
 
 
   
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Version 
No 

Date 
Approved 

Date of 
implementation 

Next 
Review 
Date 

V0.1 

Reason for change (e.g., full 
rewrite, amendment to reflect 
new legislation, updated 
flowchart, etc.) 
Reviewed by Deteriorating 
Patients and Resuscitation 
Group Members.  
Group Triumvirates 

KEY POINTS 

1.  Purpose of the Emergency Medical Response Team and Management of 

Resuscitation Policy 

This policy outlines the systems, processes, and structure in place to provide safe 
and effective care during resuscitation events to all individuals attending or working 
at Sandwell & West Birmingham NHS Trust. This policy should be viewed 
interactively in context with other organisational policies regarding the management 
of deteriorating patients or medical emergencies. 

2.  Description of the Policy 

The policy aims to assure resuscitation services within the Organisation. It directs 
staff in their roles, responsibilities, and actions to provide care and summon 
assistance in clinical emergencies. The policy incorporates current guidelines for 
resuscitation (Resuscitation Council UK 2021) and provides standards for auditing 
the service and disseminating audit findings. Compliance with this policy is 
monitored by the DP&RT and the Resuscitation Group, reporting to the Executive 
Quality Group with support from the Enhanced Care Group. 

3.  Who does this Policy affect? 

The policy applies to adult and paediatric emergency teams and cardiopulmonary 
resuscitation across all Sandwell and West Birmingham NHS Trust estates. All 
clinical and public areas where medical emergencies may occur must have adequate 
resources available and visible. 

Key Points of the Policy 

1.  Emergency Equipment 

  Emergency equipment must be checked daily and immediately after use, 

following the MyKitCheck SOP to ensure continual availability. 

  All staff must be familiar with the resuscitation equipment in their workplace or 

know the location of the nearest equipment. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 2> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Training Requirements 

  All clinical staff must be in date with the mandatory level 2 resuscitation 

training and attend annual BLS assessment. Staff working in areas dealing 
with children must also be trained in paediatric life support. The Trust will 
ensure adequate resources for relevant training specific to roles and 
specialties, including having an experienced Resuscitation Officer, designated 
training areas, and appropriate equipment. 

3.  EMRT Composition and Response 

  The Emergency Medical Response Team(s) at MMUH, known as the 

‘emergency team’, include skilled clinical professionals equipped to manage 
deteriorating patients and cardiac arrests. Core Teams consist of a Team 
Leader and clinical Team Members, described as: 

  Adult Emergency Team 
  Paediatric Emergency Team 

  Rapid Response Team in our Non-Acute (MMUH) Estates 

The emergency team within our non-MMUH Estates, including Sandwell 
Treatment Centre, Birmingham Treatment Centre, BMEC, and the Sheldon 
Block, operates with a different team structure due to the lower acuity of these 
sites and the lower-risk patient population. Unlike the comprehensive 
emergency team response at MMUH, these Non-MMUH Estates will have:  

  Team Composition: The team at these sites will respond ‘In Hours’ led by 
a doctor within the Surgical Medical Team who holds an Advanced Life 
Support (ALS) qualification. This individual will serve as the team leader 
during emergencies. 

  Supporting Team Members: The remaining team members will be drawn 

from various departments and will include qualified staff with a 
combination of Immediate Life Support (ILS) and/or Basic Life Support 
(BLS) certifications.  

A full breakdown of team compositions for each site can be found in Annex 3 of this 
policy document. This annex provides detailed information on the specific roles and 
qualifications of team members across the different sites, ensuring clarity and 
preparedness. 

Any person who needs to summon immediate, emergency, medical help on any site 
other than MMUH must call 2222 and ask for a 999 ambulance response.  

4.  Emergency Telephone Call 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 3> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 
   Regardless of location, the emergency telephone call number is 2222. There 
are several pathways where intervention may be required, for example: 

  Cardiac Arrest 
  Deteriorating Patients 
 
  999 via 2222 

Immediate Clinical Physical Review and Intervention 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 4> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CONTENTS PAGE: 

1: INTRODUCTION .................................................................................................... 7 

2: SCOPE 

....................................................................................................... 7 

3: POLICIES TO WHICH THIS POLICY RELATES ................................................... 8 

4: GLOSSARY AND DEFINITIONS ........................................................................... 9 

5: PRINCIPLES 

..................................................................................................... 12 

5.3 Recognition of the Deteriorating Patient ............................................................. 12 

5.4 Response to a Medical Emergency .................................................................... 12 

6: ROLES AND RESPONSIBILITIES ....................................................................... 13 

6.1 The Trust Board including Chief Medical Officer/Chief Nursing Officer .............. 13 

6.2 The Deteriorating Patient and Resuscitation Group and Resuscitation Team .... 14 

6.3 Procurement Department ................................................................................... 14 

6.4 Medical Engineering ........................................................................................... 14 

6.5 Switchboard  ..................................................................................................... 15 

6.6 Ward and Departmental Managers .................................................................... 15 

6.7 Clinical Staff  ..................................................................................................... 15 

6.8 Non-Clinical Staff ................................................................................................ 16 

6.9 Instructors 

..................................................................................................... 16 

6.10 Basic Life Support Assessors ........................................................................... 17 

6.11 New Staff and Students .................................................................................... 17 

6.12 EMRT Core Members ...................................................................................... 17 

7: PROCEDURE (including by site).......................................................................... 18 

7.1 Early Warning Scores ......................................................................................... 18 

7.2 CALLS FOR EMERGENCY INTERVENTION .................................................... 19 

7.3 SITE SPECIFIC RESPONSE: (SEE ANNEX 3) ................................................. 21 

7.3.1 City & Sandwell Health Campus ...................................................................... 21 

7.3.2 Other Community Sites include Rowley, Leasowes, GP Surgeries, Health 
Centres, Patients' Homes, etc. ................................................................................. 23 

7.3.3 Shared Public Areas within Main Buildings (e.g., corridors, restaurants, etc.)  24 

7.3.4 Other Areas Outside Main Buildings (e.g., grounds, car parks) ...................... 24 

7.4 Resuscitation Equipment, Defibrillators, and Defibrillation ................................. 24 

7.5 Treatment Escalation Plans and Do Not Attempt Cardio-Pulmonary Resuscitation
..................................................................................................... 24 

7.6 Not for EMRT ..................................................................................................... 25 

7.7 Simultaneous EMRT Calls - MMUH ................................................................... 26 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 5> of < 27>  

 
 
 
 
 
 
 7.8 Relatives Witnessing Resuscitation .................................................................... 26 

7.9 EMRT Call during a Fire Alarm .......................................................................... 26 

7.10 Major Incident ................................................................................................... 26 

7.11 MANAGEMENT OF TRAUMA.......................................................................... 27 

7.11.1 Management of Trauma at MMUH ................................................................ 27 

7.12 Canal Incidents................................................................................................. 27 

7.13 Management of Trauma in Retained Estates ................................................... 28 

7.14 Priority Lift Access MMUH ................................................................................ 28 

8:  EQUITY AND DIVERSITY .................................................................................. 28 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 6> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1:  

INTRODUCTION 

1.1   This Emergency Medical Response and the Management of Resuscitation 
Policy, is based on the recommendations for clinical practice and training in 
cardiopulmonary resuscitation and management of anaphylaxis published by 
the Resuscitation Council UK. This policy describes the process for managing 
and mitigating risks associated with resuscitation and deteriorating patients. 

1.2   Sandwell and West Birmingham NHS Trust (the Organisation) must provide a 
resuscitation service for patients, visitors, and staff on all its sites. The aim is 
that all relevant staff with direct patient contact must be able to provide 
cardiopulmonary resuscitation at a level appropriate to their role and 
healthcare environment, with a minimum of Basic Life Support. Defibrillation 
is now considered part of basic life support, and all resuscitation 
attempts are expected to include a defibrillator if available. 

1.3   Some staff may require additional training to provide elements of Intermediate 
or Advanced Life Support. This will be defined by their job role and where they 
actively see patients. 

1.4 

The purpose of this Policy is to:  

  Ensure that safe, early, and appropriate management of a medical 
emergency, including cardiopulmonary resuscitation, occurs in our 
Organisation.  

  Detail the duties and training requirements for all staff in our Organisation 

relating to the management of a medical emergency, including 
cardiopulmonary resuscitation.  

  Detail the process and tools in the recognition, identification, and response to 

patients/clients at risk from cardiac arrest within our Organisation.  

  Standardise the management of medical emergencies and cardiac arrests 

within our Organisation in accordance with the current Resuscitation Council 
UK guidelines. 

2:  

SCOPE 

2.1   This policy applies to all directly and indirectly employed staff, including other 

people working within the Trust in line with the Organisation. 

2.2 

2.3 

Any person (staff, patient, or visitor) who collapses within any area of the 
Organisation must be rendered assistance up to, and including, 
cardiopulmonary resuscitation according to the skills and ability of the 
individual staff member.  

Staff who work within the community and are employed by the Trust (such as 
community midwives) retain this responsibility for the patients in their care 
away from Trust areas, wherever they may be with their patient. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 7> of < 27>  

 
 
 
 
 3:  

POLICIES TO WHICH THIS POLICY RELATES 

3.1 

The list of policies below is not inclusive but references the main related 
policies any clinical staff member is likely to refer to. The Trust’s policies are 
all kept on the Trust’s intranet and are accessible to all staff. 

Immediate Care of the Newborn, Including Thermal Care (SWBH/MAT/079) 
Infection Prevention and Control Policy (SWBH/COI/001) 

  Acute Life-Threatening Events (ALTE) in Children (SWBH/PAED/170) 
  Fire Safety Management Policy (SWBH/ORG/043) 
 
 
  Management of the Acutely Ill Obstetric Woman (SWBH/MAT/059) 
  Medicines Reconciliation Policy (SEBH/Pt Care/027) 
  Maternity Escalation Guideline (SWBH/MAT/095) 
  Moving and Handling Policy (SWBH/HR/057) 
  Neonatal Resuscitation Network Guidelines 
  Observation and Monitoring Policy for Children and Young People 

(SWBH/Paed/167) 

  Paediatric Clinical Guidelines for Managing Acute Life-Threatening Events 

(ALTE) in Children (SWBH/Paed/170) 

  Physiological Observation, Monitoring, and Escalation Policy (SWBH/Pt 

Care/132) 

  Policy for Assessing Mental Capacity and Complying with the Mental Capacity 

Act 2005 (SWBH/Pt Care/02) 

  Policy for the Reporting, Management, and Investigation of Incidents 

(SWBH/ORG/050) 

  Policy Regarding Advance Care Plan (ACP) for Children and Young Persons 

with Palliative and Continuing Care Needs (SWBH/Pt Care/012) 
  Resuscitation of the Collapsed Obstetric Woman (SWBH/MAT/039) 
  Resuscitation Status and Treatment Escalation Policy (SWBH/Pt Care/062) 
  Statutory, Mandatory, and Risk Management Training Policy (SWBH/HR/016) 
  Supportive Care Plan - A Guide for Clinicians (SWBH/Pt Care/100) 
  Major Incident Plan (SWBH/ORG/01) 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 8> of < 27>  

 
 
 
 
 
 
 
 
 
 4:   GLOSSARY AND DEFINITIONS 

4.1   Advanced Life Support (ALS) 

  The term ALS describes temporary measures aimed at restoring ventilation 
and a perfusing cardiac rhythm; this is necessary to improve the chance of 
long-term survival. 

4.2   Advanced Paediatric Life Support (APLS) 

  Advanced Life Support Group (ALSG) course 

4.3   Agonal Breathing 

  Occasional gasps, slow, laboured, or noisy breathing associated with the 
initial stages of cardiac arrest and evident in up to 40% of cardiac arrest 
victims. This is not a sign of life, and resuscitation should be commenced 
unless resuscitation is not appropriate (i.e., a current and valid DNACPR 
decision is in place). 

4.4   Ambulance 

  Emergency ambulance following 2222 call to alert for a 999 call. 

4.5   Anaphylaxis 

  An acute, life-threatening hypersensitivity reaction which should be 

considered when there is an acute onset of life-threatening airway and/or 
breathing and/or circulation problems, especially if skin/mucosal changes are 
present. 

4.6   Automated External Defibrillator (AED) 

  The AED analyses cardiac rhythms and advises whether a shock is indicated 
or not. It has preset energy levels according to the Resuscitation Council (UK) 
guidelines. AEDs allow appropriately trained staff to defibrillate a person in 
cardiac arrest before more expert help arrives. AEDs can be used on 
paediatric patients ideally with the use of attenuated pads that reduce the 
energy delivered to children weighing less than 25 kg. In the event these pads 
are not available, adult pads should be used. It is not recommended to use 
AEDs on the under-one-year-old age group due to potential problems with 
rhythm recognition. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 9> of < 27>  

 
 
 
 
 
 
 
 
 4.7   Basic Life Support (BLS) 

  BLS is the maintenance of airway patency and supporting breathing and 

circulation without the use of equipment other than a protective device. This is 
carried out by artificial ventilations using a pocket mask or bag valve mask 
(not a face shield) with or without supplemental oxygen and the provision of 
chest compressions. 

4.8   Baton Bleep 

  The emergency team baton bleep notifies the individual members of the 
emergency teams and gets passed over at the end of each shift to the 
covering emergency team staff member. 

4.9   Cardiac Arrest 

  The sudden cessation of mechanical cardiac activity, confirmed by the 

absence of any obvious sign of life (or pulse for those appropriately trained to 
carry out pulse checks), unresponsiveness, and agonal/complete cessation of 
normal breathing. 

4.10   Cardiopulmonary Resuscitation (CPR) 

  A combination of airway management, artificial ventilation and chest 

compressions 

4.11   Clinical Staff 

  A member of Trust staff whose job description includes direct patient care. 

4.12   Defibrillation 

  The definitive treatment for shockable cardiac arrest rhythms, such as 

ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), is 
defibrillation. This involves delivering a DC electric shock to the myocardium 
at energy levels recommended by the Resuscitation Council (UK). 

4.13   Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) 

  A DNACPR order indicates that in case of cardiac arrest, CPR will not be 
started. It is emphasised that a DNACPR decision does not prevent other 
forms of treatment being provided, including other types of emergencies such 
as anaphylaxis or choking. 

4.14   Immediate Life Support (ILS) 

  Resuscitation Council UK accredited medical emergency and resuscitation 

course. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 10> of < 27>  

 
 
 
 
 4.15   National Early Warning Scoring System (NEWS) 

  A standardised track and trigger system for acute illness in patients 

presenting to or within inpatient areas is also used in the community. Based 
on a simple scoring system in which a score is allocated to physiological 
measurements including respiratory rate, pulse rate, blood pressure, oxygen 
saturation level, temperature, and conscious level (using AVPU: Alert, Voice, 
Pain/pressure, Unresponsive). An appropriate response is triggered according 
to the resulting score. 

4.16   Non-Clinical Staff 

  A member of Trust staff whose job description does not include direct patient 

care. 

4.17  Seizure 

  When the oxygen level to the brain drops following a cardiac arrest, the 

casualty may have a seizure-like episode. Anyone suffering a seizure should 
be suspected of being in cardiac arrest, and breathing should be carefully 
assessed. 

4.18   Situation, Background, Assessment, Recommendation (SBAR) 

  Communication tool to facilitate the comprehensive handover of patient 

information in a structured format, e.g., shift handover, nurse to doctor over 
the telephone, etc. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 11> of < 27>  

 
 
 
 
 
 
 
 
 5:  

PRINCIPLES 

5.1    The Trust is a complex Organisation offering services to individuals (both 

adults and children) with a wide range of needs on many different sites, 
including health centres, hospital inpatient and outpatient services, community 
services, and patients' own homes. As a result, the Trust cannot offer the 
same medical emergency or resuscitation response across all its services. 

5.2    This policy seeks to establish the principles and standards by which more 
site-specific procedures will operate. Where care is being provided by our 
Organisation's employed staff on non-SWB NHS Trust sites, the 
resuscitation/emergency procedure for that setting should be followed. Staff 
are responsible for ensuring they are familiar with the local emergency 
procedures. However, in all situations, basic life support will be started without 
delay. 

5.3    Recognition of the Deteriorating Patient ‘A deteriorating patient refers to an 

individual whose medical condition is worsening or declining. This can occur 
in a variety of healthcare settings and manifests through worsening vital signs, 
increasing symptoms, or a decline in overall health’.  

A. The recognition of the deteriorating patient is essential in the chain of 
survival and for the prevention of cardiac arrest. 

B. The assessment of the deteriorating patient will depend on the knowledge 
and skills of the rescuer and the equipment available to them. 

C. The Trust uses a National Early Warning Scoring (NEWS) system for 
adults and a Paediatric Early Warning Score (PEWS) system for the 
recognition of patients at risk and, as such, the prevention of cardiac arrest, 
primarily in inpatient areas. During an inpatient acute episode, the patient’s 
observations are recorded and scored as per NEWS or PEWS. 

D. To ensure the appropriate action is taken because of a calculated NEWS 
or PEWS score, the process is supported by an escalation procedure. 

5.4   Response to a Medical Emergency 

A. All staff should have the means to obtain immediate local assistance. This 
will depend on the site but may include shouting for help and activating the 
emergency response using the internal phone number 2222. If you are away 
from the buildings and alone and there is no local help, assess the patient and 
ring 999 for an emergency ambulance or as per local site procedure. 

B. Begin appropriate initial treatment according to patient needs and the skill 
level of the rescuer and continue until directed by the responding emergency 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 12> of < 27>  

 
 
 
 
 
 
 team or responding ambulance crew. 

C. Once local help has arrived, send someone to summon the site emergency 
team to the appropriate hospital sites and/or the ambulance service in other 
Trust locations, giving the exact location and brief details of the incident. 

D. Ensure the available emergency resuscitation equipment is brought to the 
victim. If there is no defibrillator on site, for example in the community, the 
emergency call handler may direct staff to the nearest defibrillator. 

E. Co-operate and assist the site emergency team/ambulance crew with the 
resuscitation attempt using the current Resuscitation Council (UK) guidelines 
according to the responding staff’s level of ability. 

F. Consider “Do Not Attempt Cardiopulmonary Resuscitation” (DNACPR) 
orders. However, if there is any doubt as to the patient having a valid 
DNACPR order, resuscitation should continue until one is located and verified.  

Even with a DNACPR in place, THE PATIENT WILL STILL REMAIN 
SUITABLE TO CALL 2222/EMRT IN THE EVENT OF AN IMMEDIATELY 
REVERSIBLE CONDITION INCLUDING: 

· Anaphylaxis 

· Choking or blocked tracheostomy tube 

· New event unrelated to current clinical condition e.g fracture following a fall 

G. Support relatives, other patients, visitors, and staff who are involved in or 
witness a resuscitation attempt. 

H. Ensure appropriate documentation is completed (e.g., medical notes, 
nursing notes on the Electronic Patient Record (Unity) of the emergency) and 
the DP&RT will be informed. 

I. In the event of a sudden unexpected death, local procedures should be 
followed. 

J. In the event of a death, an appropriate member of staff should inform the 
deceased’s next of kin as soon as practicable. 

6:  

ROLES AND RESPONSIBILITIES 

6.1   The Trust Board including Chief Medical Officer/Chief Nursing Officer. 

The Trust Board and Chief Executive have a responsibility to ensure that 
systems, policies, and procedures are in place to provide an effective and 
appropriate resuscitation service. A suitable infrastructure is required to 
Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 13> of < 27>  

 
 
 
 
 
 establish and continue support for these activities. 

The Chief Medical Officer (CMO) has executive responsibility for this policy. 
The CMO has responsibility for ensuring that all medical staff (not in training) 
receive the appropriate resuscitation training, that it is recorded, and that all 
non-attendees of resuscitation training are followed up (this may be delegated 
to Clinical Group Directors). 

The Chief Nursing Officer (CNO) has responsibility for ensuring that all non-
medical staff (not in training) receive the appropriate resuscitation training, 
that it is recorded, and that all non-attendees of resuscitation training are 
followed up (this may be delegated to Clinical Group Directors). 

6.2   The Deteriorating Patient and Resuscitation Group and Resuscitation 

Team 

The Deteriorating Patient and Resuscitation Group and Team are responsible 
for policy implementation, distribution, and monitoring compliance throughout 
the Trust, as well as advising the Trust on matters relating to the deteriorating 
patient and the patient in need of cardiopulmonary resuscitation. 

The Group and Team are responsible for providing sufficient training courses 
and places in accordance with the training matrix. This will also include the 
maintenance of the resuscitation learning modules and equipment. 

6.3   Procurement Department 

The Procurement Department has a responsibility to liaise with the 
Deteriorating Patient and Resuscitation Group and Team about any plans to 
introduce new equipment in relation to resuscitation within the Trust. This will 
require the input of Medical Engineering and/or Medical Physics in relation to 
any electrical equipment. 

All resuscitation equipment purchased should be subject to the Trust’s 
standardisation strategy. Therefore, all resuscitation equipment placed upon 
the approved purchase list should be agreed by the DP&RG, and any other 
equipment purchased outside of this should be sanctioned by the DP&RT 
prior to ordering. 

6.4   Medical Engineering 

Medical Engineering is responsible for servicing medical equipment and 
liaising with the Deteriorating Patient and Resuscitation Group and Team 
regarding product changes, alerts, or recalls. 

Medical Engineering must have a maintenance schedule and an ongoing 
replacement plan. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 14> of < 27>  

 
 
 
 
 6.5   Switchboard 

Switchboard responsibilities include ensuring the working order of telecom 
devices such as speech paging and answering emergency calls promptly to 
immediately alert the emergency team as per the procedure. 

The Organisation’s Switchboard is to keep a record of all emergency calls. 

Test Calls will perform daily test calls to the emergency team members at pre-
arranged times. If a team member does not reply within 5 minutes, 
switchboard staff will send a second test bleep for that bleep holder only. 

If again there is no reply within 5 minutes, or it has been established the bleep 
is not being covered appropriately, the switchboard will inform the emergency 
team registrar-tier doctor to arrange cover. 

If the registrar is the bleep holder who is not responding, the Medical 
Consultant on call must be informed to arrange cover. 

Test calls must be conducted and escalated appropriately. 

6.6   Ward and Departmental Managers 

Ward and Department managers are responsible for ensuring staff members 
have access to and adhere to this policy. 

Ward and Departmental Managers must recognize the training needs of their 
staff by completing a Training Needs Analysis (TNA) and an annual appraisal, 
ensuring that staff are provided with access to training at the appropriate 
level. 

Details of the training requirements are contained within the departmental 
Training Needs Analysis. Staff need to complete the e-Learning for health 
BLS module (valid for two years) before their BLS practical can be assessed 
by a BLS assessor. 

6.7   Clinical Staff 

Clinical Staff are responsible for recording patients’ physiological parameters, 
escalating variance according to the Trust’s escalation plan (Policies identified 
above) Clinical staff are responsible for accurately recording patients' 
physiological parameters and ensuring any abnormalities are escalated 
according to the Trust’s full escalation plan, which must be referenced in 
clinical documentation. This includes not only documenting actions taken but 
also any omissions, ensuring accountability and transparency. Staff must 
adhere strictly to the escalation protocol, which outlines specific thresholds for 
when and how to report patient deterioration, ensuring timely interventions. 
Being explicit in carrying out these duties can improve patient outcomes by 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 15> of < 27>  

 
 
 
 
 promoting rapid response to critical changes in a patient’s condition. 

Clinical Staff are responsible for immediately alerting for an emergency team 
or 999 Ambulance if emergency assistance is needed. 

Staff will attend training related to deteriorating patients. The type and level of 
skill will vary and depend on the role of each staff member. 

While it is the responsibility of each practitioner to maintain the appropriate 
level of skill, it is also the Trust’s responsibility to ensure that adequate 
training is available, and systems are in place to remind staff of their training 
responsibilities. 

Take account of Patients’ Resuscitation Status. 

Cooperate with the emergency team or West Midlands Ambulance Service 
Emergency crew. 

Support relatives, other patients, and staff who are involved in, or witness, a 
resuscitation attempt. 

Attend Debrief Sessions as required. 

Each staff member is responsible for ensuring that they comply with the Trust 
policy and attend designated training courses as dictated by their training 
needs and PDR (Personal Development Review) to achieve the level agreed. 

6.8   Non-Clinical Staff 

Non-clinical staff have a responsibility to respond immediately to all situations 
where there is a suspicion of resuscitation being required and to cooperate 
with the emergency team or West Midlands Ambulance Service Emergency 
crew if required. 

Each staff member is responsible for ensuring that they comply with this trust 
policy and attend training as dictated by their TNA and PDR to achieve the 
level agreed. 

6.9  

Instructors 

Life support instructors must work within the limitations of the Council they are 
registered with. Instructors’ role is to carry out life support training and are 
responsible for ensuring competency, documentation, and logging training 
sessions. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 16> of < 27>  

 
 
 
 
 6.10   Basic Life Support Assessors 

Basic Life Support Assessors (BLS Assessors) are responsible for assessing 
BLS within their clinical area as part of the Trust’s mandatory training. Their 
role is to ensure that assessments are per current National and Trust 
resuscitation guidelines/policies, ensuring that candidates have completed the 
BLS e-learning module or other Trust-agreed learning before the assessment. 

To stay current and in date for BLS, BLS Assessors are responsible for 
booking their own ‘BLS Assessors update’ to be both updated and assessed 
by the DP&RT annually. 

Where BLS assessors are available, the manager must allow an opportunity 
for assessments to be completed. 

6.11   New Staff and Students 

All new staff must complete the appropriate training indicated in the Statutory, 
Mandatory, and Risk Management Training Policy (SW BH/HR/016). 

6.12   EMRT Core Members 

All emergency team Leaders must hold a current Advanced Life Support 
Provider certificate and use the up-to-date skills recommended by the 
Resuscitation Council (UK) or Advanced Life Support Group. Practicing 
members have a responsibility to keep this certificate in date. 

Core members of the emergency team are responsible for ensuring that they 
are familiar with the emergency equipment available and how to use any 
piece of equipment relevant to their role. All members of the team are 
expected to be familiar with the contents of the standardised Adult and 
Paediatric Emergency Equipment trolley and out-of-hospital emergency bag. 

Core members of the emergency team must log in for their duty and complete 
their details using the appropriate system (see Annex 3). 

It is the responsibility of each emergency team member to familiarise 
themselves with relevant information before commencing their duty and act 
within the terms of this Policy or best practice. 

All team members must attend to any call they receive with appropriate haste 
while maintaining their own and others’ safety. 

Special conditions apply when resuscitating children, newborns, and pregnant 
women, both in the aetiology of cardiopulmonary arrest and in the techniques 
of resuscitation. It is imperative that experienced personnel are present at the 
resuscitation attempt and that the appropriate 2222 call for the speciality is 
made. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 17> of < 27>  

 
 
 
 
 Core members are to attend the emergency team briefing for the shift they are 
covering. When team members change mid-shift, the baton bleep must be 
exchanged, and they must register their role on the emergency team sign-in. 
A face-to-face handover must be attended by all core members. For meeting 
locations, please see Annex 03. 

Core members will attend 2222 Emergency calls to areas in and around the 
Organisation. The perimeter line surrounding the hospital is considered the 
boundary, and outside these areas, i.e., on footpath, staff should dial 999. If 
the emergency team is not available to attend incidents in the outside areas of 
the hospital site, a 999-ambulance response is expected. 

Core membership of the Adult and Paediatric emergency teams within the 
Trust is detailed in annex 3 of this policy. 

7:  

PROCEDURE (including by site) 

7.1 

Early Warning Scores 

Staff will record patient physiological observations, escalate according to the 
Trust’s Physiological Observations, Monitoring and Escalation Policy and 
plan, and document their acts and omissions accordingly.  

All clinical staff must be trained in the identification of the deteriorating patient 
and the use of physiological observation charts/systems to enhance decision-
making and care escalation. 

The Trust has Early Warning/Patient at Risk Systems for adults (NEWS) and 
paediatrics (PEWS), established for the detection of the deterioration or 
change in patient condition. All clinical staff will be trained in the identification 
of ill/deteriorating patients and the use of the Trust physiological observation 
tool to enhance decision-making and care escalation as indicated in the 
Physiological Observation, Monitoring and Escalation policy (SWBH/Pt 
Care/132). 

NB: Parameters (triggers) for escalation may be reset for patients on the 
Supportive Care Path in the terminal phase of their illness and patients with 
chronic long-term conditions (Ref to the Supportive care plan). Parameters 
can be re-set by a registrar tier member of medical staff in an emergency and 
confirmed with the responsible Consultant within 24 hours at MMUH and 96 
hours at Rowley Regis Hospital. 

There is a Paediatric escalation policy relating to what to do if there are 
concerns regarding a child’s condition. Escalation of concerns regarding 
patient condition (Paediatrics) can be found in the Observation and Monitoring 
Policy for Children and Young People (SWBH/Paed/167). 

Paediatric clinical guidelines for managing Acute Life-Threatening Events 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 18> of < 27>  

 
 
 
 
 
 (ALTE) In Children can be found here: (SWBH/Paed/170). 

NEWS2 and SpO2 Scale: Patients must be scored using SpO2 scale 1 
unless there is a documented amendment by an appropriately skilled clinician 
on the recommendation of arterial blood gases. 

7.2   CALLS FOR EMERGENCY INTERVENTION  

Immediately contact the emergency team or 999 Ambulance by calling the 
switchboard by dialling 2222 (‘double two - double two’) if a patient or other 
person requires emergency medical help. Indicate the category of the patient, 
for example, an adult emergency, a paediatric emergency, etc., and give the 
exact location of the incident. 

Do not differentiate between a Cardiac Arrest or a deteriorating patient, as all 
calls will be placed as emergency call. For example: “Adult Emergency, A6 Side 
Room 3”. 

Upon receiving an emergency intervention call, the switchboard operator will 
immediately relay the call details to the appropriate response team using the 
current voice bleep system. The operator will ensure that all pertinent information, 
including the location and any specific instructions, is communicated over the 
voice bleep. Each team member will then receive these details through their 
assigned bleeps. 

Critical Care and the Cardiac Cath Lab may not initially activate a 2222 call due 
to the appropriate skills mix of staff available. If the emergency team is prolonged 
or extra assistance is required, a 2222 call is available. Cardiac arrests occurring 
within these areas must be recorded on Unity (EMRT power chart), and the 
DP&RT will be informed. 

Community staff must call 999 for West Midlands Ambulance Service. They will 
require the address of your location and, where possible, the full postcode. 

Appropriately trained staff are expected to provide initial support, begin first aid 
(including BLS if required) according to the needs of the patient, and continue 
until advised to stop by the emergency team or West Midlands Ambulance 
Service Emergency crew. In areas where patients requiring resuscitation may be 
treated without alerting the emergency team (e.g., Intensive Care Unit, 
Emergency Department), Advanced Life Support (ALS) should begin as soon as 
possible, according to the patient’s needs and the individual staff member's 
abilities. Staff who are suitably trained should initiate secondary, advanced 
resuscitation interventions depending on the patient’s needs. 

CALLS FOR EMERGENCY INTERVENTION in non-MMUH Estates 

If a patient deteriorates significantly, including cardiac arrest, and is for treatment, 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 19> of < 27>  

 
 
 
 
 
 
 
 
 
 2222 will be called and a 999-ambulance requested. 

a.  In hours 0700 - 1900h the emergency team will come from the on-site 

Team as described in Annex 3 

b.  An additional emergency response from the ambulance service will be 

activated, as necessary 

c.  Out of Hours, 2222 call will be made with a request for 999-ambulance 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 20> of < 27>  

 
 
 
 
 
 
 
 7.3   SITE-SPECIFIC RESPONSE: (SEE ANNEX 3) 

7.3.1  Sandwell Health Campus  

In Hours Sandwell will have an emergency team Monday – Friday, 0700 - 
1900h. All emergency medical response bleeps are alerted. Each member of 
the site response team must respond at the earliest opportunity if it is safe to 
leave their area. 

On receiving a 2222 call, switchboard will confirm the need for a 999-
ambulance call and activate this response, if necessary, as well as 
dispatching the SWB emergency team. 

If in cardiac arrest, BLS with AED will be commenced by the local team, and 
a call will be put out for the attendance of the emergency team via 
switchboard 2222.   

Advanced Life Support will be provided by appropriately trained team 
members as necessary when they arrive. 

If the patient is acutely unwell and deteriorating and immediate emergency 
medical attention is required, a call will be put out for the attendance of the 
emergency team via switchboard 2222. 

The emergency team staff will assess and treat the patient and determine 
what ongoing management strategy is necessary. The expected pathways will 
include: 

a.  Remain in the same clinical environment at the retained estates (ie 

event has resolved or does not need interventions beyond those 
available at the retained estate). This includes patients who did not 
survive. 

b.  Urgent transfer (e.g. within the next several hours, not blue light) to 

MMUH for ongoing care  

i.  The emergency team will contact the relevant on-call doctor at 

MMUH and refer the patient to their care 

ii.  The emergency team will call 2222 to request an urgent 

ambulance transfer  

iii.  Ongoing care needs before the transfer will be determined and 

continued as needed 

c.  Immediate transfer (e.g. 999-ambulance, blue light) to MMUH for 

emergency treatment 

i.  The emergency team will contact the relevant on-call doctor at 

MMUH and refer the patient to their care 

ii.  The emergency team will call 2222 to request an immediate 

999-ambulance transfer (by a paramedic-led crew) 

iii.  Ongoing care needs before the transfer will be determined and 

continued as needed 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 21> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 d.  Complex immediate transfer to MMUH is rare and are patients with 

critical illness that would prevent safe transfer by a standard 
paramedic-led crew (eg respiratory failure requiring enhanced support, 
such as anaesthesia or ventilation, severe agitation or abnormal 
consciousness requiring anaesthesia) 

i.  The emergency team will call the relevant theatre complex to 
request critical care support from onsite anaesthesia staff (if 
available) 

ii.  The emergency team will call 2222 to initiate critical care 

support from MMUH.  

iii.  Critical care transfer from the retained estates to MMUH will be 
undertaken by the Adult Critical Care Co-Ordination & Transfer 
Service (ACCOTS) with relevant assistance from the MMUH 
critical care staff 

Outside of the specified hours, there is no SWB emergency team. In an 
emergency, call 2222 (for a 999-ambulance) or directly call 999. Local staff, 
as available, will provide first aid or life support. 

City Health Campus  

City Health Campus will have an emergency team at all times. All emergency 
medical response bleeps are alerted. Each member of the site response team 
must respond at the earliest opportunity if it is safe to leave their area. 

On receiving a 2222 call, switchboard will confirm the need for a 999-
ambulance call and activate this response, if necessary, as well as 
dispatching the SWB emergency team. 

If in cardiac arrest, BLS with AED will be commenced by the local team, and 
a call will be put out for the attendance of the emergency team via 
switchboard 2222.   

Advanced Life Support will be provided by appropriately trained team 
members as necessary. 

If the patient is acutely unwell and deteriorating and immediate emergency 
medical attention is required, a call will be put out for the attendance of the 
emergency team via switchboard 2222. 

The emergency team staff will assess and treat the patient and determine 
what ongoing management strategy is necessary. The expected pathways will 
include: 

e.  Remain in the same clinical environment at the retained estates (ie 

event has resolved or does not need interventions beyond those 
available at the retained estate). This includes patients who did not 
survive. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 22> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 Urgent transfer (e.g. within the next several hours, not blue light) to MMUH 
for ongoing care  

i.  The emergency team will contact the relevant on-call doctor at 

MMUH and refer the patient to their care 

ii.  The emergency team will call 2222 to request an urgent 

ambulance transfer  

iii.  Ongoing care needs before the transfer will be determined and 

continued as needed 

Immediate transfer (e.g. 999-ambulance, blue light) to MMUH for emergency 
treatment 

iv.  The emergency team will contact the relevant on-call doctor at 

MMUH and refer the patient to their care 

v.  The emergency team will call 2222 to request an immediate 

999-ambulance transfer (by a paramedic-led crew) 

vi.  Ongoing care needs before the transfer will be determined and 

continued as needed 

Complex immediate transfer to MMUH is rare and are patients with critical 
illness that would prevent safe transfer by a standard paramedic-led crew (eg 
respiratory failure requiring enhanced support, such as anaesthesia or 
ventilation, severe agitation or abnormal consciousness requiring 
anaesthesia) 

vii.  The emergency team will call the relevant theatre complex to 
request critical care support from onsite anaesthesia staff (if 
available) 

viii.  The emergency team will call 2222 to initiate critical care 

support from MMUH  

ix.  Critical care transfer from the retained estates to MMUH will be 
undertaken by the Adult Critical Care Co-Ordination & Transfer 
Service (ACCOTS) with relevant assistance from the MMUH 
critical care staff 

7.3.2  Other Community Sites include Rowley, Leasowes, GP Surgeries, Health 

Centres, Patients' Homes, etc. 

The response on these sites is BLS (and AED where available), which will be carried 
out by appropriately trained staff. 

An ambulance service response is initiated by calling (Hospital Site) 2222 for a 999 
call or 999 where an ambulance is required for all other sites. Advanced Life Support 
will be provided by the ambulance service. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 23> of < 27>  

 
 
 
 
 
 
 7.3.3  Shared Public Areas within Main Buildings (e.g., corridors, restaurants, 

etc.) 

In most instances, the nearest member of staff to the incident should summon 
local help and emergency calls via 2222 or 999 (as above) for ambulance service 
assistance as per site response. 

If there is a nearby clinical area, they could be contacted to provide clinical 
expertise and equipment to patients, visitors, and staff suffering a medical 
emergency. 

7.3.4  Other Areas Outside Main Buildings (e.g., grounds, car parks) 

If a person has become unwell outside any site of the main building, the staff who 
find them should summon help as per site response. 

If access to an internal phone is not possible, such as in the event the person is 
in an isolated place, then staff should call for an ambulance as they would in a 
public setting, i.e., 999, from a mobile phone. 

7.4   Resuscitation Equipment, Defibrillators, and Defibrillation 

Emergency equipment will be available for clinical areas of the hospital. Most of 
these areas will have a dedicated emergency equipment trolley, which will 
contain standardised equipment recommended by the RC(UK). The standardised 
equipment cannot be changed without authorisation from the DP&RT. 

There are defibrillators on top of the Trust emergency equipment trolleys. Some 
are dedicated to specific wards/areas; others may share equipment with other 
departments. It is the ward/unit’s responsibility to check and make available the 
defibrillators and trolleys. The ward/unit does not own them and must not remove 
them from the area or make them inaccessible without consulting the DP&RT, as 
doing so may leave the area unsafe. 

Manual defibrillation in patients for the treatment of a shockable cardiac arrest 
may be performed by a Registered Health Professional who has been trained 
and deemed competent. Automated External Defibrillation (AED) in patients to 
treat shockable cardiac arrests may be performed by a person who feels 
competent and confident in its use. Where areas do not have access to 
emergency equipment, an out-of-area emergency equipment bag will be provided 
with the EMERGENCY TEAM. 

7.5   Treatment Escalation Plans and Do Not Attempt Cardiopulmonary 

Resuscitation 

It is essential to identify patients where it is inappropriate to attempt resuscitation 
or where a patient is refusing or has refused resuscitation in advance. For further 
information, please refer to the Treatment Escalation Plan policy (SWBH/Pt Care 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 24> of < 27>  

 
 
 
 
 
 
 
 
 062). 

Having an altered resuscitation status is a positive decision not to attempt 
resuscitation in the event of cardiorespiratory arrest. It is used when clinicians 
consider that attempting to resuscitate would be medically inappropriate (i.e., 
CPR would be unsuccessful) or it has been determined not to be in the patient’s 
best interest. 

A Treatment Escalation Plan may have variables and omissions. Whenever there 
is doubt about a patient’s status, the decision must always be in favour of starting 
resuscitation until the status is confirmed. 

Even with a DNACPR/TEP in place, THE PATIENT WILL STILL REMAIN 
SUITABLE TO CALL 2222/EMRT IN THE EVENT OF AN IMMEDIATELY 
REVERSIBLE CONDITION INCLUDING: 

· Anaphylaxis 

· Choking or blocked tracheostomy tube 

· New event unrelated to current clinical condition e.g fracture following a fall 

7.6   Not for EMRT 

There may be some patients who have reached a ceiling of medical care for 
whom an emergency team call may not be appropriate; in fact, it may be 
distressing for the patient, family, and carers if the emergency team were to be 
called. In these circumstances, the team caring for the patient may decide that 
the emergency team should not be called. 

All such patients must have this decision annotated within the Treatment 
Escalation Plan on Unity. 

It is expected good practice that this decision will be discussed and 
communicated with the patient and relatives where appropriate. 

“Not for EMRT” must be a Consultant decision, with the reasons documented in 
the Treatment Escalation Plan. It must be communicated to all members of the 
Multidisciplinary Team (MDT) caring for that patient. If a Consultant is not 
available, the decision can be made by an appropriately senior member of staff 
(as described within the DNACPR/TEP policy) and must be discussed with and 
countersigned by a Consultant within the timescale defined in that policy. The 
medical staff below a registrar tier level are not considered senior enough to 
make this temporising decision. If this decision is made, consider commencing 
the End of Life care plan (Supportive Care Plan A Guide for Clinicians (SWBH/Pt 
Care/100)). 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 25> of < 27>  

 
 
 
 
 
 
 
 
 
 
 7.7   Simultaneous EMRT Calls - MMUH 

Managing Multiple Calls: In the event of a second simultaneous emergency 
team call within MMUH, the team leader is responsible for assigning available 
team members to attend the second call if resources permit. If this is not feasible, 
the team leader must promptly contact the switchboard via 2222 to activate the 
opposite A or B team. Quick and decisive action is crucial to minimise any 
inevitable delays and to optimise outcomes for all patients involved. 

Notification of Delays: Staff initiating the second call must be informed by the 
switchboard at the time of the call about the possibility of a short delay. They 
should continue providing emergency treatment, whether basic or advanced, 
within their scope of practice despite the potential delay in the arrival of additional 
support. 

Pre-Agreed Roles: The emergency team members can pre-assign roles during 
the briefing, identifying who will respond to a second call. If this hasn’t been done, 
the team leader should send non-essential staff from the first incident to the 
second as soon as it is safe. Other team members will respond to the second 
incident as soon as the first is resolved. 

Communication with Switchboard: The team leader must ensure that the 
switchboard is updated on the status and response to both incidents. 

7.8   Relatives Witnessing Resuscitation 

The Trust supports relatives if they wish to be present during a resuscitation 
attempt. There will be occasions when the emergency team leader deems it 
inappropriate for relatives to be present. 

The overall decision remains with the emergency team leader, which must be 
documented if this occurs. A competent member of staff must be delegated to 
stay with the relatives and liaise with the emergency team on their behalf. 

This member of the team must have the ability to pre-empt what process or 
intervention will be coming next to sufficiently prepare the family or relative. 

7.9   EMRT Call during a Fire Alarm 

If there is an emergency team call during a fire alarm, the following must be 
adhered to: Fire Safety Management Policy (SWBH/ORG/043). 

Core EMRT members will attend the call if their safety is maintained. 

7.10   Major Incident 

During a major incident, the emergency team will continue to operate in the same 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 26> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 way. SWB Major Incident Plan - Incident Response Plan (SWBH/ORG/01). 

7.11   MANAGEMENT OF TRAUMA 

7.11.1 Management of Trauma at MMUH 

A person may be present with serious injuries at MMUH. This will be a rare event 
and will include incidents such as falls from height (eg from overhanging levels, 
falls down escalators), violence (eg blunt or penetrating wounds), hanging, or 
drowning. 

Staff must consider their safety, undertake a personal dynamic risk assessment 
and not approach if this would significantly endanger them. 

Call 2222 to activate the standard emergency team response. 

The switchboard will call the ambulance service upon receiving a 2222 call for a 
seriously injured person. The ambulance service will determine which assets, 
such as enhanced care teams (e.g. MERIT, Critical Care Paramedic, HEMS) or 
Hazardous Area Response Teams, to send to the scene. Police and fire services 
may also be called to attend. 

At MMUH, there is a trauma team (accessed via 2222) that is available to 
respond and will be called for predetermined incidents (eg fall from a significant 
height) or after patient assessment by the initial emergency team. The trauma 
team will provide additional emergency care in situ. 

The seriously injured patient will be moved as soon as possible to MMUH 
Emergency Department, if possible and appropriate, or taken to the major trauma 
centre by the ambulance service, as per the regional major trauma triage tool. 

For major haemorrhage from trauma, management might include any or all of the 
following: 

a.  Applying appropriate direct pressure 
b.  Elevation of the affected area 
c.  Use of a Combat Application Tourniquet (CAT) if trained to do so 
d.  Use of appropriate wound bandaging 
e.  Conveying the patient to the appropriate emergency department as 

required. 

7.12  Canal Incidents 

If a person is found in the canal, no attempt to rescue by entering the water is 
expected. Appropriate flotation devices should be deployed. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 27> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 
 
 7.13 Management of Trauma in Retained Estates 

In the absence of a dedicated trauma team in areas such as the retained 
estates, the patient should be managed in situ with appropriate first-aid 
treatments. 

A 999-emergency response will be initiated. 

For major haemorrhage from trauma, management might include any or all of the 
following: 

a.  Applying appropriate direct pressure 
b.  Elevation of the affected area 
c.  Use of a Combat Application Tourniquet (CAT) if trained to do so 
d.  Use of appropriate wound bandaging 
e.  Conveying the patient to the appropriate emergency department as 

required. 

7.14   Priority Lift Access MMUH 

Members of the Emergency Medical Response Team (EMRT) at Midland 
Metropolitan University Hospital are granted priority lift access to ensure rapid 
response during emergencies. This priority access allows team members to 
override lifts when attending an emergency or for the critical transfer of patients 
following or during an emergency. 

Priority lift access is strictly for use during emergencies and critical patient 
transfers. It must not be used for non-emergency situations. 

Lift override keys or cards are provided to enable priority access. These cards 
are to be always kept with the emergency baton bleep. 

Staff members are responsible for safeguarding the lift override keys/card. They 
must ensure that these are properly handed over during shift changes and 
reported immediately if they are lost or misplaced. 

8:  

EQUITY AND DIVERSITY 

The Trust recognises the diversity of the local community and those in its employ. 
Our aim is, therefore, to provide a safe environment free from discrimination and 
a place where all individuals are treated fairly, with dignity, and appropriately to 
their needs. 

The Trust recognises that equity impacts all aspects of its day-to-day operations 
and has produced an Equity Policy Statement to reflect this. 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 28> of < 27>  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 References: 

Royal College of Nursing (2024) Recognising and managing deteriorating 
patients. Available at: https://www.rcn.org.uk/Page-Testing/Recognising-and-
managing-deteriorating-patients (Accessed: 17 September 2024). 

Emergency Medical Response and the Management of Resuscitation   Review date: 2 yrs  
Expiry date: 3 yrs  
Valid from:  1 March 2025 

Page < 29> of < 27>