VHA Directive 1177, Cardiopulmonary Resuscitation

T-1

Department of Veterans Affairs VHA DIRECTIVE 1177

Veterans Health Administration Transmittal Sheet

Washington, DC 20420 January 4, 2021

CARDIOPULMONARY RESUSCITATION

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive

maintains policy to optimize patient safety within the Department of Veterans Affairs

(VA) health care system. This ensures that VHA has emergency response capability to

manage cardiac arrests on VHA property. This includes access to appropriate

resuscitation equipment and appropriately trained responders.

2. SUMMARY OF MAJOR CHANGES: Major changes include:

a. Removal of references to vendor-specific certification standards within VA or the

Department of Defense (DoD).

b. Clarification of which personnel require Basic Life Support (BLS) and Advanced

Cardiac Life Support (ACLS) training (see paragraph 6).

c. Expansion of definitions and clarification of duties and responsibilities of clinical

personnel.

3. RELATED ISSUES: None.

4. RESPONSIBLE OFFICE: The Office of Specialty Care Services (11SPEC) is

responsible for the contents of this VHA directive. Questions may be referred to the

National Program Director for Pulmonary and Critical Care at 214-857-0405.

5. RESCISSIONS: VHA Directive 1177 Cardiopulmonary Resuscitation, Basic Life

Support, and Advanced Cardiac Life Support Training for Staff, dated August 28, 2018

is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before

the last working day of January 2026. This VHA directive will continue to serve as

national VHA policy until it is recertified or rescinded.

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Kameron Matthews, MD, JD

Assistant Under Secretary for Health

for Clinical Services

January 4, 2021 VHA DIRECTIVE 1177

T-2

NOTE: All references herein to VA and VHA documents incorporate by reference

subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publication Distribution List on January 4, 2021.

January 4, 2021 VHA DIRECTIVE 1177

CONTENTS

CARDIOPULMONARY RESUSCITATION

1. PURPOSE ................................................................................................................. 1

2. DEFINITIONS ............................................................................................................ 1

3. POLICY ..................................................................................................................... 1

4. RESPONSIBILITIES ................................................................................................. 1

5. PERFORMANCE MEASUREMENT .......................................................................... 6

6. TRAINING REQUIREMENTS ................................................................................... 6

7. RECORDS MANAGEMENT ...................................................................................... 8

8. REFERENCES .......................................................................................................... 8

APPENDIX A

DOCUMENTATION AND TRACKING OF TRAINING AND CERTIFICATION ........... A-1

January 4, 2021 VHA DIRECTIVE 1177

CARDIOPULMONARY RESUSCITATION

1. PURPOSE

This Veterans Health Administration (VHA) directive maintains policy to optimize

patient safety for those requiring resuscitation within the Department of Veterans

Affairs (VA) health care system. This is accomplished by ensuring that clinical staff that

are trained in Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) are

available at all times for resuscitation. The outcomes of these attempts are measured

accurately and reported appropriately. AUTHORITY: Title 38 United States Code

(U.S.C.) 7301(b).

2. DEFINITIONS

a. Cardiopulmonary Arrest. Cardiopulmonary arrest is the loss of airway,

breathing, or circulation necessary to maintain life that would result in death if not

treated, often referred to as a “code.”

b. Cardiopulmonary Resuscitation. Cardiopulmonary Resuscitation (CPR) is the

use of therapeutic interventions, including BLS and ACLS, which are designed to

restore spontaneous circulation following cardiac or respiratory arrest.

c. Trainees. A general term to describe undergraduate, graduate, or post graduate

students, interns, residents, fellows, and VA advanced fellows including pre- and post-

doctoral fellows whose time at a VA medical facility is spent in clinical or research

training experiences to satisfy recognized health professions training program

requirements including eligibility for a clinical degree. Trainees only provide clinical

care under supervision and are not considered staff for the purposes of this directive.

3. POLICY

It is VHA policy that any VA health care provider actively participating in direct

patient care in any clinical setting, including community or home care settings, as well

as all VA health care providers credentialed for direct patient care must maintain

training in Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) as

appropriate to the provider’s credentials.

4. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for

ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Clinical Services. The Assistant

Under Secretary for Health for Clinical Services is responsible for oversight for the

fulfillment of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under

Secretary for Health for Operations is responsible for:

January 4, 2021 VHA DIRECTIVE 1177

(1) Communicating the contents of this directive to each of the Veterans Integrated

Service Networks (VISNs).

(2) Providing assistance to VISN Directors to resolve implementation and

compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to assure compliance with this directive, relevant

standards and applicable regulations.

d. Assistant Under Secretary for Health for Discovery, Education and Affiliate

Networks. The Assistant Under Secretary for Health for Discovery, Education and

Affiliate Networks is responsible for ensuring recertification of the VHA National

Training Program, Resuscitation Education Support Initiative (REdI) over which they

have primary responsibility.

e. Director, VHA Office of Specialty Care Services. The Director of the VHA

Office of Specialty Care Services is responsible for providing the national guidance for

clinical programs and VHA policy related to the monitoring and improvement of

processes related to cardiopulmonary resuscitation.

f. VHA National Program Director, Resuscitation Education Initiative. The VHA

National Program Director of REdI is responsible for:

(1) Maintaining REdI as the official VHA national program to provide enterprise wide

oversight and support through the standardization of all resuscitation training products,

equipment, tracking, and monitoring.

(2) Identifying and recruiting subject matter experts (SMEs) for the development and

fielding of national resuscitation curricula.

(3) Working with VA medical facilities, identified as at-risk through self-identity or

through reporting to IPEC or applicable accreditation/regulatory organization to identify

gaps and solutions related to resuscitation to equip them with the tools and resources

needed to improve patient outcomes as a result of on-going training.

(4) Serving as the SME for review and evaluation of standardized resuscitation

training materials and equipment for future procurement, and the development of

assessment tools beyond the minimum requirements for BLS and ACLS.

g. Veterans Integrated Service Network Director. The VISN Director in

collaboration with the Chief Medical Officer is responsible for ensuring that every VA

medical facility, (including medical centers, Community Based Outpatient Clinics

(CBOCs), domiciliary, and administrative units) have a plan and the resources in place

to rapidly initiate the appropriate emergency response, regardless of location or time of

day, that is inclusive of patients, visitors, and employees who may suffer a cardiac

arrest while in and around the VA medical facility.

January 4, 2021 VHA DIRECTIVE 1177

h. Veterans Integrated Service Network Chief Medical Officer. The VISN Chief

Medical Officer is responsible for:

(1) Ensuring that every VA medical facility, (including medical centers, CBOCs,

domiciliary, and administrative units) have a plan and the resources in place to rapidly

initiate the appropriate emergency response, regardless of location or time of day, that

is inclusive of patients, visitors, and employees who may suffer a cardiac arrest while

in and around the VA medical facility in collaboration with the VISN Director; and

(2) Reviewing any concerns or quality issues as reported by the VISN Quality

Management Officer and following up with the facility on issues that arise from

applicable accreditation/regulatory organization or other entities.

i. Veterans Integrated Service Network Quality Management Officer. The VISN

Quality Management Officer is responsible for:

(1) Providing follow-up support to each VA medical facility, Cardiovascular

Resuscitative Committee (CRC), or equivalent committee related to cardiopulmonary

events in meeting standards from applicable accreditation/regulatory organization or

other entities conducting survey of compliance.

(2) Reporting any concerns or quality issues through appropriate channels to the

VISN Director and VISN Chief Medical Officer.

(3) Reporting any concerns or quality issues through appropriate channels to the

VHA National Program Director of REdI.

j. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Implementing this national directive locally.

(2) Ensuring easy access to public Automated Electronic Defibrillators (AEDs); this

includes placement in high-use areas, such as: lobbies, cafeterias, research buildings,

out-buildings, free-standing dialysis units, areas with therapeutic swimming pools, and

all satellite buildings. NOTE: It is strongly recommended that all VA police cars have

an AED for use in parking lots and other distant sites.

(3) Ensuring development of a scripted communication process for internal code

alert system response notifications, including switchboard operators and external

emergency response providers.

(4) Ensuring that sufficient BLS and ACLS equipment is always available for

training departments to conduct required training through the REdI coordinator or

equivalent.

(5) Ensuring that VA Talent Management System (TMS) or any future replacement

VA training documentation system is used as the tracking and reporting system for all

individuals who require VA validation of certification.

January 4, 2021 VHA DIRECTIVE 1177

(6) Ensuring that new employees who will be assigned as clinically credentialed

staff have the required BLS or ACLS certification prior to assuming clinical duties.

(7) Ensuring the VA medical facility maintains affiliation with the REdI program.

(8) Ensuring that the training for the BLS and ACLS includes components approved

by REdI.

(9) Ensuring that only certification approved by REdI or the DoD for BLS and ACLS

are accepted for staff renewing their certification. Those sites that share personnel with

the DoD can accept DoD approved certification. In-house certification is required for

existing full-time permanent staff renewing their certification, however certification

obtained through an affiliate is allowed if deemed of sufficient quality and approved by

the VA medical facility Director or Chief of Staff. All external certifications must be

validated to ensure validity of training prior to documenting compliance in TMS or for

renewal of any clinical credentialed provider privileges. This can be done by contacting

the affiliate or other institution or by entering the external certification unique eCard

identifier on the vendor website.

(10) Transitioning the VA medical facility training profile from the reliance of

instructor led classes to use of electronic courseware followed by a skills assessment

using a Voice Assisted Manikin (VAM) program.

(11) Ensuring appropriate action is taken against any employee who fails to comply

with this directive. Any disciplinary action must be in accordance with procedures

outlined in VA Handbook 5021 series, Employee/Management Relations, and any

applicable negotiated labor–management agreements.

(12) Establishing ongoing relationships with local and regional Emergency Medical

Service (EMS) providers as EMS may, in certain circumstances, be involved in either

resuscitation, transport, or both. This relationship may require written agreements

covering emergency responses on VA medical facilities, as well as transportation

within, into, and out of VA medical facilities.

(13) Ensuring a protocol is in place to ensure that CPR is not attempted with

patients who sustain a cardiopulmonary arrest and have a DNAR/DNR (do-not-

attempt-resuscitation / do-not-resuscitate) documented in the electronic health record

(EHR) or valid state-authorized portable order (SAPO) for DNAR/DNR (see VHA

Handbook 1004.03(1), Life Sustaining Treatment Decisions: Eliciting, Documenting

and Honoring Patients’ Values, Goals and Preferences, dated January 11, 2017, and

VHA Handbook 1004.04, State - Authorized Portable Orders (SAPO), dated

February 26, 2019.

(14) Approving permanent waivers for permanent disabilities.

k. VA Medical Facility Chief of Staff and Chief Nurse. The Chief of Staff and the

Chief Nurse are responsible for completing the following responsibilities for VA medical

January 4, 2021 VHA DIRECTIVE 1177

facility staff under their purview. The VA medical facility COS and Chief Nurse are

responsible for:

(1) Determining who, under their purview, receives what level of training and where.

(2) Providing training for all clinical staff during their assigned working hours. All

clinically active or credentialed staff will have sufficient uninterrupted time away from

patient care duties to complete the BLS or ACLS training.

(3) Communicating to staff on how to appropriately respond to a cardiac arrest

occurring anywhere at the VA medical facility.

(4) Reviewing extension requests of waivers past 60 days. Written waivers of up to

60 days for individuals whose certifications have expired can be granted by their

immediate supervisor to accomplish recertification if it is in the best interest of Veteran

care and access to care. Any extension of the waiver past 60 days must be granted

through the COS or Chief Nurse.

(5) Reviewing written waivers for temporary disability for an extension of up to one

year. However, these staff members are required to complete the didactic component

of the respective courses as it relates to clinical credentials.

(6) Concurring on permanent waivers for permanent disabilities. NOTE: Granting a

permanent waiver for permanent disability must be approved by the VA medical facility

Director with concurrence by the Chief of Staff and or Chief Nurse. These staff

members are required to complete the didactic component of the respective courses

as it relates to clinical credentials. Anyone assigned a permanent waiver for BLS will

complete The Advisor: BLS program which focuses on their abilities to communicate

and advise another person on how to perform the skills of CPR while waiting for

emergency responders to arrive.

l. VA Medical Facility Based Resuscitation Education Support Initiative

Program Coordinator. The VA medical facility based REdI Program Coordinator is

the liaison between the VA medical facility and the VHA National REdI training

program and is responsible for:

(1) Ensuring compliance with REdI national program requirements.

(2) Monitoring and maintaining an adequate pool of certified instructors to support

the VA medical facility training requirements.

(3) Ensuring required program documentation is provided to REdI and maintaining

archived documents according to REdI and VA records management requirements.

(4) Ensuring a mock code program is implemented across all areas of the VA

medical facility for large facilities, or centrally for small facilities, and that outcomes

from mock codes are used for code response improvement activities.

January 4, 2021 VHA DIRECTIVE 1177

m. VA Medical Facility Cardiopulmonary Resuscitative Committee (CRC) or

Facility CRC Director. The Director of the CRC is responsible for ensuring the review

of each resuscitative episode of care under the VA medical facility’s responsibility is in

accordance with applicable accreditation/regulatory organization standards.

n. VA Medical Facility Quality Manager. The VA medical facility Quality Manager,

or designee, serves as a member of the CRC. At the direction of the CRC Chair is

responsible, with the committee, for:

(1) Addressing any delays in initiating CPR in house and problems in obtaining the

assistance of EMS or use of the 911 call system when the event occurs on a VA

medical facility. Following up on any quality improvement measures identified through

the analysis of:

(a) Real code events.

(b) Rapid response calls.

in the collection, aggregation and analysis of data from code blue, rapid response, and

other critical events. See paragraph 5.

(2) Storing information for presentation to applicable accreditation/regulatory

organization, the VA medical facility Chief of Staff, and the VISN Quality Management

Officer.

o. Health Profession Trainees. Health profession trainees (e.g., medical students,

nursing students, clinical pharmacy students, residents) are responsible for

maintaining the BLS or ACLS certification required by their national accrediting body or

local program certification standards. Only VA sponsored trainees are eligible to

receive VA sponsored resuscitation training. These records are maintained by the

sponsoring educational institution.

5. PERFORMANCE MEASUREMENT

The VA medical facility Quality Manager must aggregate and analyze the data and

compare internally over time and externally with published studies, when available

(benchmarking), and use the data to identify and implement desired changes. The

Inpatient Evaluation Center (IPEC), http://ipec.vssc.med.va.gov/Pages/default.aspx,

maintains an optional site to enter the data from rapid response and resuscitation

efforts and is strongly recommended for sites struggling with outcomes. NOTE: This is

an internal VA website that is not available to the public.

6. TRAINING REQUIREMENTS

a. Advanced Cardiac Life Support Certification. ACLS certification is required

for:

January 4, 2021 VHA DIRECTIVE 1177

(1) Health care personnel that order, administer, monitor, or supervise moderate

sedation, monitored anesthesia care, or general anesthesia.

(2) For dental suites, ACLS is required for dental providers administering or

monitoring moderate sedation or general anesthesia.

(3) Independent practitioners and registered nurses who work in primary support of

patients in the following high risk or critical areas:

(a) Intensive Care Units (medical, surgical, and Coronary Care Units)

(b) Step-down and Telemetry Units.

sedation or anesthesia in post-operative recovery areas, same day surgery suites

recovery areas or operative suites. Surgeons/Proceduralists are not required to have

ACLS certification unless they are responsible for moderate sedation or have primary

responsibility (as opposed to shared responsibility) for Intensive Care Unit patients. A

provider performing a procedure under moderate sedation must have ACLS only if that

provider is also responsible for the moderate sedation, such as ordering the drugs for

the patient.

(d) Procedure rooms or suites, such as Cardiac Catheterization Laboratories,

Electrophysiology Laboratories, Interventional Radiology Laboratories, and

Gastroenterology Endoscopy Laboratories.

(e) Any health care provider, including the Medical Officers of the Day, who would

be required to serve as a “Code Leader.”

b. Basic Life Support Certification. BLS certification is required for:

(1) All clinically credentialed and/or clinically privileged staff employed within VA not

identified for the ACLS training, including any employee involved in patient care for

inpatient, outpatient or residential VA-treatment programs or VA home care programs.

It is not necessary to be certified in both ACLS and BLS. Exceptions include staff

enrolled in low-dose, high-frequency training programs. Staff working in areas with

potential exposure to child and infant resuscitation events, and mandatory for

Emergency Departments and Urgent Care Centers (UCCs) unless currently Board

Certified in Emergency Medicine, or as otherwise determined by the facility CPR

committee. NOTE: Emergency Departments; Current Board-Certified Emergency

Medical Physicians are strongly encouraged, but not required, to have current BLS and

ACLS certification. Clinically-credentialed staff includes all individuals that have the

potential to provide direct clinical care to patients.

(2) Trainees supported by Office of Academic Affiliations must follow the academic

center BLS and ACLS policy requirements.

January 4, 2021 VHA DIRECTIVE 1177

(3) All members of a team that respond to codes in the hospital, VA medical facility

building, or outlying areas (e.g., parking lots, garages, administrative buildings, day

hospitals, etc.) must be ACLS or BLS certified.

(4) Local VA medical facility leadership has the option to require BLS certification

for individuals who serve in a volunteer role, a without compensation employee, or a

contractor.

c. Layperson Training.

(1) Laypersons with the VA medical facilities are often called upon to initiate a code

response or participate in the initial intervention (such as VA Police). Additionally, VHA

is part of the larger community and can support community-based resuscitation

awareness and help increase overall survival rates from cardiac arrests.

(2) Layperson training ranging from awareness to actual training must be available

to all non-clinical staff members. Individual staff members will have the opportunity to

participate and obtain course completion documentation according to the level of

training completed.

7. RECORDS MANAGEMENT

All records regardless of format (paper, electronic, electronic systems) created in

this directive must be managed per the National Archives and Records Administration

(NARA) approved records schedules found in VHA RCS 10-1. Any questions regarding

any aspect of records management should be directed to the VA medical facility

Records Manager or Records Liaison.

8. REFERENCES

a. 38 U.S.C. § 7301(b).

b. VA Handbook 5021, Employee-Management Relations, dated

December 28, 2017.

c. VHA Handbook 1004.03(1), Life Sustaining Treatment Decisions: Eliciting,

Documenting and Honoring Patients’ Values, Goals and Preferences, dated

January 11, 2017.

d. VHA Handbook 1004.04, State - Authorized Portable Orders (SAPO), dated

February 26, 2019.

e. The Inpatient Evaluation Center (IPEC):

http://ipec.vssc.med.va.gov/Pages/default.aspx. NOTE: This is an internal VA website

that is not available to the public.

f. Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, Brooks

SC, de Caen AR, Donnino MW, Ferrer JM, Kleinman ME, Kronick SL, Lavonas EJ,

January 4, 2021 VHA DIRECTIVE 1177

Link MS, Mancini ME, Morrison LJ, O'Connor RE, Samson RA, Schexnayder SM,

Singletary EM, Sinz EH, Travers AH, Wyckoff MH, Hazinski MF. 2015 American Heart

Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2): S315-67, parts 1 to14.

https://www.ncbi.nlm.nih.gov/pubmed/26472989.

g. Strategies to Improve Cardiac Arrest Survival: A Time to Act. Consensus Report.

Robert Graham, Margaret A. McCoy, and Andrea M. Schultz, Editors

https://www.nap.edu/read/21723/chapter/1. NOTE: This is an internal VA website that

is not available to the public.

h. Robert W. Neumar, Brian Eigel, Clifton W. Callaway, N.A. Mark Estes, James G.

Jollis, Monica E. Kleinman, Laurie Morrison, Mary Ann Peberdy, Alejandro Rabinstein,

Thomas D. Rea, Sue Sendelbach, American Heart Association. The American Heart

Association Response to the 2015 Institute of Medicine Report on Strategies to

Improve Cardiac Arrest Survival Circulation, 2015 Sep 15;132(11):1049-1070

10.1161/CIR.0- 0233. https://www.ncbi.nlm.nih.gov/books/NBK321497/.

January 4, 2021 VHA DIRECTIVE 1177

A-1

APPENDIX A

DOCUMENTATION AND TRACKING OF TRAINING AND CERTIFICATION

AND RESUSCITATION EDUCATION INITIATIVE TRAINING

1. The Department of Veterans Affairs (VA) Talent Management System (TMS), or any

future VA replacement training documentation system, is used to track compliance with

the Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) training

requirement for all VA paid staff employees for whom VA is responsible for maintaining

and reporting on training completions. The TMS includes the ability to:

a. Report on status (active, expired) certifications ACLS and BLS.

b. Generate reports of upcoming and current expirations of certifications within

specified time frames.

c. Forward Email reminders out of system for expiring certifications.

d. Waiver certification with appropriate upload of documentation.

2. Resuscitation Education Initiative (REdI) provides critical train-the-trainer clinical

training support to the field’s efforts to provide training and sustainment of a

resuscitation educational program. REdI provides oversight and recommendations for

nationally funded resuscitation training material and equipment. Specifically, REdI

provides the following core products and services:

a. Resuscitation Education Course Evaluation and Administrative Oversight;

b. Resuscitation Simulation Systems Testing; and

c. Field Based Education.

(1) Mock Code Training Program

(2) Resuscitation Instructor and Provider Courses