Emergency physicians’ voice in the ACLS protocol: Guideline’s Eclectic Committee should serve as model

Article Outline

• The birth of cardiac life support
• A shining example of inclusion
• The dollars make sense
• The logic of emergency physician involvement

More emergency physicians than ever before were involved in the development of the 2005 Advanced Cardiac Life Support (ACLS) protocol in what should serve as a model for the creation of guidelines commonly used in the emergency department (ED), experts said.

Every 6 years, the American Heart Association (AHA) publishes a new set of ACLS guidelines, which is no simple task. For the 206 pages of guidelines published last year, 600 reviewers prepared worksheets on more than 300 topics. They consulted 25,000 references. And after 18 months of work, a committee of leading doctors met in Dallas to reach a consensus on how best to draft the detailed medical protocols for lifesaving cardiac care.

Dr. Robert O’Connor, director of education and research at Christiana Care Health System in Delaware, chaired the ACLS subcommittee. Himself an emergency physician, O’Connor said emergency medicine was the best-represented specialty on the committee, and played an integral role in drafting the guidelines. The reason, O’Connor said, is obvious.

• 
  • View Large Image
  • Download to PowerPoint

• Physicians from sundry specialties gather in Dallas to examine the evidence and update the Advanced Cardiac Life Support guidelines. Photo used by permission of the American Heart Association.

“By having increased representation, you increase buy-in by doctors using the guidelines,” said O’Connor, who served as Delaware’s Emergency Medical Services director from 1990 to 1998. “You will only get guidelines as diverse as the composition of your committee. And the more diverse it is, the more relevant the guidelines will be to all disciplines.”

The widespread involvement of emergency physicians in drafting the ACLS guidelines for the AHA has made the process an admirable model for the development of similar guidelines, published both by the AHA and other organizations, said Dr. Judd E. Hollander, clinical research director in the Department of Emergency Medicine at the University of Pennsylvania.

“The participation of emergency physicians in the current guidelines is a reflection of the important role we play in caring for cardiac patients,” Hollander said. “Clearly, for emergency medicine to be reached out to by another society is only a good thing… This is a recognition that some portion of their care, a very important part, happens in the emergency department.”

It hasn’t always been this way.

Until 1947 there was little that doctors could do for heart attacks other than advise rest and provide nitroglycerin for the pain. But then, for the first time, Claude Beck successfully revived a patient in an operating room using an open-chest defibrillator. And 9 years later, Paul Zoll and his colleagues at Harvard University used a more powerful unit to accomplish the first closed-chest defibrillation. Later, the AHA and other organizations began establishing methods for saving the lives of people whose hearts had stopped.

The first emergency cardiovascular care guidelines were established by the AHA in 1974, and they have been updated, based upon the best available scientific evidence, in 1980, 1986, 1992, 2000 and, most recently, last year. (See table for major changes in 2005 ACLS guidelines.)

Table. Major changes in 2005 ACLS Guidelines.

Back to Article Outline

The birth of cardiac life support 

At the time of the first set of guidelines, the field of emergency medicine was in its cradle. The first ACLS protocols were developed by cardiologists and anesthesiologists. That didn’t really change until the early 1980s, said Dr. Allan S. Jaffe, a professor of medicine at the Mayo Clinic College of Medicine. Jaffe, a cardiologist, became chairman of the ACLS working group in the mid-1980s.

“At that point in time, the committee structure was dominated by anesthesiologists and cardiologists,” he said. “I began to think it was important to widen the nature of the committee. I thought people like emergency physicians had the appropriate skills to contribute. I don’t remember anyone standing up and saying ‘How can you bring those SOBs in?’ but there was definitely a sort of quiet exclusion. That was just the way it had always been, it was sort of like a good-old-boys network.”

Jaffe knew of emergency physicians like the University of Washington’s Dr. Mickey Eisenberg, who were contributing important research to the field of sudden cardiac death, and he desired their input. So he sought to broaden the panels.

“You have to remember, emergency medicine was in its infancy back then, as opposed to now, where there is a great depth of high quality people,” Jaffe said. “But I was looking for talented people to help write the guidelines. Their designations didn’t matter to me, their skill sets did. I’m sure I wasn’t perfect at finding people, but that was the motivation. So we began finding these skills in emergency physicians. I’d love to tell you there was this great conspiracy against emergency physicians and that we fought a tooth-and-nail battle to win a great victory for civil rights. Most people just realized it was a natural fit. That’s not to say there weren’t some tensions. There were. But the trend that started then has continued through today.”

The editor for the 2005 emergency cardiovascular care guidelines, Mary Fran Hazinski, a registered nurse, said the researchers from different professions worked together almost seamlessly.

Yes, there was plenty of debate, she said. A typical issue was weighing the effectiveness of certain drugs in laboratory or staid clinical settings, versus their potential efficacy in a more hectic out-of-hospital setting or an emergency department. Emergency physicians weren’t always ready to accept that all drugs would be as effective in both settings. Debates such as these lend themselves to requiring all perspectives, Hazinski said. And if the debates became a little passionate, ultimately, that was best for the guidelines.

“The people that become involved in establishing the guidelines are both knowledgeable and dedicated,” said Hazinski, a senior science editor for the AHA. “They are passionate about their specialties, and they’re passionate about getting the science right. They want the guidelines to be as accurate and practical as possible.”

Back to Article Outline

A shining example of inclusion 

Half a dozen leading emergency physicians surveyed for this news article agreed that the modern ACLS guidelines are probably the most inclusive of all specialties, and therefore should be emulated by the American College of Cardiology (ACC) and other organizations that establish medical-care protocols.

These leading emergency physicians, many of whom have helped write the ACLS or other similar guidelines, thought it was appropriate for the AHA to continue publishing them, although the primary user is often an emergency physician. They noted the AHA’s broad efforts to disseminate the findings freely in the journal Circulation, and that a copy was recently mailed to every member of the American College of Emergency Physicians. As long as the process to develop the guidelines remains inclusive, the doctors contacted for this article said the AHA should continue to publish them. When asked directly, not one of the emergency physicians took issue with another professional organization, the AHA, getting credit for guidelines that govern work in emergency medicine.

“What matters is that our patients get the best care,” said Hollander.

Back to Article Outline

The dollars make sense 

The AHA does derive considerable revenue from the sale of textbooks and course materials. The ACLS Experienced Provider Course, for example, requires that students purchase ACLS: The Reference Textbook, which costs $25, and “strongly recommends” the ECC Handbook, which costs $13.95. According to the AHA’s 2005 annual report, the organization earned $34 million from educational materials last year.

But once again, the emergency physicians contacted for this article weren’t put off by the AHA recouping fees for the considerable work that goes into preparing and disseminating the guidelines.

All of this is not to say the ACLS development process can’t be improved, or that the ACLS model should not be exported to other AHA guidelines and those developed by other professional societies that impact emergency medicine.

Indeed, there have long been disconnects between professional guidelines for clinicians and the emergency department, said Dr. Brian Gibler, chairman of the Department of Emergency Medicine at the University of Cincinnati College of Medicine.

He recalled the protocol for patients, prior to 1991, presenting in the emergency department with a heart attack. Before administering a thrombolytic agent such as tissue plasminogen activator, or tPA, an emergency physician would have to consult with a cardiologist. Gibler, who participated in the development of the National Heart Attack Alert Program launched in 1991, helped change the emergency department rules.

“It seems pretty logical that the first physician competent to read an EKG ought to treat the patient right away,” said Gibler, who is also director for the Center of Emergency Care of the University of Cincinnati Hospital. “But having an emergency medicine physician involved in those types of discussions was still pretty novel at that time.”

Gibler has been involved in efforts to make certain guidelines more user-friendly for emergency physicians, protocols such as those published jointly in 2000 by the AHA and American College of Cardiology for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction.

vIn that effort, he has been joined by Dr. Charles V. Pollack, chairman of the Department of Emergency Medicine at Pennsylvania Hospital. Pollack has also written other “interpretations” of guidelines, such as the 2004 ACC/AHA protocols for the Management of Patients with ST-Elevation Myocardial Infarction, or STEMI guidelines, for emergency physicians.

“Unfortunately, our involvement comes only after the guidelines are finished,” Pollack said. “We really feel like we should be involved earlier. We can optimize the care of patients before they get to the cardiologists. But we need to be more involved.”

Other emergency physicians contacted for this article expressed similar frustrations. At the heart of the arguments: the specialties developing critical care guidelines have a fairly narrow focus: the heart and arteries, or the brain, or orthopedics, or obstetrics. But the emergency physician must be ready to encounter these health problems and many more.

It’s impossible to expect the emergency physician to consult the specialty journals for every medical discipline, Pollack said. If those specialties want their patients handled in the best possible manner, then it simply makes good sense to bring emergency physicians into the discussion of primary treatment for their patients. Such participation will likely also make the guidelines more legitimate in the eyes of other emergency physicians, Pollack said, and increase the possibility that they will appear, in some form, in the literature that first responders read.

Back to Article Outline

The logic of emergency physician involvement 

“At some point you have to hope what is really important to your specialty finds its way into our journals, because that’s where emergency physicians are looking,” Pollack said.

Hollander agreed that if emergency physicians are not involved in the drafting of guidelines, the entire discipline of emergency medicine is unlikely to use them.

“The STEMI guidelines are very relevant to emergency medicine, but they would just get better penetration if they had a bunch of emergency room guys involved,” he said.

There’s another way most guidelines could be made more relevant, Hollander said. The method by which pneumonia, psychiatry and other protocols are written simply doesn’t emphasize enough one variable that’s extremely important in the emergency department–time management.

What’s most critical to an emergency physician, Hollander said, is what must be done for a pneumonia patient, not a lengthy list of action items in a guideline. That’s because while a doctor in the ED is grappling with a pneumonia patient, he or she might also have several heart attack patients.

Having emergency physicians involved in the evaluation process, when committee members are poring over data and discussing the guidelines, would increase the chances that participants are looking for time-sensitivity in the research, and incorporating it into the final protocols, Hollander said.

As for the ACLS guidelines themselves, there are still more ways to diversify the committee membership, said Dr. Lance Becker, a professor of medicine at the University of Chicago.

For the 2005 guidelines a concerted effort was made to include European ideas. During the January 2005 consensus conference in Dallas, Becker conducted a daily wrap-up on the most controversial topics. His co-moderator was from Norway. Among the biggest changes in the emergency cardiovascular care guidelines in 2005 were doing CPR prior to defibrillation and the use of hypothermia, Becker said. Both of those ideas came from European scientists, he said.

When the next ACLS guidelines are drafted, Becker said the AHA would do well to continue pushing for still more international participation, looking to China, and the rest of Asia, for additional input. That’s clearly the next evolution for the committee, Becker said. After all, it would be hard to dramatically increase the participation of US emergency physicians who already hold the majority.

“I think it’s a tribute to the maturation of emergency medicine,” he said. “Emergency medicine now has lots of practitioners who are considered by unbiased review to be highly qualified. What you have is the AHA and other organizations looking at their qualifications, identifying them as the best people, and putting them on important committees. So what you end up with is a process that is far superior to just about every other consensus process that I have ever seen.”