AED
MEDICAL DIRECTION:
An essential component of every community AED program is the active
participation of an interested and qualified physician Medical Director,
whether that community is a city or an industrial site. The role of the Medical
Director is to:
- Provide medical leadership, including coordination with
local EMS and 911 centers
- Provide guidance in equipment selection and deployment
- Develop guidelines for responder actions
- Oversee medical care that is rendered through the
program, including review of all responses to medical emergencies
- Ensure appropriate initial training and skill
maintenance
- Assume overall responsibility for the conduct and
operation of all patient care related activities
New federal legislation
(Cardiac Arrest Survival Act of 2000) and legislation in most states now
provide Good Samaritan protection to laypersons who use AEDs and to entities
which deploy AEDs if certain guidelines are followed. Although these guidelines
may not mandate physician oversight, such involvement is strongly recommended.
Most highly effective early defibrillation programs have active, committed
Medical Directors as champions, teachers, and key team members. The role and
time commitment of the Medical Director will vary, depending on the size and
characteristics of the population served by the AED program.
What Medical Directors
do:
The Medical Director as
champion
One of the Medical
Director's primary tasks is to step back, take a look at how a particular
location or community deals with sudden cardiac arrest, and then help lead the
process for making improvements. The Medical Director should be someone who has
the energy and dedication to help get the program up and running-and then
provide ongoing guidance. Ideally, the Medical Director should be a champion
for improving survival from sudden cardiac arrest in his or her community. He or
she should also be someone who relates well with the community and who is
willing to get involved with public education and advocacy. Often, this
includes serving as a champion of the Chain of Survival concept among local
decision-makers, a visible spokesperson for public awareness initiatives, and
lobbying community groups and government agencies to enlist support for AED
access, training, equipment purchases and ongoing quality assurance.
The Medical Director as
planner
The Medical Director should
be involved in the planning of a comprehensive program to address medical
emergencies. This includes development of a response system to assure rapid
activation and arrival of personnel and equipment to the victim, as well as
dispatch of local EMS. The Medical Director should provide guidance in
equipment selection, deployment, and determination of response team composition
(e.g. security, managers, volunteers). These decisions must be based on
specific characteristics and resources of the program venue and must include
significant input from administrative personnel.
The Medical Director
develops or approves detailed plans, called protocols or algorithms, to guide
individuals providing defibrillation therapy. The protocols must follow state,
regional and local standards of medical practice and outline the exact
procedures that AED users should follow. Recommended protocols have been
developed by the American Heart Association and these can be adapted for local
use. AED manufacturers also provide device-specific protocols.
The Medical Director as
teacher
The Medical Director
approves and oversees initial and refresher AED training. This includes
ensuring that the training program is medically sound and educationally
effective. The training should be appropriate to the characteristics of the
specific audience and targeted to the duties expected as determined in the
system planning.
The Medical Director does
not need to create a new training program, however. National AED training
models are available from a number of agencies. Training programs should follow
state and regional training standards. (For information, contact your state EMS
office. Link to State EMS Offices.) Programs should include provisions for
skill review at regular intervals to improve performance and increase
confidence.
The level of the Medical
Director's involvement in hands-on training often is determined by the size of
the program, the availability of other resources and the management style. At
smaller sites, the Medical Director may be involved in all training sessions.
In larger communities, a program coordinator may do most of the training with
guidance from the Medical Director.
The Medical Director as
guardian of quality
Every time an AED is used,
the case must be reviewed. The main purpose for the review process is to give
responders positive feedback and practical suggestions for improvement. The
review process also enables early identification and adjustment of system and
device problems, based on quality assurance or continuous quality improvement
principles. The review should include viewing of the recorded ECG rhythm and
AED actions, responder actions, and system performance.
In small communities, the
Medical Director may review all cases. In larger centers, a coordinator may be
delegated to review all cases and refer ones with potential problems to the
Medical Director.
It is important to collect
information on all AED cases. Entering this information into a simple database
can facilitate analysis of specific events and overall system performance. The
data elements that should be collected are clearly outlined in an
internationally accepted data collection template called the Utstein Guidelines
for Cardiac Arrest. (See chart below.) The Utstein guidelines not only help
define important data elements, they also provide a common framework that
enables communities to see how well they are doing in comparison with others.
Data management software, consistent with Utstein guidelines, is available
through AED manufacturers. Small AED programs do not need to maintain
individual databases. It is sufficient to supply this information to the
Medical Director, a multi-site coordinating center, or the local EMS agency.
Data to collect for each
case of cardiac arrest
To help ensure quality and
gauge system effectiveness, data should be collected for each case of cardiac
arrest, using the internationally accepted Utstein template for uniform
reporting of data from out-of-hospital cardiac arrest. The template advises
collection of the following data elements:
Times*
- Time of initial recognition or internal system
activation
- Call to EMS (911 Center)
- CPR started
- First shock (defibrillation)
- EMS vehicle stops at scene
- EMS arrives at patient side
- Return of pulse
Clinical information
- Age
- Gender
- Site (home, street, public place, work place, mass
gathering, ambulance, nursing home, other long-term care facility) and
specific location at site
- Witnessed (Y/N)
- Breathing on arrival of designated responders (Y/N)
- Pulse on arrival of designated responders (Y/N)
- Bystander CPR (Y/N)
- Cardiac arrest after arrival (Y/N)
- Initial recorded rhythm (ventricular fibrillation,
ventricular tachycardia, asystole, other)**
- Number of shocks (AED only)
Follow-up data***
- Cause of arrest (presumed cardiac, trauma, poisoning,
other)
- Attempted resuscitation (Y/N)
- Number of shocks (AED and manual)
- Efforts terminated at the scene (Y/N)
- Admitted to hospital intensive care unit (Y/N)
- Admitted to general hospital ward (Y/N)
- Died in emergency department (Y/N)
- Discharged alive (Y/N)
- Number of days in hospital
- Alive at one year (Y/N)
*To ensure that measured time
intervals are accurate, it is essential to have all timepieces synchronized.
These include dispatch clocks and AED clocks.
**Determined by AED tape review or initial ECG monitoring by EMS.
*** May be collected by local EMS or AED coordinating center.
The Medical Director as
team member
While the Medical Director
brings authority, expertise and guidance to the program, he or she is only one
member of a team of individuals dedicated to the success of the program. This
team should include appropriate local management and administrative personnel,
representing site/community leadership, the responders and the population
served. Local EMS should also be represented. Program coordinators usually do
most of the day-to-day work associated with operations. However, the Medical
Director should be an active participant, readily available, and not merely a
figurehead. At the same time, he or she should respect the integral roles of
other team members so that all can work cooperatively to achieve program
success.
Qualifications of a
Medical Director
The most important criteria
for selection as a Medical Director are:
- Appropriate medical training and current medical
licensure;
- Commitment to the cause of improving survival from
sudden cardiac arrest in the community, with appropriate related
experience and knowledge;
- An ability to relate well to the community or
population served, designated responders and program management.
The Medical Director often
is an Emergency Physician or someone who has formal training in or previous
experience with emergency medical services. However, physicians from other
specialties also can serve in this role. The most appropriate person in your
community may be a family physician, an internist, a cardiologist, or a
physician specializing in occupational health medicine.
As long as the physician is
committed to the cause and cares about the community, he or she can always
learn more about medical direction of early defibrillation programs through
established educational resources. In addition, physicians acting as Medical
Directors in larger programs and EMS Medical Directors at the local, regional
or state level are usually willing to provide advice and support.
Sometimes Medical Directors
for early defibrillation programs do not have an official role within the
community's EMS system, but instead have authority over a facility such as a
corporation, industrial site or retirement home. Physicians who serve as
Medical Directors for these locations can serve as Medical Directors for
in-house AED programs. To ensure continuity of care, they should notify the
local EMS system about AED placement within their facilities and make certain
that information about each event becomes part of the larger EMS database.
Liability coverage
Medical direction involves
granting authority and accepting responsibility for care provided by AED
responders. Physicians considering becoming AED program Medical Directors
should be aware of liability risks, but the risks associated with AED medical
oversight activities are minimal. Victims of sudden cardiac arrest are destined
to die without prompt medical intervention, including defibrillation. AEDs are
designed to provide timely defibrillation therapy and improve survival. When
used according to protocols, AEDs can only help. The legal system is extremely
unlikely to assign blame to a Medical Director who is trying to help sudden
cardiac arrest victims by developing and overseeing an AED program. (Link to
Understanding laws)
A clear understanding of
the job description can help minimize risks associated with liability.
Carefully define the authority, duties and responsibilities of the Medical
Director. Tasks assumed by the Medical Director should be consistent with
existing state laws and regulations. Tasks may include authorizing AED
purchases, training and quality assurance. Tasks may include specific
responsibility for the actions of AED responders in each case of AED use. Both
the Medical Director and the AED Program Manager should clearly understand the
scope of the Medical Director's authority.
One very effective way of
managing expenses and damages that may be associated with liability is through
the use of insurance. Many physicians carry liability insurance. Their
insurance policies can be reviewed to determine whether liability coverage
already exists for AED program medical direction activities. If not, determine
whether inexpensive supplemental coverage can be obtained. The purchase of comprehensive
insurance coverage significantly minimizes the Medical Director's risks from
legal liability.
Legal responsibility may be
assumed by the agency administering the AED program. This is another way to
reduce the Medical Director's risks from legal liability. Assumption of
responsibility by the agency can occur through legislation or through a
contract between the agency and the Medical Director.
Legislatures can promote
AED program development by providing statutory immunity to AED program Medical
Directors. Some states possess "Good Samaritan" laws that may
significantly limit risks from liability for Medical Directors, Program
Directors and AED users. A review of current laws and regulations in your state
will help you determine whether such laws exist, and if so, the scope of their
coverage. (Link to Chart of State AED Laws)
Establishing formal
agreements
A formal agreement
documenting duties and responsibilities must be established between the agency and
the Medical Director. Models from state or neighboring jurisdictions may be
helpful.
Larger programs, especially
at sites owned, operated or occupied by for-profit entities, may reimburse the
Medical Director for his or her time. In smaller programs with volunteer
responders, many physicians volunteer their time and expertise. Your community
must look at the Medical Director's duties and the annual number of cardiac
arrest calls to estimate the Medical Director's time commitment. Public
education and advocacy and training can be time-consuming. In addition, the
Medical Director has ultimate responsibility for call review and must be
available to discuss AED responder concerns. Taking time to plan an efficient
system for medical direction tasks at the front end can save time in the long
run.
On-line medical
direction
In some EMS systems,
medical direction for certain types of emergencies is given by telephone or
radio. If designated responders are trained and an AED is available, such
"on-line" medical direction prior to attempted defibrillation is
inappropriate. This communication can only serve to delay defibrillation
efforts and reduce the likelihood of survival. With well-established protocols
and strong training programs, AED responders can act quickly and effectively.
The ability of an AED to automatically analyze the heart rhythm and coach
responders with voice and visual prompts ensures appropriate care.
Emergency dispatchers can
be trained to assist bystanders to provide CPR. In the future, dispatchers may
assist untrained lay responders in the use of AEDs. Designated and trained
responders should not require on-line assistance with defibrillation.
Summary
It is
essential that every AED program have a physician Medical Director. The qualifications
of a Medical Director includes appropriate medical training, certification and
capabilities, a commitment to the cause of improving survival from sudden
cardiac arrest, and an ability to relate well to program participants. The
liability risks associated with providing medical oversight are negligible and
manageable and should not serve as a deterrent to physician involvement. In
well-designed programs, serving as a Medical Director requires a limited time
commitment, but yields tremendous professional and personal benefits.
adapted from:
http://www.early-defib.org/03_06_03.html
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