Medical Oversight

Medical Oversight

 

This section addresses medical oversight for community-wide CPR-AED programs. Optimal medical oversight for on-site CPR-AED programs at individual facilities, such as fitness clubs, hotels, manufacturing plants and schools, should reflect many of the concepts presented here, but need not be as comprehensive and should not be as demanding.

The CPR-AED Program Medical Director

A physician Medical Director is an important part of your community CPR-AED program. The role of the Medical Director is to:

  • Provide medical leadership
  • Ensure the program is medically sound
  • Oversee medical care that is rendered through the program
  • Ensure skill maintenance
  • Assume responsibility for the clinical conduct and operation of the program

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.

This section addresses medical oversight for community-wide CPR-AED programs. Optimal medical oversight for on-site CPR-AED programs at individual facilities, such as fitness clubs, hotels, manufacturing plants and schools, should reflect many of the concepts presented here, but need not be as comprehensive and should not be as demanding.

The Medical Director as Champion

One of the Medical Director’s primary tasks is to step back, take a look at how the 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 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 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. The Medical Director should be familiar with the scientific evidence and be able to understand how to implement the science into day to day practice. 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. If any protocol changes are recommended by national agencies or AED manufacturers, or if any clarifications are needed, the revisions must be endorsed by the local Medical Director.

The Medical Director as Teacher

The Medical Director approves and oversees initial and refresher CPR and AED training. The physician’s role is to ensure that the training program is medically sound and educationally effective.

The Medical Director does not need to create a training program. 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. Programs should include provisions for skill review to improve performance and increase confidence.

The level of the physician’s involvement in hands-on training often is determined by the size of the program, the availability of other resources and the physician’s management style. In smaller communities, 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.

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The Medical Director as Guardian of Quality

Every time an AED is used in your community, the case must be reviewed. The main purpose for the review process is to give responders feedback and practical suggestions for improvement. The review process also enables early identification and adjustment of system problems, based on quality assurance or continuous quality improvement principles. This also reinforces appropriate care and provides an opportunity to answer questions about the event.

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.” 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 core information to the area EMS system.

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.

(Cummins RO, et al. “Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. ” Ann Emerg Med 1991;20:861-874.)

The template advises collection of the following data elements:

First CPR by bystanders

  • Call to Emergency Medical Services
  • Vehicle stops at scene
  • First CPR by designated responders
  • First defibrillation shock
  • Return of pulse
  • Resuscitation attempts stopped

*To ensure that measured time intervals are accurate, it is important to synchronize all timepieces, although this is a technically difficult task in most EMS systems. These include dispatch clocks, responder watches and AED clocks.

Clinical Information

  • Age
  • Gender
  • Site (home, street, public place, work place, mass gathering, ambulance, nursing home, other
  • long-term care facility)
  • 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)
  • Cause of arrest (presumed cardiac, trauma, poisoning, other)
  • Attempted resuscitation (Y/N)
  • Endotracheal intubation (Y/N)
  • Number of shocks
  • 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)

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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 could include fire and police authorities, local EMS representatives and concerned citizens. In most communities, program coordinators may actually do most of the day-to-day work associated with operations. However, the Medical Director should be an active participant 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.

Job Description for a Medical Director

The most important criteria for selection as a Medical Director are:

  • Appropriate medical training and a current medical license
  • Commitment to the cause of improving survival from sudden cardiac arrest in the community
  • An ability to relate well to the community
  • An ongoing understanding of the evidence associated with management of cardiac arrest.

The Medical Director often is an Emergency Physician or someone who has formal training in emergency medical services. However, physicians with 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 either in neighboring communities or in larger jurisdictions, such as the county or state, often are instrumental in coaching and supporting local Medical Directors.

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 on-site 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 must be aware of legal liability risks.

A clear understanding of the job description can help minimize risks associated with liability and help you recruit a Medical Director. 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 potential Medical Directors 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. All states have “Good Samaritan” laws designed to limit liability risks liability for Medical Directors and other program participants, such as Program Directors and AED users.

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. In other words, 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.

Establishing Formal Agreements

A formal agreement documenting duties and responsibilities should be established between the agency and the Medical Director. Larger programs 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 may 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. While this generally takes only a few minutes, it may happen frequently. 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. The 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 and use AEDs. Designated and trained responders should not require on-line assistance with defibrillation.

Personal Benefits

Why should a physician become a Medical Director? Interaction with other health care providers and members of the community can lead to many professional benefits. But the most important incentive for most Medical Directors is the simple joy of serving others in a meaningful, tangible way. It is incredibly rewarding to be part of a proactive community initiative that can make a real difference in the lives of friends, relatives and co-workers.

Summary

It is essential that every AED program has a physician Medical Director. The job description of a Medical Director includes appropriate medical training, certification and capabilities, a commitment to the cause of improving survival from sudden cardiac arrest in the community and an ability to relate well to the community. The legal 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.

By Mary M. Newman

Originally published in Challenging Sudden Death: A Community Guide to Help Save Lives

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Why I Am a Medical Director

By Roger D. White, MD
Medical Director, City of Rochester Police Department Early Defibrillation Program, Mayo Medical School, Rochester, Minnesota



“For the physician willing to assume the function of Medical Director of an early defibrillation program, the gratification and satisfaction balance the responsibility and commitment this function entails. It is truly an opportunity for the physician to exercise a life-saving mission and fulfill a professional and personal desire to help patients in the most critical time of need.

Responsibility and commitment include active participation in training and retraining of persons providing defibrillation, precise and detailed review of all incidents and critiques of incidents with the rescuers. In my opinion, an essential component of this responsibility is the collection of accurate data on each incident to assess system performance. This includes acquisition of accurate times for time interval measurements, review of all pre- and post-shock electrocardiographic data, and follow-up on patient outcome.

This level of involvement does not require a significant time commitment on the part of the physician. Much of the ongoing work can be delegated to a Program Director or Training Coordinator. Still, it is essential for the physician to be intimately involved with these aspects of early defibrillation programs. Long-term benefits of AED programs depend on strong physician commitment.

The rewards for Medical Directors come in various forms. They include moments when a police officer tells you after a successful resuscitation that this is the most gratifying part of his or her work. And moments when you visit with a patient who was defibrillated and is ready to go home to his or her family.”

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Mission & Vision

The mission of the Sudden Cardiac Arrest (SCA) Foundation is to prevent death and disability from sudden cardiac arrest. The vision of the SCA Foundation is to increase awareness about sudden cardiac arrest and influence attitudinal and behavioral changes that will reduce mortality and morbidity from SCA.

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877-722-8641

Sudden Cardiac Arrest Foundation
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