Understanding Medical Direction, medical direction coverage
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.1 ion 1991;84:960 The template advises collection of the following data elements:
- 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-975.
- 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)
- 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.
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.
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.
Why I am a Medical Director: The testimony of Roger White, MD
"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."
by RogerD. White, MD
Medical Director, City of Rochester Police Department Early Defibrillation Program
Mayo Medical School, Rochester, Minnesota
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.