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1. 2 Emergency Medicine News | January 2015
Changing an ECC Guideline (or Not)
By John Stewart, RN
The American Heart Associ-
ation has advocated for two
decades that hospitals purchase
and use automated external de-
fibrillators to address the problem
of delayed defibrillation, first in its
teaching materials and officially
in their Emergency Cardiac Care
(ECC) Guidelines in 2000.
A decade after the 2000
guidelines, a large multicenter
study by Chan, et al., using AHA
data (JAMA 2010;304[19]:2129)
and two smaller studies (Crit Care
Med 2009;37[4]:1229; Resuscitation
2011;82[12]:1537) provided good
evidence that AED use in hospitals
has not improved survival from car-
diac arrest and appears to have ac-
tually decreased survival rates. Those
studies engendered criticism of the
guidelines in the lay press as having
had no evidentiary basis and having
been unduly influenced by industry.
(“Bad Shock: Automated Devices
for Jolting Hearts May Save Fewer
Lives in Hospitals.” Fairwarning.org,
Nov. 14, 2011; http://bit.ly/1qSEQ1T.)
Is it likely that the guideline will
be changed in the upcoming AHA/
International Liaison Committee
on Resuscitation (ILCOR) 2015
Guidelines revision? Signs are not
encouraging. The endorsement of
AEDs for hospitals has become
somewhat more equivocal in the
2010 guidelines, but AED deploy-
ment continues to be the only ap-
proach offered by AHA/ILCOR to
address the problem of delayed
in-hospital defibrillation. A 2013
AHA/ILCOR consensus statement
on in-hospital resuscitation included
an analysis of AED use that reached
no conclusion and instead stated
that “additional randomized clinical
trials are required to evaluate and
optimize use of AEDs in the hos-
pital.” (Circulation 2013;127[14]:1538;
http://bit.ly/1uEzkp2.)
My own experience with this
issue dates to the mid-1980s when I
brought the issue of delayed in-­
hospital defibrillation to the atten-
tion of several ECC researchers. Their
response was to promote the use
of AEDs by hospitals, an approach
that I came to question. I expressed
my doubts privately and in print.
(Ann Emerg Med 1996;27[1]:104.)
The only response I received was
a letter from an AHA official inform-
ing me that my views were unwel-
come. Most recently, I wrote a
­critique of the 2013 consensus
statement analysis, characterizing it
as weak and biased in favor of pre-
serving the status quo. Following
guidance I received from the ECC
office, I submitted it to the writing
group. I received no response. (The
critique is now in press.)
My experience is consistent
with descriptions in the literature
of AHA/ILCOR’s responses to
evidence and arguments regard-
ing ECC guidelines. (JAMA
2005;293[3]:363; Resuscitation
2005;64[3]:261; Am J Emerg Med
2008;26[5]:618.) Parts of the
guidelines may have been intro-
duced because they were mar-
keted well or seemed to make
sense at the time, but they may
be continued for years despite
little supporting evidence. Poorly
supported guidelines are contin-
ued by making change contingent
on quantities and levels of evid-
ence that are difficult if not
­impossible to achieve in clinical
resuscitation research.
Changing a guideline with
­evidence-based arguments may be
an agonizingly slow process, but a
strong case can be made that the
guideline is not only incorrect but
illegitimate because its adoption
contravened AHA/ILCOR’s stated
standards and policies. An AHA of-
ficial stated in the “Bad Shock” art-
icle that the guideline mandating
AEDs for hospitals was “very care-
fully considered and based on the
evidence available at the time.”
That statement is an expression of
AHA/ILCOR’s professed standard,
but it is not accurate in this case.
The ECC Committee issued in
1999 a lengthy and detailed public
invitation to submit “evidence-based
worksheets” for consideration in the
formulation of the 200 guidelines.
Two coauthors and I submitted two
worksheets, one of which addressed
the use of AEDs by trained care-
givers. (http://bit.ly/11pv2FY.) These
worksheets essentially disappeared,
with no written acknowledgment of
their existence. My phone inquiries
about them were met with vague
responses.
In making the initial decision on
the guideline endorsing AEDs in
hospitals, AHA/ILCOR’s AED/Public
Access Defibrillation Panel did
not consider our invited worksheet
on AEDs and trained caregivers,
nor was it made available for
­subsequent levels of review. (Ann
Emerg Med 2001;37[4 Suppl]:S60.)
AHA/ILCOR’s decision to promote
the use of AEDs in hospitals was
made without consideration of
­invited evidence that could and
should have been considered, and
therefore was arguably illegitimate.
AHA/ILCOR should explicitly res-
cind the guideline mandating in-­
hospital use of AEDs based on the
illegitimacy of the original decision
and the current good evidence
against it. Relying on AED techno-
logy alone to fix the problem of
delayed in-hospital defibrillation is a
dead end that instead of saving lives
appears to decrease survival. But
dropping the guideline should not
mean a return to ignoring the prob-
lem. AHA/ILCOR should actively
­encourage investigators and hospit-
als to explore other approaches to
shortening defibrillation delays, with
the goal of increasing survival. EMN
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Dustin Ballard, MD
Kaiser-Permanente
William G. Barsan, MD
University of Michigan
William Brady, MD
University of Virginia
Charles Bruen, MD
Hennepin Co. Medical Center
Christine Butts, MD
Louisiana State University
Theodore Chan, MD
University of California
Thomas Cook, MD
Palmetto Health Richland
Steven J. Davidson, MD
Maimonides Medical Center
Mark L. DeBard, MD
Ohio State University
Peter M.C. DeBlieux, MD
Louisiana State University
Timothy B. Erickson, MD
University of Illinois-Chicago
Jonathan Glauser, MD
Case Western Reserve University
Lewis Goldfrank, MD
NYU Langone Medical Center
Richard Hamilton, MD
Drexel University
Seth Collings Hawkins, MD
University of North Carolina
Katherine Heilpern, MD
Emory University
Jerome Hoffman, MD
UCLA School of Medicine
George Hossfeld, MD
University of Illinois
Lawrence Isaacs, MD
Temple University
David Karras, MD
Temple University
Brent R. King, MD
UT-Houston Medical School
Edwin Leap, MD
Oconee Memorial Hospital
Luis M. Lovato, MD
UCLA School of Medicine
Robert M. McNamara, MD
Temple University
Larry Mellick, MD
Georgia Regents University
Alex Mohseni, MD
Sibley Memorial Hospital
Ravi Morchi, MD
UCLA Medical Center
Stephen Playe, MD
Baystate Medical Center
Carlos Reyes, MD, JD
Los Robles Hospital &
Med Ctr
Martha Roberts, ACNP, CEN
Inova Fairfax Hospital
Ryan Stanton, MD
Baptist Health Lexington
Stuart Swadron, MD
University of S. California
Loice Swisher, MD
Mercy Philadelphia Hospital
David A. Talan, MD
UCLA School of Medicine
Ellen Taliaferro, MD
UT-Southwestern
Peter Viccellio, MD
SUNY School of Medicine
David Wagner, MD
Drexel University
Graham Walker, MD
Stanford School of Medicine
Ron Walls, MD
Harvard School of Medicine
Shari J. Welch, MD
Salt Lake City, UT
Jennifer Wiler, MD, MBA
University of Colorado
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Drexel University College of Medicine
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Emergency
Medicine News
VIEWPOINT
Vol. 37, No. 1
Mr. Stewart has
been a hospital
nurse for more than
30 years, and is the
author of the blog,
No Heroics (http://
n o h e ro i c s b l o g .
blogspot.com). He
is currently working at Providence
Elderplace in Seattle.
Corrections
The November article, “Are
Hospital/CMG Joint Ventures
a Threat to Emergency Medi-
cine?” contained incorrect in-
formation. (2014;36[11]:1.) Joint
ventures are not in the works
between HCA and ApolloMD
or between Community Health
Systems and Hospital Physician
Partners. A statement in the
article also lacked attribution; it
was Andy Walker, MD, who said
joint ventures remove peer re-
view and due process from the
physician employment contract.
EMN apologizes for the errors.