There’s a workaround, but the risk posed to your ED might not be worth the initial convenience.
Dear Director,
I’m tired of the merit badges we have to produce for jobs. As a board-certified emergency physician, why do I need to take ACLS?
As emergency physicians, we have a broad skill set that ranges from managing a hangnail to caring for the critically ill. Never once have I been questioned by a colleague or an administrator in the hospital about our team’s ability to appropriately manage cardiac arrests.
And I can’t remember the last serious conversation I had about our skills managing airway or procedural sedation. These skills are part of our training and part of our regular practice. Residency training and board certification (and renewal) certainly support our expertise in these high-risk patient encounters.
While eliminating merit badges such as ACLS, ATLS, and PALS may sound obvious based on those statements, it’s actually a little more complex than that.
Background
You’re probably not surprised to hear that The Joint Commission (TJC) has a role in this. But what may surprise you is that TJC doesn’t mandate what training we need. As an example, I typically see ACLS required for procedural sedation credentialing. This isn’t because TJC states we need to have ACLS. Rather, TJC passes the responsibility off to the hospital and states the hospital must determine what education and training are necessary to perform a task. Hospitals develop policies and TJC ensures that the hospitals follow those policies.
Here’s a few sentences from TJC pertaining to procedural sedation, last reviewed February 2022.
Individuals who are privileged to administer sedation must be able to rescue patients at whatever level of sedation or anesthesia is achieved either intentionally or unintentionally, e.g., when the patient slips from moderate into deep sedation or from deep sedation into full anesthesia.
Organizations must define how it will determine that the individuals are competent to perform the required types of rescue. Acceptable examples may include, but are not limited to, ACLS certification, a satisfactory score on a written examination developed in concert with the department of anesthesiology (see LD.04.01.05 EP 7), a mock rescue exercise evaluated by an anesthesiologist, etc.
Even in the eyes of TJC, sedation and anesthesia have long been under the supervision of the anesthesiologists. Most hospitals typically have an anesthesiologist chair heading the procedural sedation quality committee.
Since hospitals are left to develop their own policies and procedures — given the many specialties who are potentially involved in procedural sedation (ranging from GI and cardiology, to interventional radiology to name a few) — many hospitals accept ACLS as the standard “proof” that a doctor has training to manage the complications of procedural sedation.
After all, TJC lists ACLS as an acceptable credentialing tool. Because the anesthesiologists are the default owners of procedural sedation within the hospital, this allows the hospital to have one committee charged with maintaining procedural sedation and quality across all specialties. This process is streamlined, easy and greatly reduces the hospital’s risk during a TJC survey.
Additionally, many states require providers who perform sedation to be certified in ACLS. From what I can tell, this is geared towards protecting patients in the outpatient setting, which ranges from the dentist’s office to plastic surgeons, but may be inclusive of hospitals. Laws vary by state, so definitely know your state laws before you try to change hospital policy.
Can I get rid of ACLS?
There are some groups who have successfully gotten away from requiring ACLS. I was able to do this at my previous site. Because TJC does allow hospitals to have their own rules regarding training and education, it is possible to develop a procedural sedation carve out for the emergency department.
This would mean developing privileges specific for “emergency procedural sedation” and the result could pull our subset of sedations out of the general hospital sedation quality committee. It would also leave the quality and patient safety reviews to be performed by the emergency department.
To get this off the ground, one would need to work closely with the hospital’s quality director, chief medical officer and probably the anesthesiologists. It would likely need approval by the Credentials Committee and then the Medical Executive Committee. When completed, the real work begins as the department would have to commit to a quality review process that mirrors that done by the “other” procedural sedation committee that is typically run by the anesthesiologists.
In talking to a quality director colleague recently, she said this just increases the risk to the hospital during a TJC review and she’d have to have incredible trust in the ED director to pull it off.
Any Benefits to Merit Badges?
I’ve worked in hospitals where each doc ran a code a week and at others where one might not run a code for months. As a chair that is responsible for ensuring quality, I must consider a couple of options when it comes to ensuring quality. I could, and perhaps should, have a committee that reviews every cardiac arrest.
I could bring the team through a sim lab on a regular basis. Or I could require the team be ACLS certified, ensuring a standard across the board that providers meet a basic knowledge threshold. I’ve reviewed my share of cardiac arrests and the yield for improvement is low. People rarely deviate from the standard algorithms and the ROSC rate is still generally low. Because there is evidence suggesting that resuscitation skills diminish over time, refresher courses like ACLS seems like an easy solution.
Years ago, our chair of medicine, an intensivist and pulmonologist, asked me if I used ATLS as a credentialing tool for low frequency procedures like chest tubes. I hadn’t considered that before, but it certainly caused me to spend some time thinking about it.
There are many low frequency yet critical emergency procedures that are part of our training, and many procedures emergency physicians could go years without performing. It’s very challenging to account for many of these, though a chair must be able to grant privileges for these procedures initially and confirms the privileges every six months through the Ongoing Professional Practice Evaluation (OPPE) required by TJC.
In full disclosure, like most of you, I finished residency with all of my merit badges (ACLS, ATLS, PALS). I was also an ACLS instructor for a long time though most of the motivation to do that was that I liked teaching. Ultimately, they all expired. My current job required ACLS so I had to find a way to get it. And hopefully like many of you, I have found a way to maintain certification that required me to refresh my knowledge base, but doesn’t take a lot of time. I use CME money to pay for it.
Although I worked in a trauma center for a long time, my ATLS did expire long ago. I had to take ATLS about seven years ago for a side gig I was looking at with a pro sports team, who ultimately hired another group. And just as my ATLS was about to expire, my hospital decided to become a trauma center and the state regs require the ED medical director (me) to have ATLS, so I took the renewal course. It’s probably my favorite of the courses and if I get reimbursed, it’s not tough convincing me to recertify.
For those of us who see peds patients, but don’t have access to PEM docs, peds critical care is among the most stressful parts of our job. I’ve found courses that prepare me better than PALS to manage sick kids.
This is a clear example of where I don’t think it’s about the merit badge as much as ensuring education and simulation. Both ATLS and PALS may ultimately be more about remaining familiar with low frequency, but important emergency events though other educational venues may provide the necessary review of the skills.
Conclusion
I am not arguing that ACLS leads to better outcomes, particularly for emergency physicians who are often required to have it for procedural sedation. I’m also not a fan of mandatory merit badges. Providers should obtain ongoing education for high-risk encounters. Sim labs are great and hands-on competency evaluation for providers are wonderful tools to train providers (and teams) and to assess skills.
However, the reality for most department chairs is they don’t have ready access to sim labs and/or there isn’t enough time to get everyone through it on regular basis. What I do recognize is that hospitals must find a way to credential providers and that the more streamlined it can be, the easier it is to standardize, which may decrease the risk of TJC finding an issue during a survey.
1 Comment
Good article. Thanks.
What courses, other than PALS, do you recommend for managing sick or traumatized kids?