ACCELERATED ADOPTION
NEW LIFE-SAVING PRODUCTS FOR CRITICAL CARE CAN GO FROM INITIAL MARKET ENTRY TO WIDESPREAD ADOPTION IN 1-3 YEARS. HOW CAN THIS BE POSSIBLE?
BEFORE THE 1970s HOSPITALS COULD DIFFER MARKEDLY FROM THE WAY THEY CARE FOR CLINICAL EMERGENCIES
During this era, it could take a decade or more for "word to get around" that a new life-saving drug or device saved lives
Many found this long lag time between breakthrough and adoption unacceptable
CONSENSUS WAS LACKING AMONG HOSPITALS REGARDING THE SIGNIFICANCE OF SCIENTIFIC EVIDENCE, LEADING TO DISPARATE APPROACHES TO DELIVERING CRITICAL CARE
Hospitals had difficulty identifying what "current" critical care standards might be, with varying interpretations and weighing of scientific evidence further preventing consensus
NOW THERE ARE FOUR KEY AUTHORITIES THAT CONSTANTLY UPDATE A FOUR STEP PROCESS TO DEFINITIVELY ESTABLISH AND PUBLISH CRITICAL CARE STANDARDS FOR HOSPITALS TO FOLLOW
Step 1 Evidence Review
Medical journals are monitored for high quality peer-review evidence demonstrating a drug, device and/or procedure improves outcomes in critical care
Step 2 Guideline Issuance
Experts follow systematic processes to evaluate evidence and achieve consensus on significance; those deliberations culminate in published guidelines for hospitals and providers to follow in order to rapidly catalyze universal adoption of the latest critical care standards (including which drugs and/or devices to use and how)
Step 3 Course Curriculum Updates
Each of the four authorities maintain an official training curricula and issue certifications to attendees after successful initial and recurring completion
Step 4 Provider Accreditation
Hospitals ensure their personnel remain up to date with the latest critical care guidelines by requiring ongoing certification (often as a condition of employment for those who work in critical care areas)
Neonatal Resuscitation Program (NRP)
Publishes guidelines and standards for neonatal critical care
Advanced Cardiac Life Support (ACLS)
Advanced Trauma Life Support (ATLS)
Critical Care Providers Must Recertify Every Four Years
Critical Care Providers Must Recertify Every Two Years
Publishes guidelines and standards for pediatric critical care
American College of Surgeons
Publishes guidelines and standards for traumatic emergencies (all ages)
American Academy of Pediatrics
Critical Care Providers Must Recertify Every Two Years
Publishes guidelines and standards for adult non-truamatic critical care
American Heart Association
Critical Care Providers Must Recertify Every Two Years
American Heart Association
American Academy of Pediatrics
Pediatric Advanced Life Support (PALS)
HOSPTIALS MUST COMPLY WITH CARE STANDARDS
The Joint Commission* (TJC) conducts independent audits of hospitals to ensure compliance with current standards of care
*formally the "Joint Commission for the Accreditation of Healthcare Organizations" or JCAHO
Hospitals typically deploy robust procedures to ensure TJC accreditation is safeguarded
Issues affecting TJC accreditation can jeopardize:
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license to operate
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reimbursement eligibility from payers (e.g. Medicare/Medicaid, insurance companies)
The Joint Commission
HOSPITALS TYPICALLY HAVE A THREE-YEAR RECURRING TJC ACCREDITATION CYCLE, AND ADOPT NEW CRITICAL CARE GUIDELINES PRIOR TO THEIR NEXT SCHEDULED TJC COMPLIANCE INSPECTION
To remain accredited, hospitals must demonstrate they are up-to-date with latest care standards; to demonstrate this for critical care, most hospitals simply stay current with the latest critical care guidelines:
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Hospitals establish a policy that all critical care providers must remain certified in NRP, PALS, ACLS, and/or ALTS (as applicable)
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Hospitals stock the latest drugs and devices required to implement NRP, PALS, ACLS, ATLS guidelines
THIS MECHANISM GREATLY ACCELERATES ADOPTION WHEN GUIDELINES CHANGE
WHAT TYPICALLY HAPPENS WHEN GUIDELINES CHANGE?
COURSE CURRICULA UPDATED
Year 2:
50% of certifications due to expire (providers must attend course to recertify)
End of Year 2: 100% critical care personnel updated to new guidelines
Year 1:
50% of certifications due to expire (providers must attend course to recertify)
End of Year 1: Approximately 50% critical care personnel updated to new guidelines
HOSPTIALS NOTIFIED
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Risk management
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Compliance Officer
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Relevant clinical areas
Year 1:
33% of hospitals due for TJC inspection (must adopt any new guidelines)
End of Year 1: Approximately 33% of hospitals compliant with new critical care guideline
Year 2:
33% of hospitals due for TJC inspection (must adopt any new guidelines)
End of Year 2: Approximately 66% of hospitals compliant with new critical care guideline
Year 3:
Last 33% of hospitals due for TJC inspection (must adopt any new guidelines)
End of Year 3: 100% of hospitals now compliant with new critical care guideline
SOME GUIDELINES ARE IMPLEMENTED FASTER
Peer-reviewed data demonstrates that, when a new resuscitation guideline supersedes a previous one, over 80% of hospitals actually transition to the new standard of care within 18 months
Berdowski J, Schmohl A, Koster RW. Implementation of new resuscitation guidelines takes one-and-a-half years. Clinical research presentiona, American Heart Association Sessions 2008 November 8-12.