The ACEP Clinical Policies Committee (CPC) was established in 1989 to develop guidance in the form of clinical policies for practicing emergency physicians. Over the years, the committee has evolved in its sophistication and scope of effort in guideline development. The purpose of this report is to bring members up to date on the current operation of the CPC and its policies and processes.
Current Clinical Policy Development Process
Potential topics for clinical policy development are referred to the CPC from members, internal ACEP sources, staff, and external sources. Topics may also arise in response to changes in the external medical environment. Emergency medicine topics are usually areas of high risk, high frequency, or high cost. Potential topics are then recommended to the ACEP Board of Directors by the CPC. After Board approval of the topics, committee and subcommittee members are appointed by the President. Subcommittees consist of committee members and other interested ACEP members, ideally with expertise in the area of the proposed topic, and are assigned by the committee chair. The CPC has a process for identifying and managing conflicts of interest for committee and subcommittee members. The proposed topic area is then posted within ACEP communication pieces for members to suggest areas of topic focus. Critical clinical questions are then formulated in the PICO (Patient, Intervention, Comparison, Outcome) format for clarity. Comment on the proposed questions is then solicited from the Board and the ACEP Quality and Performance Committee (for potential performance measure creation). The critical questions are then approved by the full CPC and transmitted to the subcommittee.
A literature search related to the critical questions is then performed by a professional librarian, with the subcommittee performing the initial relevance screen and selecting the articles for full text review. These selected articles are then formally graded by a team of methodologists. Each article is graded by two or more methodologists and is assigned a Class of Evidence with respect to the critical question to which it relates. The Class of Evidence classifications include Class I (highest class; ie, a well-designed randomized controlled trial), Class II (ie, a nonrandomized study), Class III (ie, a case series or report), or Class X (ie, a study that does not address the question at hand or is fatally flawed). An evidentiary table is then constructed based on the graded articles.
The national expectations for clinical policies have increased over the years. Currently, we are implementing the recommendation from the Agency for Healthcare Research and Quality that we explicitly list potential benefits and harms for each policy srecommendation.
The subcommittee uses these graded articles to develop a draft policy that will include recommendations, which can range from Level A (generally accepted principles for patient care that reflect a high degree of clinical certainty), Level B (reflecting moderate clinical certainty), or Level C (limited evidentiary support or consensus). This draft is then reviewed and approved by the full CPC and is sent for external review and comment by expert reviewers, the Board, and Council Officers. It is also posted for a 60-day member comment period within ACEP communication vehicles. Based on evidence provided, the CPC then revises the clinical policy and presents it to the Board for approval. After approval, the clinical policy is published in the Annals of Emergency Medicine, placed on the ACEP website, publicized by ACEP Communications, and submitted to the National Guideline Clearinghouse for abstraction. Implementation tools, such as mobile-ready applications, are also developed. (The full description of the CPC clinical policy development process can be found at www.ACEP.org/clinicalpolicies.)