Finally, a ruefully unsatisfying bit comes from an evaluation of The Joint Commission on Accreditation of Healthcare Organizations measures.4 The Joint Commission, functioning in the U.S. as a bit of a de facto quality-enforcement body, generally requires measure compliance as a result of the financial impact associated with potentially losing accreditation. The Joint Commission standards reports, also known as R3, “requirement, rationale and reference,” describe the evidence in support of their actionable standards. Breaking down the 20 actionable standards with 76 distinct components, the authors found only six were completely supported by cited references. Upon evaluating the quality of the evidence, the authors found only one of those six supported by GRADE level B evidence, while the remainder were GRADE level D: “very low”. While these standards may indeed reflect high-quality medical practice and improved outcomes for patients, it is clear compliance may also ultimately represent unsupported, low-value investment.
Explore This Issue
ACEP Now: Vol 41 – No 12 – December 2022In summary, much of our current clinical practice remains prone to medical reversal and the guidelines upon which we base our practice rely on low-quality evidence, as do the standard measures enforced for hospital accreditation. While this may seem cause for despair, the better lens through which to view these limitations is humility. While emergency physicians continue to work to provide the best care possible for patients, we must recognize and embrace that change is inevitable.
References
- Brown J, Lane A, Cooper C, Vassar M. The results of randomized controlled trials in emergency medicine are frequently fragile. Ann Emerg Med. 2019;73(6):565-576.
- Parish AJ, Yuan DMK, Raggi JR, Omotoso OO, West JR, Ioannidis JPA. An umbrella review of effect size, bias, and power across meta‐analyses in emergency medicine. Academic Emergency Medicine. 2021;28(12):1379-1388.
- Fanaroff AC, Califf RM, Windecker S, Smith SC, Lopes RD. Levels of evidence supporting American College of Cardiology/American Heart Association and European Society of Cardiology guidelines, 2008-2018. JAMA. 2019;321(11):1069.
- Ibrahim SA, Reynolds KA, Poon E, Alam M. The evidence base for US Joint Commission hospital accreditation standards: cross sectional study. BMJ. 2022:e063064. doi: 10.1136/bmj-2020-063064. Available online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9215261. Accessed October 9, 2022.
Pages: 1 2 3 | Single Page
4 Responses to “There Are Only Four Effective Interventions in Emergency Medicine”
December 18, 2022
Stephen BohanIn 1980 a wise, old teacher noted that “the only use of a Swann Ganz catheter in a patient with heart failure is as a tourniquet”
Please add “Pain is the fifth vital sign” to the Joint Commission indictment. Not only was there no support for it but it proved lethal to so many lethal.
December 20, 2022
Joseph SolerThis is a.GREAT article and full of very useful information. It should be given high priority. THANK YOU – Dr Radecki for providing very difficult to obtain and valuable information. Medico-legally is also important because it shows that not all guidelines are equal .
Joseph Soler MD
Bradenton, FL
January 31, 2023
Margrethe WestonGreat reminder to maintain humility. There is always more we don’t know. We should try to gently manage any patient’s misperception that medicine is an exact or settled science. We have a responsibility born of years of clinical experience to keep a cool and appropriately watchful attitude in the face of any monolithic narrative, no matter how convincing initially.
June 19, 2023
Andrew MarloAs an emergency physician, I found this article on the effective interventions in emergency medicine quite intriguing. It’s fascinating how medical practices can experience significant shifts over time, leading to medical reversals and changes in treatment protocols.