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.)

Funding for ACEP clinical policy development is provided mainly by the College, although in rare cases there has been topic-specific funding by the Centers for Disease Control and Prevention and the Emergency Medical Services for Children National Resource Center. Companies are not allowed to participate in or provide direct support for the development of ACEP’s clinical policies.

Recent Improvements to the Development Process

The most substantial recent improvement to the development process is the inclusion of additional methodologists with formal advanced training and applied methodological and emergency medicine experience. Historically, all evidence grading was performed by CPC subcommittee members. This difficult and demanding task is now performed by a team of methodologists. We feel this will improve and standardize the grading process.

We have also received approval and have increased the committee membership in 2014 and have been provided additional staff assistance. We welcome Mary Anne Mitchell, ELS, who will now be assisting Rhonda Whitson, RHIA, our long-time staff member, in our CPC activities.

Other recent changes include increasing the clinical policy draft open comment time period from 30 to 60 days, allowing member input on clinical policies areas for focus within clinical policy topics, and soliciting Board comments on the topic-specific critical questions.

Evolutionary Changes

The industry of clinical guideline and clinical policy development has made significant strides over the past several years. As a committee, we have attempted to incorporate these changes into our processes and products. Conflict of interest (COI) is one such area. Over the years, the CPC has strengthened the processes related to the identification of both financial and intellectual COI, asking for more details from committee and subcommittee members. In 2011, even more focus was put on COI submissions when the Council of Medical Specialty Societies published its “Code for Interactions With Companies” and the Institute of Medicine released their report, “Clinical Practice Guidelines We Can Trust.”^1,2

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 recommendation.

For more than 25 years, the CPC has worked to provide valuable assistance to emergency physicians for the care of their patients. This remains a challenging and rewarding area of effort. We appreciate the support of ACEP members, the ACEP Board, Council Officers, and staff in our ongoing work. Special thanks to the full ACEP Board and especially to Dr. Robert O’Connor and Dr. Alex Rosenau for their support while we continue to improve the CPC processes. Much of this work was begun under the leadership of the late Dr. Francis Fesmire.

Dr. Cantrill is an emergency physician at Denver Health Medical Center and Immediate Past Chair of the ACEP Clinical Policies Committee.

References

1. Code for interactions with companies. Council of Medical Specialty Societies Web site. Available at: http://www.cmss.org/codeforinteractions.aspx. Accessed Nov. 18, 2014.
2. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, D.C.: The National Academies Press; 2011.