Can EMS providers be negligent for not following current AHA guidelines?
What is the clinical obligation vs. legal obligation when the standard of care changes for cardiac arrest treatment?
The American Heart Association updated its Emergency Cardiovascular Care and CPR guidelines in late 2015. For many health care providers, in both the pre-hospital and in-hospital setting, these guidelines are integrated into the daily practices of patient treatment and transportation.
This shapes the AHA ECC and CPR guidelines into the standard of care for patients experiencing acute cardiac, respiratory, and neurological emergencies either in the field, ambulance, or hospital setting. When the guidelines and standard of care change, what must one do to satisfy their clinical and legal obligations when treating patients?
Standard of care
The standard of care is often defined in the context — and as a component to — negligence. Black’s Law Dictionary defines negligence as "the failure to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation ... " and defines the standard of care as "the degree of care that a reasonable person should exercise."
If one fails to exercise the standard of care as a reasonably prudent person would, there are potential grounds for a civil lawsuit. However, and as a general statement of law, those persons demonstrating advanced knowledge or skill will be held to the degree that a reasonable person, of that same advanced knowledge or skill, will be held.
This means a layperson will be compared to other lay people and that a paramedic will be compared to a paramedic of similar education, training, and experience. The paramedic won’t be compared to the skills of a layperson; they will be held to a higher level standard of care because of their advanced knowledge and skill developed through education, training, and experience. If a paramedic fails to exercise the standard of care, as a reasonably prudent paramedic with similar education, training, and experience, they may be negligent and potentially at fault, or liable, in a civil lawsuit.
Remember, these are general definitions and statements, and each state is free to define negligence and standard of care as it so wishes.
Clinical and legal obligations to the standard of care
Black’s Law Dictionary defines an obligation as a "legal or moral duty to do, or, not to do something". EMS providers are given duties to do, or, not do something, via scopes of practice and treatment guidelines or protocols. These governing documents are often populated after much discussion between state government agencies, medical directors, advanced practice individuals, and providers. More and more scopes of practices and guidelines are being updated, on a more frequent basis, to reflect the most current trends and incorporate more evidence based treatments.
Some states even reserve the right to only update a portion of the guidelines or protocols, rather than the entire document, to enact an immediate change in practice when evidence suggests such a change should occur. Essentially, these scopes and guidelines not only create duties, but standardize these duties of care.
The easiest way to answer the question of "what should I do" is to understand the immediate policies, protocols, or guidelines that provide both the scope of practice and the authorization for treatments during patient care. These immediate policies or protocols, listed in ascending order of governance, can be from a service, organization, county, region, and lastly any governmental entity, such as a state. It’s these governing documents that create the standards of care and legal duties to which a provider is held accountable and responsible. And it is deviation from these that lay the ground work for civil negligence lawsuits.
When these immediate policies and protocols conflict with additional education and knowledge, such as an update to guidelines or the standard of care, acquired in the course of maintaining licensure or certification, such as BLS, ACLS, or ACLS-EP, it is best to seek additional clarification. This clarification should come from the service, organization, county, region, or governmental entity which governs the scope of practice and treatments. The clarification should be on not only if the new guidelines will be adopted, but if so, what the timeline is for implementation, and the start date of using the new guidelines.
Need to update protocols and policies
It is important to remember that although EMS personnel are guided in the field by protocols and policies, that failure to update protocols and policies when indicated can itself be considered to be negligent. Say, for instance, that a medical director who possesses the authority to update your agency’s protocols fails to do so and clings to outdated treatments despite overwhelming clinical evidence that the protocols need to be changed. Although the standard of care would almost always permit a reasonable time to implement new protocols after medical evidence changes, the medical director and the agency could face liability if they negligently fail to implement those changes in a reasonable, timely manner.
When the guidelines and standard of care change, what must one do to satisfy their clinical and legal obligations when treating patients? One must be aware of the governing documents that define scope of practice and treatment guidelines, as these create the standard of care to which one is held responsible and creates the clinical obligation. The legal obligation that must be satisfied is to comply and act as another provider, with similar education, training, and experience, would act under similar circumstances. Deviance from either may result in fault, or liability, in a lawsuit.
A practical test to use in any situation where you are a bit unsure of your actions (or inactions) is to simply ask yourself: Am I about to do what other reasonable EMS providers would do in this situation? If the answer is yes, you are likely on the path to do the right thing for your patient, and with the least amount of risk.