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Title: Concept review: ALS, ACLS and Advanced cardiopulmonary resuscitation

Differentiate the following concepts:

• 243185007 | Advanced life support (procedure)

• 431267001 | Advanced cardiac life support (procedure)

• 428805003 | Advanced cardiopulmonary resuscitation (procedure)

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Document review

Table of Contents

Statement of problem as requested or initially identified

IHTSDO-691 | artf222607: Concept review: ALS, ACLS and Advanced cardiopulmonary resuscitation artefact description:

Received the following request for "advanced cardiac life support (ACLS)": "ACLS is a "detailed medical protocol for the provision of lifesaving cardiac care in settings ranging from the pre-hospital environment to the hospital setting." Health care providers can be trained and certified in ACLS. We noticed a new concept in the Jan 2008 release "Advanced cardiopulmonary resuscitation (procedure)" with concept ID 428805003. Would this be considered equivalent to ACLS? If so, would you consider adding a synonym of ACLS?"

This question has arisen before. We have Advanced life support (procedure). The question is whether ALS the same thing as ACLS or should ALS be the parent of ATLS and ACLS?  We also have Advanced cardiopulmonary resuscitation (procedure) There are quite a few uses of these phrases in the internet advanced Cardiopulmonary resuscitation (CPR), advanced Cardiopulmonary resuscitation (ACLS), advanced cardiopulmonary resuscitation (ACPR). Should there be ALS, ACLS, and Advanced cardiopulmonary resuscitation (procedure) as three separate concepts or if any of them are duplicates for each other?

Relevance to International edition

The three concepts identified in the artefact description already exist in the International Release; therefore, resolution of any ambiguity or redundancy should occur within the International Release as well.   

Related changes impacted by this content development request

Aside from addressing the three concepts in this artefact, no other related changes are suggested.  These concepts are leaf-node concepts and are not used as attribute values in the modelling of any other concepts, therefore, there will be minimal impact on other content. 

Post-review addendum: The project reviewer inquired as to whether the concepts involved in this artefact would be more appropriate in the <regime/therapy> sub-hierarchy.  The author replied that based on one of the strict definitions provided in the IHTSDO Editorial Guide (January 2016, Section 6.2.5.2 Regimes and Therapies), it appears technically correct that these concepts could be subtypes of 243120004 | Regimes and therapies (regime/therapy): “procedures focused on a single purpose but do not have any single sub-procedure as a necessary part.”  However, if such a change in hierarchy assignment is made, these concepts should be evaluated in the context of other <procedure> concepts that also represent an algorithm or protocol with multiple sub-procedures/tasks.  At a minimum, the concepts referenced in this artefact should be evaluated in the context of both the 78823007 | Life support procedure (procedure) and 439569004 | Resuscitation (procedure) sub-hierarchies, which have concepts that are somewhat similar in nature.  These changes would likely require the creation of a new content project for a more comprehensive assessment of the content involved. 

Agreed scope statement

In scope: Addressing the definitions of the three concepts identified in the artefact description:

• 243185007 | Advanced life support (procedure)

• 431267001 | Advanced cardiac life support (procedure)

• 428805003 | Advanced cardiopulmonary resuscitation (procedure)

Out of scope: Any additional concepts which may have redundancy, ambiguity, or modelling issues in the 78823007 | Life support procedure (procedure) or 439569004 | Resuscitation (procedure) hierarchies.

Identify additional changes         

No other additional changes are needed to implement the recommendations.

Solution proposed

The following terms were researched extensively and the high-level proposed solutions are described for each individual concept.   Specific authoring suggestions are provided below in the section titled “Details of content changes.”

431267001 | Advanced cardiac life support (procedure)

Definition: Of the three concepts, “Advanced cardiac life support” (ACLS) has the most clearly defined meaning.  ACLS refers to a series of clinical intervention algorithms (a protocol), published by the American Heart Association (AHA), for the resuscitation of patients who have sustained cardiovascular arrest.  It involves basic life support processes (airway, breathing, circulation) as well as additional advanced interventions such as invasive airway measures, electrocardiogram monitoring, defibrillation, and medication administration.  (American Heart Association, 2015) Note that while ACLS includes the phrase “life support,” in practice, it is essentially a protocol for resuscitation. 

Recommendation: Based on the above definition, it is suggested that this concept have a text definition and additional descriptions to clarify its meaning.  It is also suggested that this concept should have an additional parent, 89666000 | Cardiopulmonary resuscitation (procedure).

243185007 | Advanced life support (procedure)

There appear to be two definitions for the term “Advanced life support” (ALS).

Definition 1: In the United States (US), the term may be used to generally refer to any advanced resuscitation efforts that extend beyond basic cardiopulmonary resuscitation.  (McGraw-Hill, 2002) (Stedman's Medical Dictionary, 2006) 

Definition 2: In Europe, the term refers more specifically to a series of clinical intervention algorithms (a protocol), published by the European Resuscitation Council (ERC), for the resuscitation of patients who have sustained cardiovascular arrest.  It involves basic life support processes as well as additional advanced interventions such as invasive airway measures, electrocardiogram monitoring, defibrillation, and medication administration.  The ERC ALS and AHA ACLS protocols are nearly identical, and both are based on the guidelines published and revised every 5 years by the International Liaison Committee on Resuscitation (ILCOR).  (European Resuscitation Council, 2015), (Resuscitation Council (UK), 2015) 

Recommendation: There appear to be two definitions for the term “Advanced life support” and the second definition provided above is more specific than what the current FSN and descriptions suggest.  Based on the existing FSN and descriptions and because 431267001 | Advanced cardiac life support (procedure) is a subtype, it is inferred that the meaning of this concept is consistent with the first definition provided above.  For these reasons, it is recommended that a text definition reflecting the first definition be added to this concept.  If a concept is needed to represent the second definition, then a new concept with a more specific FSN and descriptions should be added.  It is expected that such a new concept would be a subtype of 243185007 | Advanced life support (procedure) and a sibling to 431267001 | Advanced cardiac life support (procedure). 

428805003 | Advanced cardiopulmonary resuscitation (procedure)

Despite extensive research, no clear, authoritative definition for the term “Advanced cardiopulmonary resuscitation” (ACPR) could be found.  Unless such a definition can be determined and differentiated from the above concepts, it is recommended that this concept be retired. 

Stakeholder input

These requests appear to originate from SIRS Requests 3825 and 249948, which were addressed in 2008.  The recommendations address the content issues expressed in the artefact description. 

Impact assessment

The recommendations will reduce ambiguity within existing SNOMED CT content.  The distinction in meaning between ALS and ACLS will be clarified through the use of text definitions.  In addition, it suggested that unless a definition can be determined for ACPR and it can be distinguished from ALS and ACLS, this concept should be retired since its meaning is unclear. 

Risk assessment

The risk of inaction is that SNOMED CT content related to advanced life support procedures will continue to remain ambiguous.  The primary risk for implementing the recommendations is the potential retirement of 428805003 | Advanced cardiopulmonary resuscitation (procedure).  However, the risk is somewhat mitigated in that it is unclear how users would implement a concept which does not have a clear definition. 

Approval process 

Priority         

?Very high

?High

?Medium

?Low

Specify the basis for the above priority assignment

The priority assignment is based on IHTSDO assessment.  The JIRA tracker for this artefact currently has a priority setting of “5” or “lowest priority.”

Content editing

As described in the next section below. 

Details of content changes

Specific authoring recommendations for each of the three concepts in the artefact description:

431267001 | Advanced cardiac life support (procedure)

• Add additional synonyms:

  • American Heart Association advanced cardiac life support protocol

  • AHA ACLS protocol

• Add text definition: The American Heart Association advanced cardiac life support (ACLS) protocol is an algorithm of clinical interventions for the resuscitation of patients who have sustained cardiovascular arrest.  It involves basic life support as well as additional advanced interventions such as invasive airway measures, electrocardiogram monitoring, defibrillation, and medication administration. 

• Add additional parent concept: 89666000 | Cardiopulmonary resuscitation (procedure)
  
  

243185007 | Advanced life support (procedure)

• Add text definition: Advanced resuscitation efforts that extend beyond basic cardiopulmonary resuscitation.

• As stated above in the “Solution proposed” section, if a new concept is needed to represent the second definition of ALS, the new concept should be added as follows:

  • FSN: European Resuscitation Council advanced life support protocol (procedure)

  • Preferred Term: European Resuscitation Council advanced life support protocol

  • Description: ERC ALS protocol

  • Text definition: The European Resuscitation Council advanced life support (ALS) protocol is an algorithm of clinical interventions for the resuscitation of patients who have sustained cardiovascular arrest.  It involves basic life support as well as additional advanced interventions such as invasive airway measures, electrocardiogram monitoring, defibrillation, and medication administration.

  • Parent concepts:

    • 243185007 | Advanced life support (procedure)

    • 89666000 | Cardiopulmonary resuscitation (procedure)
      
      

428805003 | Advanced cardiopulmonary resuscitation (procedure)

• As previously stated, unless a clear definition can be determined for this concept, it is recommended that it be retired as Ambiguous

• Create MAY BE A attribute relationships with the following values:

  • 243185007 | Advanced life support (procedure)

  • 431267001 | Advanced cardiac life support (procedure)

Manual quality check

Primary terminology author evaluation with secondary validation by peer review. 

Automated quality check

Routine automated QA.

Publish to release branch

To be determined by the IHTSDO.

References

American Heart Association. (2015). 2015 American Heart Association Guidelines: Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 7 Adult Advanced Cardiovascular Life Support. Circulation, 132, S444-S464. Retrieved March 2016, from http://circ.ahajournals.org/content/132/18_suppl_2/S444.full

European Resuscitation Council. (2015). European Resuscitation Council: Guidelines for Resuscitation 2015: Section 3 Adult advanced life support. Retrieved March 2016, from European Resuscitation Council: http://ercguidelines.elsevierresource.com/

McGraw-Hill. (2002). Advanced life support. Retrieved March 2016, from http://medical-dictionary.thefreedictionary.com/advanced+life+support

Resuscitation Council (UK). (2015). Resuscitation Council (UK): Adult advanced life support. Retrieved March 2016, from Resuscitation Council (UK): https://www.resus.org.uk/resuscitation-guidelines/adult-advanced-life-support/

Stedman's Medical Dictionary. (2006). Advanced life support (ALS). Retrieved March 2016, from MediLexicon: http://www.medilexicon.com/medicaldictionary.php?t=1427