Medical Direction of Emergency Medical Services PREP

This Policy Resource and Education Paper is an explication of the Policy Statement Medical Direction of Emergency Medical Services.

ACEP EMS Committee

All aspects of the organization and provision of basic (including first responder) and advanced life support emergency medical services (EMS) require the active involvement and participation of physicians. Furthermore, every out-of-hospital service that provides any level of life support or expanded scope service must have an identifiable physician medical director at the local level as well as at the regional or state level to ensure quality patient care. Additional responsibilities include involvement with design, operation, evaluation and ongoing revision of the system including initial patient access, dispatch, out-of-hospital care, and/or delivery to an emergency treatment facility.

If medical direction is to be effective, the physician must have official authority directly over patient services. The medical director, therefore, must have a well defined role with respect to the other components of the system, the responsibility to develop necessary medical policies and procedures, and the power to limit the activities of those under the medical director's supervision who deviate from the establish clinical standards of care or do not meet training standards.

Physician direction of out-of-hospital care may be accomplished through a combination of off-line and on-line medical direction using prospective, concurrent, and retrospective methods.

OFF-LINE (PROSPECTIVE AND RETROSPECTIVE) MEDICAL DIRECTION

Off-line medical direction includes the administrative promulgation and enforcement of accepted standards for out-of-hospital care. Off-line medical direction can be accomplished through both prospective and retrospective methods. Prospective methods include, but are not limited to, training, testing and certification of providers, protocol development, operational policy and procedures development, and legislative activities. Retrospective activities include, but are not limited to medical audit and review of care, (process improvement), direction of remedial education, and limitation of patient care functions if needed. Committees functioning under the medical director with representation from appropriate medical and provider personnel can perform various aspects of prospective and retrospective medical direction.

ON-LINE (CONCURRENT) MEDICAL DIRECTION

On-line medical direction is the medical direction provided directly to out-of-hospital providers by the medical director or designee, generally in an emergency situation, either on-scene or by direct voice communication. The mechanism for this contact may be radio, telephone or other means as technology develops, but must include person-to-person communication of patient status, and orders to be carried out. Ultimate authority and responsibility for concurrent medical direction rests with the medical director.

ROLE OF THE LOCAL EMS MEDICAL DIRECTOR

The medical director should have authority over all clinical and patient care aspects of the EMS system or service, with the specific job description dictated by local needs. The job description should include, as a minimum, the following qualifications and responsibilities.

QUALIFICATIONS

To optimize medical direction of all out-of-hospital emergency medical services, these services should be managed by physicians who have demonstrated the following:

Essential:

  1. License to practice medicine or osteopathy.
  2. Familiarity with the design and operation of out-of-hospital EMS systems.
  3. Experience or training in the out-of-hospital emergency care of the acutely ill or injured patient.
  4. Experience or training in medical direction of out-of-hospital emergency units.
  5. Active participation or experience in the ED management of the acutely ill or injured patient.
  6. Experience or training in the instruction of out-of-hospital personnel.
  7. Experience or training in the EMS improvement process.
  8. Knowledge of EMS laws and regulations.
  9. Knowledge of EMS dispatch and communications.
  10. Knowledge of local mass casualty and disaster plans including preparation for responding to terrorism and weapons of mass destruction.

Desirable:

  1. Board certification in emergency medicine by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine.
  2. EMS Fellowship training.
  3. Completion of an EMS Medical Directors training course.

* Service as an EMS medical director which began prior to January 1, 2000 can be substituted for the above two requirements.

RESPONSIBILITIES

To optimize medical direction of all out-of-hospital emergency medical services, physicians functioning as medical directors should, at a minimum:

  1. Serve as patient advocates in the EMS system.
  2. Set and ensure compliance with patient care standards including communications standards and dispatch and medical protocols.
  3. Develop and implement the protocols and standing orders under which the out-of-hospital care provider functions.
  4. Develop and implement the process for the provision of concurrent medical direction.
  5. Ensure the appropriateness of initial qualifications of out-of-hospital personnel involved in patient care and dispatch.
  6. Ensure the qualifications of out-of-hospital personnel involved in patient care and dispatch are maintained on an ongoing basis through education, testing, and credentialling as the local/state authorities have determined.
  7. Develop and implement an effective process improvement program for continuous system and patient care improvement.
  8. Promote EMS research.
  9. Maintain liaison with the medical community including, but not limited to, hospitals, emergency departments, physicians, out-of-hospital providers, and nurses.
  10. Interact with regional, state, and local EMS authorities to ensure that standards, needs, and requirements are met and resource utilization is optimized.
  11. Arrange for coordination of activities such as mutual aid, disaster planning and management, and hazardous materials response including weapons of mass destruction and terrorism. This must include training of providers in these areas.
  12. Promulgate public education and information on the prevention of emergencies.
  13. Maintain knowledge levels appropriate for an EMS medical director through continued education.

AUTHORITY FOR MEDICAL DIRECTION

Unless otherwise defined or limited by state or regional requirements, the medical director must have authority over all clinical and patient care aspects of the EMS system including, but not limited to, the following:

  1. Recommend certification, recertification, and decertification of non-physician out-of-hospital personnel to the appropriate certifying agency.
  2. Establish, implement, revise, and authorize the use of system-wide protocols, policies, and procedures for all patient care activities from dispatch through triage, treatment, transport, and/or non-transport.
  3. Establish criteria for level of minimal initial emergency response (e.g., first responder, Basic EMT, EMT-Intermediate, Paramedic).
  4. Establish criteria for determining patient destination in a non-discriminatory manner.
  5. Ensure the competency of personnel who provide on-line medical direction to out-of-hospital personnel including, but not limited to, physicians, EMTs, and nurses.
  6. Establish the procedures or protocols under which non-transport of patients may occur.
  7. Require education and testing to the level of proficiency approved for the following personnel within the EMS system:
    1. First Responders
    2. EMTs, all levels
    3. Nurses involved in out-of-hospital care
    4. Dispatchers
    5. Educational coordinators
    6. On-line physicians
    7. Off-line physicians
  8. Implement and supervise an effective process improvement program. The medical director shall have access to all relevant records needed to accomplish this task.
  9. Remove a provider from medical care duties for due cause, using an appropriate review and appeals mechanism.
  10. Set or approve hiring standards for personnel involved in patient care.
  11. Set or approve standards for equipment used in patient care.

OBLIGATIONS OF THE EMS SYSTEM

The EMS system has an obligation to provide the medical director with the resources and authority commensurate with the responsibilities outlined above, including:

  1. Compensation for the time required.
  2. Necessary material and personnel resources.
  3. Liability insurance for duties/actions performed by the medical director.
  4. A written agreement that delineates the medical director's authority and responsibilities and the EMS system's obligations.

REGIONAL or STATE MEDICAL DIRECTOR

The regional medical director when appointed by the geo-political entity will be the person responsible for the medical oversight of the EMS system and out-of-hospital system within a defined area whether it is a designated region or an entire state. The individual appointed should have oversight responsibility for all units within the area. Treatment protocols should be reviewed for consistency, and a systematic approach to process

improvement for the entire system designed and implemented. The Regional/State medical director will be the focus of the system, and will set guidelines for timely and appropriate care for all constituents. In order for this system to function properly, the position should be codified in state regulation, and backed by the lead agency for EMS.

QUALIFICATIONS

Regional/State Medical Directors should possess the following:

Essential:

  1. License to practice medicine or osteopathy in the State.
  2. Experience with the design and operation of out-of-hospital EMS systems.
  3. Experience or training in medical direction of out-of-hospital emergency units.
  4. Active participation or experience in the ED management of the acutely ill or injured patient.
  5. Experience or training in the EMS process improvement process.
  6. Knowledge of EMS laws and regulations.
  7. Knowledge of EMS dispatch and communications.
  8. Knowledge of regional/state mass casualty and disaster plans.

Highly Desirable:

  1. Board certification in emergency medicine by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine.
  2. EMS Fellowship training.

* Service as a State EMS medical director which began prior to January 1, 2000 can be substituted for the above two requirements.

RESPONSIBILITIES

To optimize medical direction of all out-of-hospital emergency medical services, physicians functioning as regional/state medical directors should, at a minimum:

  1. Serve as an advocate for the EMS system in governmental relations.
  2. Set and ensure consistency in local patient care protocols, including communications standards, dispatch and medical protocols.
  3. Work with local directors to develop and implement the protocols and standing orders under which the out-of-hospital care provider functions.
  4. Ensure the appropriateness of initial training of out-of-hospital personnel involved in patient care and dispatch.
  5. Ensure the certifications of out-of-hospital personnel involved in patient care and dispatch are maintained on an ongoing basis through education, testing, and credentialling.
  6. Develop and implement an effective regional/state process improvement program for continuous system and patient care improvement.
  7. Promote EMS research at the local, regional and state level.
  8. Interact with regional, state, and local EMS authorities to ensure that standards, needs, and requirements are met and resource utilization is optimized.
  9. Provide for coordination of activities such as mutual aid, disaster planning and management, and hazardous materials response.
  10. Promulgate public education and information on the prevention of injury and handling of emergencies.

AUTHORITY FOR MEDICAL DIRECTION

Unless otherwise defined or limited by state requirements, the regional/state medical director must have authority over clinical and patient care aspects of the EMS system as well as advisory responsibility to the lead agency for policy development.

  1. Adjudicate certification, recertification, and decertification decisions made in the underlying layers of the EMS system, with final authority for clinical matters (at the state level).
  2. Establish, implement, revise, and authorize region/state-wide protocols, policies, and procedures for all patient care activities from dispatch through triage, treatment, and transport with the power to enforce recommendations to the underlying system.
  3. Establish the procedures or protocols under which non-transport of patients may occur.
  4. Advise the certifying body on required education and testing to the level of proficiency approved for all personnel within the EMS system:
  5. Implement and supervise an effective regional/state level process improvement program. The medical director shall have access to all relevant records needed to accomplish this task.
  6. Establish and approve standards for equipment used in patient care throughout the system.

OBLIGATIONS OF THE EMS SYSTEM

The EMS system has an obligation to provide the regional/state medical director with the resources and authority commensurate with the responsibilities outlined above, including:

  1. Compensation for the time required.
  2. Necessary material and personnel resources.
  3. Liability insurance for duties/actions performed by the medical director.
  4. A written agreement that delineates the regional/state medical director's authority and responsibilities and the EMS system's obligations.

AIR MEDICAL TRANSPORT PROGRAMS

An air medical service must appoint the medical director for an air medical program. The medical director will be the person responsible for the clinical oversight of the flight program. The medical director shall possess, at a minimum, the credentials required for medical control in the jurisdiction where the service is based. Most air transport services provide more interfacility transfers than scene medical/injury care. For this reason, the medical director must be well versed in EMS out-of-hospital care as well as critical care. They should develop a cadre of consulting physicians who can provide backup in necessary special circumstances that arise in transfer from one institution to another. Medical control may be on-line through radio communication, off-line (predominant) with protocol and standard order development, and visual. The visual control will be seen where services have an on-board physician directing care at the scene.

QUALIFICATIONS

Air Medical Directors should possess or perform the following:

Essential:

  1. License to practice medicine or osteopathy in the jurisdiction where the program is based.
  2. Knowledge of the design and operation of out-of-hospital EMS systems, both ground and flight.
  3. Experience or training in medical direction of out-of-hospital emergency units.
  4. Active participation or experience in the management of critically ill or injured patients.
  5. Experience or training in the EMS process improvement process.
  6. Knowledge of EMS laws and regulations.
  7. Knowledge of air dispatch and communications as well as the interface to the ground communications system.
  8. Knowledge of regional/state mass casualty and disaster plans.

Desirable:

  1. Board certification in emergency medicine by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine.

* Service as a medical director prior to January 1, 2000 can be substituted for this
 requirement.

RESPONSIBILITIES

To optimize medical direction of the air medical service, physicians functioning as medical directors should, at a minimum:

  1. Have final authority over all clinical aspects of the service.
  2. Oversee that medical personnel are adequately trained and qualified to provide care.
  3. Ensure that appropriate equipment and pharmaceuticals are provided for the mission.
  4. Ensure that medical protocols for treatment are commensurate with the capabilities of the crew, and governing regulations.
  5. Ensure the certifications of flight and dispatch personnel are maintained on an ongoing basis through education, testing, and credentialling.
  6. Develop and implement an effective process improvement program for continuous service and patient care improvement.
  7. Promote EMS research at the local, regional and state level.
  8. Interact formally with regional, state, and local EMS authorities to ensure that standards, needs, and requirements are met and resource utilization is optimized.
  9. Provide for coordination of activities such as mutual aid, disaster planning and management.
  10. Promulgate public education and information on the prevention of injury and handling of emergencies.
  11. Ensure that service personnel and equipment meet regulatory standards

AUTHORITY FOR MEDICAL DIRECTION

Unless otherwise defined or limited by state requirements, the medical director must have authority over clinical and patient care aspects of the service.

  1. Establish, implement, revise, and authorize treatment and transfer protocols, policies, and procedures for all patient care activities from dispatch through treatment, and transport.
  2. Establish the procedures or protocols under which non-transport of patients may occur.
  3. Implement and supervise an effective process improvement program. The medical director shall have access to all relevant records needed to accomplish this task.
  4. Advise and approve standards for equipment used in patient care.

OBLIGATIONS OF THE AIR MEDICAL SERVICE

The EMS system has an obligation to provide the regional/state medical director with the resources and authority commensurate with the responsibilities outlined above, including:

  1. Compensation for the time required.
  2. Necessary material and personnel resources.
  3. Liability insurance for duties/actions performed by the medical director.
  4. A written agreement that delineates the regional/state medical director's authority and responsibilities and the EMS system's obligations.

NONEMERGENCY TRANSPORT SERVICES

The medical director of a nonemergency transport service is one who will function as the person with medical oversight of the out-of-hospital services provided such as in transportation of stable, interfacility patients, and expanded scope areas as they develop. This role may be filled by the EMS Medical Director if personnel are shared, and should have authority over all clinical and patient care aspects of the service provided, with the specific job description dictated by local, governmental, and environmental needs. The job description should be similar to those of the local medical director with the addition that the nonemergency transport service medical director must be aware of the differing conditions extant in the varied services provided. The nonemergency transport service medical director will be expected to function as advisor to out-of-hospital personnel who will be able to function primarily by offline control and protocols. Certain areas of expanded scope will be necessary, and should be taught, tested and approved by the nonemergency transport medical director.

WILDERNESS EMS

The wilderness EMS medical director should have authority over all clinical and patient care aspects of the service, with the specific job description dictated by local and environmental needs. The job description should include those of the local medical director with the addition that the wilderness medical director should be aware of the environmental conditions and hazards such as hiking, climbing, caving, water sports, etc., extant in the area. The medical director will function as an advisor to out-of-hospital personnel who will function primarily by off-line control, and protocols due to lack of radio communications. Certain areas of expanded scope will be necessary, and should be taught, tested and approved by the medical director, with concurrence of the regional or state director as well as the lead agency for the state. These areas of expanded scope should be encouraged, as the care will be emergent, and often otherwise unavailable to the victim until evacuation. Flexibility will be required, with individualized programs for various areas of the country.

TACTICAL EMS MEDICAL DIRECTOR

The tactical EMS medical director should have authority over all clinical and patient care aspects of the service, with the specific job description dictated by local and environmental needs and participating public safety authorities. The job description should include those of the local medical director with the addition that the tactical EMS medical director should be aware of the environmental conditions and hazards of a tactical scene with the needs for personal protective equipment and prolonged duty of EMS as well as police personnel. By definition, many scenes will be related to terrorism, and a special need for knowledge of the weapons used by terrorists and those weapons of mass destruction. Knowledge must be available to each operator on the hazards of WMD, and the basics for dealing with weapons such as biologic and chemical agents. The medical director will be expected to function as advisor to out-of-hospital personnel and as a resource to the community. Personnel must be able to function primarily by visual and offline control, and protocols must be established in advance for evacuation of casualties and care in scenes of various levels of security. Certain areas of expanded scope will be necessary and should be taught, tested and approved by the medical director with concurrence of the regional or state director as well as the lead agency for the state. These areas of expanded scope should be encouraged, as the care will be emergent and, even in urban areas, assumed to be out of the scope of normal EMS service.

INTERFACILITY PATIENT TRANSFERS

Medical direction is a critical component of all ground and air ambulance services, including interfacility transfer services. Air and ground ambulances that transfer patients must be capable of providing emergency care during transport. Optimal planning for transfer considers individual patient medical requirements and an understanding of the capabilities of the personnel and system used for patient transfer. The system design, determination of the scope of practice of its providers, and the assurance that patient care is rendered consistent with this scope of practice, are essential medical direction functions.

Medical direction of the transferred patient is a shared responsibility. The transferring physician is responsible under Federal laws for assuring that the patient is transferred by qualified personnel and appropriate equipment. Off-line medical control for the interfacility transfer of patients is the responsibility of the EMS system and its medical director unless another responsible physician is identified, such as exists in hospital-based or private ambulance critical care transport or air medical services.

 
 
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