Direction of Out-of-Hospital Care at the Scene of Medical Emergencies

Revised and approved by the ACEP Board of Directors titled, "Direction of Out-of-Hospital Care at the Scene of Medical Emergencies" April 2008
Reaffirmed by the ACEP Board of Directors October 2001 and October 1997
Revised and approved by the ACEP Board of Directors titled, "Direction of Prehospital Care at the Scene of Medical Emergencies" October 1993
Originally approved by the ACEP Board of Directors April 1984 titled, "Control of Advanced Life Support at the Scene of Medical Emergencies"
 

The American College of Emergency Physicians (ACEP) believes that the direction of out-of-hospital care at the scene of a medical emergency should be the responsibility of the individual in attendance who is most appropriately trained and knowledgeable in providing out-of-hospital emergency management and transport.

During routine operations, the out-of-hospital provider is responsible for management of the patient and acts as an agent of the EMS medical director. 

Notwithstanding the special situations noted below, the out-of-hospital provider:

  • shall not comply with orders which exceed their scope of practice.
  • retains the right to re-establish medical direction with the on-line physician if the out-of-hospital provider believes that the emergency care rendered by the scene physician is inconsistent with standard of care.
  • reverts to off-line medical direction (ie, existing EMS protocols) or on-line medical direction for the continued management of the patient
    • at any time when the scene physician is no longer in attendance.
    • if the treatment at the emergency scene differs from existing EMS protocols and is contradictory to quality patient care.
     

However, in some cases, a physician on scene may assume responsibility for patient care and provide medical direction. 

If the private physician is present (as may occur in a physician’s office) and assumes responsibility for the patient’s care: 

The out-of-hospital provider should defer to the orders of the private physician. On-line medical direction, if that capability exists, should be contacted for record keeping purposes.

If an intervener physician is present and on-line medical direction is not available: 

The out-of-hospital provider at an emergency scene should relinquish responsibility for patient management when the intervener physician has:

  1. been properly identified
  2. agreed to assume responsibility
  3. agreed to document the intervention in a manner acceptable to   the local emergency medical services system (EMSS)
  4. agreed to accompany the patient to the hospital, with the potential exception of a mass casualty incident or disaster.

When all of these conditions exist, the out-of-hospital provider should defer to the wishes of the physician on the scene. EMS protocols for the continued management of the patient: Out-of-hospital providers shall not comply with orders which exceed their scope of practice. The intervener physician should agree in advance to accompany the patient to the hospital if required or needed. In the event of a mass casualty incident or disaster, however, patient care needs may require the intervener physician to remain at the scene.

If an intervener physician is present and on-line medical direction is available: 

The on-line physician is ultimately responsible. It is the on-line physician’s option to manage the case entirely, work with the intervener physician, or allow the intervener physician to assume responsibility. In the event:

  1. of disagreement between the intervener physician and the on-line physician, the out-of-hospital provider should take orders from the on-line physician and place the intervener physician in contact with the on-line physician.
  2. the intervener physician assumes responsibility, all orders to the out-of-hospital provider should be repeated over the radio for purposes of recording. The intervener physician should document the intervention in a manner acceptable to the local EMSS.
  3. the out-of-hospital provider or on-line medical direction believes that the emergency care rendered by the intervener physician is inconsistent with EMS protocols and quality patient care, on-line medical direction should be reestablished. The decision of the intervener physician to accompany the patient to the hospital should be made in consultation with the on-line physician.
 

If a disaster or mass casualty situation exists: 

An EMS physician shall provide medical oversight within the established command and control system.
 

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