EMS Subspecialty Certification Review Course. Learning Objectives 2. Medical Oversight of EMS Systems 2.1 Medical Oversight

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1 EMS Subspecialty Certification Review Course Medical Oversight of EMS Systems 2.1 Medical Oversight Version Date: Learning Objectives 1 Upon the completion of this program participants will be able to: Understand the definitions and perspectives of indirect and direct medical oversight Describe distinct features of the medical practice of emergency medical systems (EMS) Relate specialized proficiencies required by the medical practice of EMS Recognize the time dependency of immediate treatment for some conditions 2 Learning Objectives 2 Upon the completion of this program participants will be able to: Relate other essentials of understanding including: Fiscal management Medical device procurement Science evaluation Resource stewardship Political obstacles Bureaucratic obstacles Political and governmental protocol interfaces Stakeholder interfaces 3 1

2 Brief History of EMS 1966: National Academy of Sciences National Research Council Accidental Death and Disability: The Neglected Disease of Modern Society Listed 24 proposed recommendations Became blueprint for EMS development Highway Safety Act of 1966 Established Dept of Transportation $142M for regional EMS Systems from Brief History of EMS 1973: The Emergency Medical Services System Act Grant funds available EMS regions were to become financially self sufficient Emphasized Regional systems, trauma orientation 15 Essential Components Each funded system must address 10 The years from 1967 to 1973 had funding for regional demonstration projects and progress was made toward defining a potential program goal. Although the regional approach seemed to work there was no built in research with these programs and consequently no validity of one approach over another could be stated. 15 essential components became a framework for EMS development and goal setting 11 2

3 Comparison of 1973 Essential Components and Attributes 15 Essential Components Manpower Training Communication Transportation Facilities Critical Care Units Public Safety Agencies Consumer Participation Access to Care Patient Transfers Coordinated Patient Record Keeping Public Information and Education Review & Evaluation Disaster Planning Mutual Aid Attributes Integration of Health Services EMS Research Legislation and Regulation System Finance Human Resources Medical Direction Education Systems Public Education Prevention Public Access Communication Systems Clinical Care Information Systems Evaluation 12 Brief History of EMS: Hallmarks 1996 EMS Agenda for the Future 14 Attributes of the EMS system EMS Education Agenda for the Future National EMS Core Content National EMS Scope of Practice National EMS Education Standards National EMS Education Program Accreditation National EMS Certification 13 History of EMS Medical Direction? Throughout the development of EMS, physicians provided important leadership and credibility 1966: NAS NRC recognized importance of physician leadership and training IN EMS 1968: ACEP founded, 1979 EM specialty recognized 1981: First full time EMS Medical Director Great variability has existed regarding the physician s qualifications and role 14 3

4 Basic Definitions Direct Medical Oversight/Control Indirect Medical Oversight/Control 15 Types of Medical Oversight Prospective Education and training, Research Concurrent Online/offline medical control; scene response Retrospective System research, run reviews 17 Direct Medical Oversight Direct Medical Oversight/Control Online Medical Control (OLMC) by the Medical Director Physician directed care via radio or telephone May be provided by the Medical Director s designee State certification may be required to provide OLMC Provision of direct patient care on scene In person EMS physician direction of care given by EMS system providers Telemedicine 18 4

5 Direct Medical Oversight On scene Physician Supervision of EMS Systems Assures the medical director has improved medico legal accountability Provide patient care delivery suggestions Provide feedback for suboptimal behavior Scrutinize scene performance Provider advocacy Provide recommendations to management 20 Guidelines for On Scene Oversight Appropriate vehicle Response needs Important to respond to the field frequently Not just the adrenaline calls Establish criteria for notification of the Medical Director Mass casualty events Specialized rescue Anticipated complications Airways, deliveries, amputations Hazardous events 21 Communications Safety Equipment Attire On scene functions Ground rules Liability 1. Geographic boundaries and huge caseload make it impossible for the physician medical director to directly oversee each patient encounter. The medical director must have an appropriate structure (modified for the local environment) to provide for out-of-hospital oversight. 2. The Medical Director must respond in an appropriate vehicle or with established crews, discouraging personal vehicle use 3. New EMS directors should respond to many calls, not just the adrenaline calls. 4. Criteria for notification of the Medical Director should be established including Mass Casualty events, specialized rescue, complicated calls, and hazardous events such as major fires and structural collapse 5. Appropriate communications equipment should be available for the Medical Director. 6. The Medical Director should have appropriate identification including for the vehicle and have had safety training. 7. Appropriate equipment should be available including adequate training in the use of the equipment. 8. The Medical Director should have the appropriate equipment to respond on-scene. 9. The functions of the Medical Director responding on-scene include: 1. Scene supervision 2. Be prepared to do any task : How can I help you 3. Be primarily a non-patronizing observer, not interfering with smooth-running routines 4. Take appropriate corrective actions, doing what s best for the patient 5. Be a role model! 10. Ground rules include 1. The Medical Director does have jurisdictional authority 2. Support other chain-of-command officers 3. Praise publicly, criticize privately 11. The Good Samaritan laws may not apply to the Medical Director responding to the scene. The presence of a physician may raise expectations of good outcomes. Develop knowledge base and expertise! 22 5

6 Indirect Medical Oversight/Control Indirect Medical Oversight/Control The EMS Medical Director Authorization for Ambulance Service Licensure Authorization for provider clinical practice Protocol Development Quality Management Programs Determination of Medical Necessity in the field Assessment of provider competence and fitness for duty 23 The physician providing EMS medical direction must be able to handle simultaneously multiple medical activities in different locales across the entire community. This practice is a public service, and by its nature is also high profile and political in nature. EMS medical practice requires specialized proficiencies in clinical care scenarios and medical conditions that may not be approached or treated the same once the patient is inside the emergency department or other hospital settings The EMS medical director must recognize time dependency of immediate treatment for some conditions. Indeed prehospital treatment may be more critical for life-saving or some patients that all of the resources available in the emergency department. A clear example of this is ventricular fibrillation. Survival is dependent upon the patient being resuscitated rapidly with restoration of pulse and blood pressure in the prehospital setting. Innovations such as destination policies have driven hospital-based medical care With the proliferation of terrorism and disaster management the medical director must be able to deal with public health emergencies. This must include the proper planning and preparation for these events 24 Defining Requirements for EMS Medical Direction Must be able to handle simultaneous multiple medical activities in different locales across the community Requires specialized proficiencies in patient care matters that may not be managed the same as in the hospital setting 25 6

7 Administrative Direction vs. Medical Direction Administrative Direction Budget, personnel allocation, and policy development May answer to officials, public complaint(s), employee matters, and human resource (HR) issues HR issues include racial and gender matters, salaries, and promotional grievances Medical Direction The doctor s domain May be less vulnerable to legal/political attack 26 There is an important distinction between administration and medical direction of EMS. Administration often focuses on budget, allocation of personnel, and policy development They may also have to answer to elected officials, complaints from the public, work schedules and assignments, union discussions, and human resources problems (HR). This aspect may make the EMS Med Dir more vulnerable to political attacks/issues Whereas, the medical direction that the medical director provides is more in his/her domain of unequivocal expertise, not that of fire unions, city admin, special interest groups HR problems include racial and sexual harassment, salary equity, and promotional grievances. Medical administration may be significantly less vulnerable politically. 27 Medical Direction Legal Authority Examples of Legal Authority May remove personnel from delivering care if judged unsafe to treat the public Decisions based upon medical quality grounds unlikely to be successfully challenged Medical Director credentials EMS providers in some states Medical Director defines the provider scope of practice in some states 28 7

8 EMS medical directors may have legal authority that even fire chiefs or EMS administrators do not have. Specifically medical directors may remove personnel from delivering medical care if they judge them to be unsafe to treat the public The physician, basing decisions on medical quality grounds, is unlikely to be successfully challenged. Indeed in some states the EMS medical director credentials EMS providers to practice in the local system. In most states the EMS medical director defines the scope of practice. EMS physicians who are medical directors should constantly ensure that the public receives the best possible medical care from prehospital providers. As EMS physicians gain trust, they will become the medical experts for the public interest. Most medical quality accomplishments in an EMS system are proportional to the time and effort that the medical director puts into the EMS system. 29 Perception of the Role of the EMS Medical Director In general, the roles of medical directors are best defined by the invested time that they provide. The consistency of their actions is very important. These matters include areas from the dispatch office to the scene of the call, to the classroom, or to meetings and liaison activities. 30 Scope of Modern EMS Medical Direction Quality is Job One! Stakeholder Satisfaction Cost Effectiveness Outcomes Planning/Preparation Employee wellness 31 8

9 The SCOPE of Modern EMS Medical Direction 1. Quality is Job One 2. Stakeholder Satisfaction: How do the various stakeholders view the EMS system? How do the city managers, mayors, and administrators view the EMS system? What does the public say? What does the media report? What do the receiving hospitals view the EMS system as? 3. Cost-Effectiveness: Does the data prove that a given outcome will be changed by a given procedure/drug for a frequently occurring event? Will it change the outcome if given/used in the EMS setting? 4. Outcomes: What outcome is desired? Is it observational data like the number of annual EMS calls, the number of heart attacks, or temporal variation in service demands? Outcome measures can also include whether or not aspirin was given for a patient with chest pain, or whether appropriate medication was given for bronchospasm. 5. Planning/Preparation: Planning includes everything from mass casualty potential events such as sports championships, national conventions, or even state fairs. It also includes training for hazardous material and counterterrorist events. Proactive planning should be the core of successful medical direction. 6. Employee Wellness: Employee wellness includes medical care, employee physical exams, training, appropriate personal protective gear, and even prevention of back injuries from stretcher use. 32 Medical Director s Job vs. Public Expectations Addressed by state regulations, local ordinance,contract Actively involved in medical audit, review and critique of performance Involved with MCI plans and dispatch operations Understands EMS laws and regulations 33 The EMS Medical Director Approves the level of prehospital care rendered by each of the EMS personnel within the agency May not correspond with the provider s level of state certification of licensure Approval subject to compliance with performance guidelines, training requirements Must meet standards set out by state EMS agencies 35 9

10 The EMS Medical Director Develops, implements, and revises treatment guidelines and standing orders Primary liaison between EMS system and the local medical community Establishes transport standards, including transport against a patient s will Develops management of patient care incidents 37 The EMS Medical Director State regulations vary in support of these tasks Must be a public advocate Must specialize in public health area such as: Injury prevention Early stroke and heart attack identification and treatment Environmental injuries Must be current on the applicable medical literature Research by medical director is usually advocated 39 Medical Direction of Rural EMS Systems Rural settings present unique challenges regarding resource access and distance to definitive care Different protocols and destination decisions Maintenance of skills in low clinical volume areas may be difficult for field providers Medical Director more involved in training Medical Director reimbursement issues 41 10

11 EMS system Administrative Direction differs from Medical Direction in that the Administrator: a. Manages the system budget. b. Determines what medical supplies will be carried in the ambulances. c. Gives final approval for clinical protocols. d. Acts as liaison to the medical community. 43 EMS system Administrative Direction differs from Medical Direction in that the Administrator: a. Manages the system budget. b. Determines what medical supplies will be carried in the ambulances. c. Gives final approval for clinical protocols. d. Acts as liaison to the medical community. 44 Take Home Points The EMS Medical Director is the authorizing agent for an EMS Entity to practice EMS Medicine EMS Medicine is the clinical practice of a medical subspecialty Standards of training, practice, and quality management must be established and maintained Direct Medical Oversight Provides real time Medical Direction to providers Is essential to provide a more comprehensive evaluation of the provision of care Allows advocacy for patients and providers that cannot be gained otherwise 45 11

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