Increasing Education from a perspective of system management

[AnthonyM83]

Nate's right.

That's actually one of the main reasons people decide to become doctors (among others of course).

There'd have to be a system to actually measure quality care. The last thing we'd want are people who don't care and are doing this just for the money (i think...hmm)

[PRPGfirerescuetech]

Nate's right.

That's actually one of the main reasons people decide to become doctors (among others of course).

There'd have to be a system to actually measure quality care. The last thing we'd want are people who don't care and are doing this just for the money (i think...hmm)

Nate is right, yes. But,...we already are short providers. To just toss the bad providers wont leave enouigh providers to cover the workload. But were past this discussion. Scroll up to Ridryders last thread, and mine.

PRPG

[Ace844]

Nate is right, yes. But,...we already are short providers. To just toss the bad providers wont leave enouigh providers to cover the workload. But were past this discussion. Scroll up to Ridryders last thread, and mine.

PRPG

"PRPG,"

Sadly, IMHLO, the management, administration, and owners for the most part don't want a highly trained, educated and professional EMS force, as it would force them to pay more, provide a better more professional work environment, and in general eat into their profit margin. This is part of the reason why you see some private and municipal providers fighting new equipment requirements at the state level, etc....Sadly, I think it will take nothing short of an act of god, to bring the providers, management, and docs/DPH's together to create a cohesive, functioning, progressive, educated, professional, EMS practice environment.

To further answer your question, if the companies and management/marketing apparatus were to approach their contracts with a cohesive, well defined explanation of how they were planning to improve education, service, and pt care, and present it to them with a timeline, and explanation, that there may be periods of time where the service delivered will be affected but that it would be for the better. I bet, you'd find a more recptive client...and less adverse action/lost revenue, than if they were to just do it without any of the aforementioned actions...

Furthermore, I think that the medical directors may be willing to put more effort into their EMS system, if they were adequately compensated for it, as well as having the support of the providers/hospital admin in the system of being willing to undergo, more training, and perhaps previously unrequired oversight for a short time until they got to know the providers...and thus their capabilities. From this they would be able to form an objective measure of system status, and the services would benefit from their insight and input into how they could best improve and grow in a positive direction.

YMMV, JMHLO & .02...

out here,

Ace844

[AnthonyM83]

Wow after spending a day at at the local firehouse and hearing the trainers talk about the horror stories of their Paramedic II applicants about their what private compnaies will do to get their way, I'm starting to think it really will take an act from God.

Or rather an act from higher government. Maybe something needs to be horribly wrong (a mistake leading to media scandle) or there needs to be a few studies done and another White Paper written on the state of things.

[Ace844]

"PRPG,"

Sadly, IMHLO, the management, administration, and owners for the most part don't want a highly trained, educated and professional EMS force, as it would force them to pay more, provide a better more professional work environment, and in general eat into their profit margin. This is part of the reason why you see some private and municipal providers fighting new equipment requirements at the state level, etc....Sadly, I think it will take nothing short of an act of god, to bring the providers, management, and docs/DPH's together to create a cohesive, functioning, progressive, educated, professional, EMS practice environment.

To further answer your question, if the companies and management/marketing apparatus were to approach their contracts with a cohesive, well defined explanation of how they were planning to improve education, service, and pt care, and present it to them with a timeline, and explanation, that there may be periods of time where the service delivered will be affected but that it would be for the better. I bet, you'd find a more recptive client...and less adverse action/lost revenue, than if they were to just do it without any of the aforementioned actions...

Furthermore, I think that the medical directors may be willing to put more effort into their EMS system, if they were adequately compensated for it, as well as having the support of the providers/hospital admin in the system of being willing to undergo, more training, and perhaps previously unrequired oversight for a short time until they got to know the providers...and thus their capabilities. From this they would be able to form an objective measure of system status, and the services would benefit from their insight and input into how they could best improve and grow in a positive direction.

YMMV, JMHLO & .02...

out here,

Ace844

As a follow up post, to my which I forgot to add my input on the staffing issue. This is how I would address the issue. Posted in no particular order

A.) Give a definitive timeline for the in house personnell to complete the trianing and come up to "standard. The timeline will be uniform and as many provisions as possible will be made to train them and to allow them to meet the expectation.

B.) Bring in marketing professionals, the Medical director, management, and come to an agreement as to what the training, standards and minimal education is and must be. The service must fight the urge to be CHEAP while doing this

C.) Make all ne whires/applicants meet the standard, education, and provide what additional training is needed for canidates who are exceptional but minimally/but educationally qualified...

D.) Test the above applicants written, practical, oral interviews, then have them meet with the Md director, and go through the process he'd require to work/practice. Also, require a lifting test, drug test, physical etc...for those who pass the preceding, and are good canadtes

E.) Once word gets out that you are a progressive provider/service, that you have progressive, professional work environment and pay well and also have great training the canadates will come to you!! Think King County medic one! 8)

F.) As your services capabilities, education, and morale grow so will the desire to work there and be affiliated with them. By having a competent, educated workforce, who provides quality, professional care, will have no problems recouping the costs as facilities/contracts will see and hear a noticable difference in service.

G.) All of the above will result in positive press, and force the competition to adapt and also raise their standards..

E.) Maintain, and purchase nice, effective, state of the art equipment.

F.) The rest will take care of itsself with good management, marketing, MD Direction, and QA/QI...

But it should be noted that it is clear from MD advocacy groups/professional associations how they may help...I will post this as a third follow up...

Food for thought,

Ace844

[Ace844]

Hi All,

Here's my MD Director responsibilites follow up post and this may give insight as to how they could help with this problem.

Check here:: http://www.acep.org/webportal/PracticeReso...calServices.htm , and here:: http://www.emedicine.com/emerg/topic716.htm

Medical Direction of Prehospital Emergency Medical Services

Taken from ACEP Policy

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

Introduction

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 prehospital service that provides any level of life support must have an identifiable physician medical director at the local, regional, or state level (or combination thereof) whose primary responsibility is to ensure quality patient care. Additional responsibilities include involvement with design, operation, evaluation and ongoing revision of the system including initial patient access, dispatch, prehospital care, and delivery to the emergency department.

If medical direction is to be effective, the medical director must have official authority over patient care. The medical director, therefore, must have a well-defined position with respect to the other components of the EMS 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 established clinical standards of care or do not meet training standards.

Physician direction of prehospital emergency care may be accomplished through off-line and on-line medical direction using prospective, concurrent, and retrospective methods.

Off-Line (Prospective and Retrospective) Medical Direction

Off-line medical direction is the administrative promulgation and enforcement of accepted standards of prehospital 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, direction of remedial education, and limitation of patient care functions if needed. Various aspects of prospective and retrospective medical direction can be handled by committees functioning under the medical director with representation from appropriate medical and EMS personnel.

On-Line (Concurrent) Medical Direction

On-line medical direction is the medical direction provided directly to prehospital providers by the medical director or designee either on-scene or by direct voice communication. Ultimate authority and responsibility for concurrent medical direction rests with the medical director.

Role of the 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 prehospital emergency medical services, these services should be managed by physicians who have demonstrated the following:

Essential:

License to practice medicine or osteopathy.

Familiarity with the design and operation of prehospital EMS systems.

Experience or training in the prehospital emergency care of the acutely ill or injured patient.

Experience or training in medical direction of prehospital emergency units.

Active participation in the ED management of the acutely ill or injured patient.

Experience or training in the instruction of prehospital personnel.

Experience or training in the EMS quality improvement process.

Knowledge of EMS laws and regulations.

Knowledge of EMS dispatch and communications.

Knowledge of local mass casualty and disaster plans.

Desirable:

Board certification in emergency medicine.

Responsibilities

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

Serve as patient advocates in the EMS system.

Set and ensure compliance with patient care standards including communications standards and dispatch and medical protocols.

Develop and implement protocols and standing orders under which the prehospital care provider functions.

Develop and implement the process for the provision of concurrent medical direction.

Ensure the appropriateness of initial qualifications of prehospital personnel involved in patient care and dispatch.

Ensure the qualifications of prehospital personnel involved in patient care and dispatch are maintained on an ongoing basis through education, testing, and credentialing.

Develop and implement an effective quality improvement program for continuous system and patient care improvement.

Promote EMS research.

Maintain liaison with the medical community including, but not limited to, hospitals, emergency departments, physicians, prehospital providers, and nurses.

Interact with regional, state, and local EMS authorities to ensure that standards, needs, and requirements are met and resource utilization is optimized.

Arrange for coordination of activities such as mutual aid, disaster planning and management, and hazardous materials response.

Promulgate public education and information on the prevention of emergencies.

Maintain knowledge levels appropriate for an EMS medical director through continued education.

Authority for Medical Direction

Unless otherwise defined or limited by state or local 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:

Recommend certification, recertification, and decertification of non-physician prehospital personnel to the appropriate certifying agency.

Establish, implement, revise, and authorize system-wide protocols, policies, and procedures for all patient care activities from dispatch through triage, treatment, and transport.

Establish criteria for level of initial emergency response (e.g., first responder, Basic EMT, EMT-Intermediate, Paramedic).

Establish criteria for determining patient destination.

Ensure the competency of personnel who provide concurrent medical direction to prehospital personnel including, but not limited to, physicians, EMTs, and nurses.

Establish the procedures or protocols under which non-transport of patients may occur.

Require education and testing to the level of proficiency approved for the following personnel within the EMS system:

First Responders

EMTs, all levels

Nurses involved in prehospital care

Dispatchers

Educational coordinators

On-line physicians

Off-line physicians

Implement and supervise an effective quality improvement program. The medical director shall have access to all relevant records needed to accomplish this task.

Remove a provider from medical care duties for due cause, using an appropriate review and appeals mechanism.

Set or approve hiring standards for personnel involved in patient care.

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:Compensation for the time required.

Necessary material and personnel resources.

Liability insurance for duties/actions performed by the medical director.

A written agreement that delineates the medical director's authority and responsibilities and the EMS system's obligations.

December 20, 2005

Medical Control

Last Updated: June 9, 2005

AUTHOR INFORMATION

Author: Eric Lavonas, MD, FACEP, Director, Medical Toxicology Hospital Services, Adjunct Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center

Eric Lavonas, MD, FACEP, is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, North Carolina Medical Society, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Editor(s): Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple University; Chief, Department of Internal Medicine, Section of Emergency Medicine, Temple University Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Amin Antoine Kazzi, MD, Vice Chair, Associate Professor, Division of Emergency Medicine, University of California at Irvine Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Craig Feied, MD, FACEP, FAAEM, FACPh, Director, National Institute for Medical Informatics, Director, Federal Project ER One, Director of Informatics, Washington National Medical Center, Director, National Center for Emergency Medicine Informatics

OVERVIEW

Medical direction is the process by which a physician or, occasionally, group of physicians guide and oversee the patient care provided by an emergency medical services (EMS) system.

Law requires medical direction for all advanced life support (ALS) service providers. Most states require basic life support (BLS) agencies to have a medical director as well. Medical direction from a physician is recommended for all EMS activities.

EMS Medical Director/Administrators

The role of an EMS medical director is far greater than merely lending the physician's name and license number to satisfy a legal requirement. The medical director is responsible for all aspects of care provided in the EMS system. In addition to writing protocols for prehospital care, the EMS medical director offers continuing education for EMS personnel, contributes expertise to the process of system planning and dispatch, reviews quality of care, supervises individuals providing on-line medical care, and solves problems.

In most cases, the administrative chain of command in an EMS system is separate from the position of medical director. The EMS system administrators hire, fire, schedule, and promote employees; purchase and maintain equipment and supplies; and perform the hundreds of other tasks required to operate the EMS system. The EMS medical director must have a good working relationship with EMS system administrators. Ultimately, the medical director has the responsibility to certify and decertify EMS medical providers and decide what forms of prehospital care will be provided.

Any physician who is seriously considering becoming an EMS medical director should, at minimum, read the American College of Emergency Physicians (ACEP) publication, "Medical Direction of Emergency Medical Services." This concise 80-page guide outlines the standards of responsibility and reviews national policies on EMS medical direction in more detail than is possible in this article.

DEFINITION OF MEDICAL CONTROL

Off-line medical control refers to all physician activities that prospectively and retrospectively are performed to improve quality of care in an EMS system. On-line medical control is the process through which an emergency physician guides prehospital care while it occurs.

When most people think of medical control, they envision on-line medical control (eg, paramedics communicating with and receiving instructions from a physician in the ED). However, in order to maintain a quality EMS system, several hours of off-line medical control activity are necessary for every minute of on-line control.

Off-Line Medical Control

The medical director of an EMS system is responsible for off-line medical control actions, including the following:

Development and implementation of protocols and standing orders

Supervision of any initial and recertification training programs provided by the EMS agency

Retrospective review of the care delivered (to ensure compliance with patient care standards)

Liaison of activities between EMS professionals and others, including other physicians; ED personnel; and regional, state, and local EMS authorities

Providing input on dispatch, mutual aid, disaster planning, and hazardous materials response activities

General supervision of physicians who provide on-line medical control

Acquiring and maintaining up-to-date knowledge of EMS issues

Support of EMS research, where practical

Problem solving

Generally, an EMS system has one overall medical director for off-line activities and a group of physicians designated as the source of on-line medical control.

On-Line Medical Control

On-line medical control involves directing the care of a single patient. The on-line medical control physician evaluates information given by medics, makes decisions regarding immediate patient care, and gives appropriate orders. Medics and their patients benefit from having immediate access to an emergency physician for advice in difficult or unusual situations.

In addition, the EMS medical director may use mandatory on-line physician authorization to maintain tight control of certain potentially dangerous prehospital treatment options (eg, prehospital thrombolytic administration).

THE EMS MEDICAL DIRECTOR

Qualifications of a Medical Director

An EMS medical director must be a licensed physician with interest, experience, and knowledge in emergency medicine and prehospital care. It is extremely helpful if the medical director is a full-time, practicing, emergency physician at the lead hospital for the EMS system, with additional training and experience in EMS.

When looking for a medical director, many emergency medicine physician groups may find a former paramedic and who maintains an enthusiasm for EMS. Although these are helpful qualifications, a medical director also must be knowledgeable in medical, administrative, and legal issues. However, this information is not taught in medical school or by direct EMS experience and may only partially be covered in an emergency medicine residency training program.

Medical director courses, which are available through ACEP and the National Association of EMS Physicians, are a valuable experience. For those with a career commitment to EMS, 1-year fellowships are available.

Duties of the Medical Director to the EMS System

The medical director is responsible to the EMS system and the community for ensuring that prehospital care providers function at the highest possible level, given their available resources.

Responsibilities of the medical director include the following:

To actively participate in system design, personnel training and retraining, supervision, and quality improvement

To ensure that appropriate standing orders and protocols are in place for prehospital care of common and foreseeable medical conditions, interfacility transfer, disaster response, and hazardous materials response

To be responsible for general protocol to cover the unforeseen situations that inevitably arise

Above all, to serve as a patient advocate

Duties of the EMS System to the Medical Director

Responsibilities of the EMS system include the following:

To provide the medical director with the authority to enforce standards of care; this includes the authority to decertify individual EMS providers who fail to maintain training, patient care, or communications standards

To provide administrative help because, without it, the medical director's role would be impossible owing to the amount of time this responsibility requires.

To provide liability insurance for the physician's actions as the medical director

Possibly, to compensate the physician for time spent working as medical director

The medical director's duties, responsibilities, and authorities, as well as the EMS system's obligations, should be recorded in a written agreement.

Individual Medical Director Versus the EMS Council

Some EMS systems choose to provide off-line medical control through an EMS council or physician advisory board. This body usually consists of representatives from each hospital within the EMS system's coverage area.

It often includes a representative from each EMS agency within the system. In this case, the chairman of the EMS council becomes the overall medical director for legal purposes; however, decisions about system design, protocols, and certification and decertification of EMS personnel are made by the entire committee.

Advantages of an EMS Council

By definition, an EMS council is less autocratic than an EMS system with a single medical director. Occasionally, an EMS council can buffer the EMS system from the politics that are inherent in competition between hospitals and companies. A system design decision (eg, designating a preferred receiving center for trauma, pediatrics, or burns) that seems to favor the single medical director's hospital may be perceived by personnel of other hospitals as being motivated by the medical director's proprietary interest. The same decision by an EMS council does not draw such criticism.

Discipline of individual medics or agencies by a council may not seem as personally vindictive as when the same actions are taken by an individual medical director; therefore, the discipline may be better accepted when it is imposed by an EMS council.

By distributing responsibilities among more people, an EMS council can sometimes accomplish more without overburdening any one individual, and a council may be able to devote more energy to planning improvements.

If the EMS council includes senior paramedics, then a practical, experience-based standpoint is brought into each decision; however, such a point of view may be lacking in the decisions of a single medical director.

Often, a given paramedic (ie, medic) or emergency medical technician (EMT) will work for 2 or more different EMS agencies. In these situations, it becomes difficult for the medics to follow one set of protocols. Regional protocols, as designed by regional EMS councils, are used to avoid this problem.

Advantages of a Single Medical Director System

Political and economic concerns can be detrimental to an EMS council; these concerns can make it impossible to serve as an impartial patient advocate. Sometimes, in a rush to be fair, the patient's interests take second place. This is particularly likely if hospitals or EMS agencies are in extreme economic competition.

EMS councils rely on a consensus for action to transpire but usually only meet once a month. To quote Elbert Hubbard, "A committee is a thing, which takes a week to do what one good man can do in an hour."

The administrative work involved in operating the council can divert energy from accomplishing the actual work at hand.

Maintaining confidentiality is very difficult when an EMS council has to make difficult or high profile decisions. Although federal law tries to protect quality assurance activities from discovery in legal trials, in many states these statutes have been diluted to the point that records of quality assurance activities by an EMS council can be used in court against medics, EMS agencies, or the council.

Once an EMS council is formed, it virtually is impossible to revert to a single medical director system.

Politics and the Medical Director

The absolute duty of the medical director is to serve as a patient advocate and protect the patient from politics and profit-making influences. Competing hospitals and EMS agencies often try to put pressure on the EMS system, especially when questions of patient destination and choice of EMS provider are involved. The EMS medical director must ensure that the patient's interests (eg, autonomy, best medical care) are of absolute priority when the standard operating procedures are devised.

EMS councils often consist of people with strong personalities who tend to have difficulty receiving criticism; therefore, politics in an EMS system may be more volatile than in other organizations of similar size. Everyone involved makes life-or-death decisions; this increases the energy driving politics and consequences of ignoring a real problem. The medical director must be diligent to distinguish actual performance problems from personality conflicts and to address both in a way that protects the patients and the medics.

Medicolegal Liability

Fortunately, lawsuits against EMS medical directors remain uncommon; however, this will probably change. Losing a lawsuit is unlikely as long as reasonable written protocols exist, and medics complete frequent refresher training and testing on these protocols.

Several studies have shown that the risk of being sued for involvement in an EMS system is many times less than the risk of being sued for involvement in regular clinical practice. The EMS system has an obligation to provide the medical director with appropriate liability insurance.

PREHOSPITAL CARE PROTOCOLS

EMS medical directors write prehospital care protocols (ie, standing orders) to instruct medics of the kind of care needed for patients in a wide variety of situations. This document provides the framework for all prehospital care, including assessment and management instructions for a variety of patient conditions, dosing and indications for medications, and specific instructions for occasions when the paramedic or EMT must call for advice and authorization from on-line medical control.

While writing or revising prehospital care protocols, consider the following:

Use previously established protocols

Contact the medical directors of EMS systems in the area and request permission to review and copy their protocols. Read several different protocols and look for the subtle, but important, differences among them.

Do not fix what is not broken

If the EMS system already has an effective protocol in place, only incorporate changes when the benefit is clear. Avoid changing the same part of the protocol several times. Examples of this are as follows:

The current protocol may still include the use of military antishock trousers (MAST) for hemorrhagic shock. Currently, solid evidence indicates that MAST are harmful, and no research supports a likely change to this conclusion. Therefore, the use of MAST should be removed from prehospital protocols.

Based on active research, recommendations for fluid resuscitation in trauma are rapidly changing. Rather than modifying the fluid resuscitation protocol several times, it is usually wise to leave an acceptable current protocol in place until definite changes can be made.

Write protocols for each level of certification

If the EMS system includes providers with different levels of training, a protocol for each level of medic needs to be written. For example, the cardiac arrest protocol for different levels of medics should be written as follows:

An EMT-Basic (EMT- should perform cardiopulmonary resuscitation (CPR), placement of oropharyngeal airway, and bag-valve-mask resuscitation.

An EMT-Defibrillation (EMT-D) should perform the above protocol and apply a semiautomatic external defibrillator.

An EMT-Intermediate (EMT-I) should perform the above protocol, start an IV line, and, perhaps, intubate or place a Combi-tube.

An EMT-Paramedic (EMT-P) should perform the above protocol, intubate, and administer epinephrine and IV antiarrhythmics per advanced cardiac life support (ACLS) protocol.

What works in the city may not work in the country

Protocols that work well in urban areas often fail in rural areas (and vice versa).

Volunteers staff many rural EMS systems; therefore, their time available for training often is less than if the staff was comprised of full-time medics.

Lower call volumes offer rural medics fewer opportunities to apply their skills; thus, skill atrophy is a problem.

Rural EMS systems have longer average transport times than urban EMS systems; this influences the effect of prehospital care.

Comparison of rural and urban EMS protocols may create a paradox. For example, consider the following factors for whether to train EMT-Bs to intubate:

In an urban area, paramedics may be full-time employees who transport up to 2500 emergency patients per year and who have access to full-time training personnel. These paramedics have many opportunities to intubate and have access to frequent refresher programs.

In contrast, a rural volunteer EMT may transport an average of 100 patients per year and have few opportunities to maintain skills, which often decay when not frequently practiced.

ALS in urban areas is often readily available and transport times are likely to be 10 minutes or less. However, rural EMTs may face average transport times of 30 minutes with no ALS back up. Intubation by an EMT is potentially advantageous over prolonged bag-valve-mask ventilation.

Target your protocols to the skill of the medics involved

When writing protocols, take into account the average and the lowest skill level of the medics in the EMS system. Provide medics with enough information about drugs, devices, and latitude to do their jobs effectively; however, do not allow potentially dangerous modalities unless all medics in the system can safely handle them. Resist expanding protocols until the entire group is ready to advance to the necessary level of competency.

Avoid protocol sprawl

Every skill, drug, or device in an EMS protocol requires initial training, memorization, and continuing training for EMS caregivers to remain proficient. In addition, purchase and resupply of equipment and medications costs money. Whenever possible, remove treatment modalities that are out-of-date or no longer necessary from the protocol. Do not expand protocols beyond the level of a capable medic's competence.

Query the receiving physicians about the patients' needs

Solicit feedback from the emergency physicians who treat the patients being transported by the EMS agency.

Determine prehospital conditions that the medics inappropriately are managing because of current protocols.

Determine what the medics are doing that may make receiving physicians uncomfortable.

Determine if medics are spending time on prehospital tasks that easily could wait until the patient's arrival.

Involve EMS personnel in protocol development

Ask medics for suggestions when writing the protocol. If the medical director is uncertain whether a protocol change is worth the required amount of time and money, a mock protocol should be written. After the medics have reviewed the mock protocol, have them make a copy of the patient's chart for whom they feel would have benefitted from the proposed treatment. This process gives the medical director an idea of how many times a new treatment will likely be used. It also acts as a check to evaluate if the medics are likely to inappropriately apply the treatment.

Make on-line medical control mandatory in certain situations

If a particular treatment decision has particularly high medical or medicolegal risk (eg, administration of prehospital thrombolytics, termination of resuscitative efforts in the field), consider requiring approval of the on-line medical control physician. In addition to providing guidance, oversight, and experience, this relieves the medics of some medicolegal responsibility.

The process of establishing on-line medical control slows the delivery of care, prolongs scene time, and occupies a busy emergency physician for several minutes. Limit mandatory on-line medical control to those situations in which a physician's judgment is necessary.

Decide in advance how to handle "Do not resuscitate orders"

Situations in which medics are called to care for a patient who is dying of an incurable condition are volatile and emotionally charged. Morally, medics are bound to respect a patient's desires not to be resuscitated. Several states have adopted statutes that govern prehospital orders not to resuscitate. Incorporate the state statute into the protocol, if possible.

If the state EMS codes do not address this situation, the medics need to be instructed through the protocols.

A 1988 ACEP position statement provides guidance in this area. In general, if on-line medical control is available, instruct the medics to discuss each potential do-not-resuscitate (DNR) situation with the on-line physician.

It often is helpful for the medics and/or the on-line medical director to discuss the situation with the patient's personal physician and family if this quickly can be accomplished.

Written DNR orders generally should be honored as long as the identity of the patient is not in question and all involved agree.

The decision not to attempt resuscitation does not include withholding fluids and oxygen when they are needed.

Allow for variations from protocol

No set of standing orders will provide the correct instructions for every situation that medics encounter. The simplest way to authorize medics to deviate from their protocols is to require the medic to contact the on-line medical control physician to discuss the situation and receive appropriate orders. The protocol also should permit medics to perform to their level of training in the event of communications failure.

Include procedures for interfacility transfer

Interfacility transfer requires different skills and behavior than prehospital emergency care. If the EMS agency provides this service, standing orders must address the important differences.

In general, EMT-Bs can transport medically stable and spontaneously breathing patients who are on oxygen, including patients with tracheostomies. With minimal additional training, EMTs can be taught to maintain noncritical IV lines. The protocol clearly should state what types of IV the EMTs are allowed to supervise. Because EMT-Bs are not trained to restart IVs if pulled out, they should not accept a patient with life-sustaining IV fluids or medications unless accompanied by a paramedic or registered nurse (RN).

It is suitable for an appropriately trained EMT-Ambulance (EMT-A) to transport patients who are on maintenance crystalloid with no more than 20 mEq/L potassium chloride (KCl). The addition of benign additives (eg, vitamins) does not pose a problem.

Paramedics are capable of performing the wide range of ACLS skills, can titrate and restart IVs, and can manage much more unstable patients during interfacility transfer than EMTs. If many unstable cardiac patients are transported, the paramedics need to know how to run IV infusion pumps and should have additional training on drugs (eg, IV heparin, nitroglycerin, common vasopressors, paralytic medications).

Occasionally, critically unstable patients need to be accompanied by an RN during transfer from a hospital. Under the federal Emergency Medical Treatment and Active Labor Act (EMTALA), the transferring hospital is legally responsible for providing an RN, respiratory therapist, or medical doctor to accompany the patient during transport in case an advanced level of care is needed. Legal considerations aside, this is expensive and inconvenient for the transferring hospital. Trusting the paramedics to effectively transfer the patient is highly tempting, even when the patient's needs are more complex than those the paramedics are trained to handle. The system's protocols should specify the situations in which paramedics may transport an unaccompanied patient and the situations that mandate a nurse to accompany the patient during transport.

Patients who at least require an RN-paramedic team to assist in transport include the following:

Patients with unstable vital signs at the time of transfer, with the possible exception of patients presenting with fresh trauma who have not yet been to the operating room

Patients in advanced or preterm labor

Seriously ill children younger than 6 years

Patients likely to require intubation en route

The medical director or on-line medical control physician should become involved in difficult cases. Paramedics are professionals and their judgment should be trusted; when paramedics are uncomfortable accepting a patient, that admission should be respected, even if it inconveniences the transferring hospital.

Specify the procedure for medical control when a physician is on the scene

Prehospital care protocols need to provide guidelines for the medics' actions when a physician is on the scene. Sometimes, on-scene physicians tend to interfere more than help. These situations must be handled with tact and diplomacy, but must not delay patient care.

ACEP has chosen a clear and rational position on this issue. It is summarized in a 1984 position that states, "When an ALS squad, under medical direction, is requested...a doctor/patient relationship has been established between the patient and the physician providing medical direction. The paramedic is responsible for management of the patient and acts as an agent of medical direction unless the patient's physician is present (as would occur in a doctor's office)."

If the patient's private physician is present and assumes responsibility for treatment, medics should defer to that private physician. If an intervening physician is present and on-line medical direction is possible, the intervening physician should speak directly with the on-line medical control physician to discuss the situation. The on-line physician has the option of entirely managing the case, working with the intervening physician, or allowing the intervening physician to assume responsibility. If an intervening physician is present and on-line medical control is not possible, ACEP states, "A paramedic...should relinquish responsibility for patient management, but if the treatment...differs from that outlined in local protocol, the physician should agree in advance to accompany the patient to the hospital...."

QUALITY ASSURANCE AND PROBLEM SOLVING

Medical directors have the responsibility to ensure that all care provided under their authority is of the best quality possible. Several actions are required to accomplish this goal, including the following:

Routine Run Review by EMS Agency Leadership

Someone within the EMS organization routinely should review all EMS run records for completeness. This person, usually the chief medic for the service, should perform the following:

Maintain statistics on factors (eg, scene times, number of attempted IVs and intubations, number completed IVs and intubations, number of cardiac arrests managed for each medic in the system)

Collect data to determine necessary areas of improvement for the entire service (ie, continuous quality improvement [CQI] data)

Screen for problems that might otherwise be undetected (ie, quality assurance [QA])

Random and Focused Run Review by the Medical Director

The medical director should review a reasonable percentage of EMS runs for the preceding month.

If all runs cannot be reviewed, critical runs should be targeted (eg, runs in which ACLS drugs and advanced airway modalities were used, runs by problem medics). Additional runs for review should be selected by random sampling of those remaining.

Provide written feedback for individual medics and identify patterns of behavior that need individual or group retraining.

Maintain a file of each paramedic's feedback for future review, if needed.

Soliciting Feedback from Receiving Physicians

Emergency physicians (EPs) and administrators at all receiving hospitals in the EMS system's coverage area need to know whom to call with problems or questions about the service. The medical director should be introduced to colleagues at other hospitals, preferably during an ED or EP group meeting. This process should periodically be repeated to encourage open communication and feedback, which can prevent many interinstitutional problems and may quickly help identify problems with specific medics or situations. The medical director should meet with the administrative directors of hospitals in the area where the EMS system regularly operates (eg, coronary care staff for frequent interfacility transfers).

Handling Problems

No organization or person does the right thing every time. By its nature, EMS requires medics with incomplete knowledge of the situation to make complex life-or-death decisions very rapidly and during continuous distraction. It is a tribute to EMS professionals that, through dedication and training, they get things right the vast majority of the time.

When mistakes happen, the challenge of the medical director is to decide the following:

If, given the situation faced by the medics, the mistake is understandable

If the mistake at hand indicates a need for further training

If the mistake was simply a fluke

If a specific medic or the entire service needs to be addressed about the mistake

All possible information should be gathered before action is taken to handle a potential problem situation. Feedback should be collected from everyone involved, including the medics, physicians, and nurses at the receiving hospital and, perhaps, the patients and their families. Obtain run records, ED reports, and, when relevant, inpatient care records and autopsy records. Often, what initially appeared to be a dangerous mistake will turn out to be a reasonable decision based on the information available to the medic at the time.

Situations That Always Require Intervention

Unrecognized esophageal intubation

Although an endotracheal tube (ETT) can become dislodged when the patient becomes agitated, it should not become displaced with simple movement of the patient. This occurs more often than many would imagine, and a response to this problem should be consistent. The director should meet with the paramedic involved to discuss the situation. If a pattern develops, refresher training for the individual paramedic or, perhaps, all paramedics in the service should be required.

Colorimetric carbon dioxide detectors and esophageal intubation detectors are commercially available, inexpensive, and reasonably reliable. These could be added to the equipment list and protocols. If a specific paramedic has recurrent problems with unrecognized esophageal intubations, the paramedic should be decertified until the problem has been corrected.

Inappropriate medical care and inappropriate withholding of medical care

The medical director should conduct a thorough investigation. Policies should be revised, refresher training should be provided, or discipline of medics should be carried out, as appropriate.

Injuries to patients

Patient injuries usually occur because of the following 2 situations:

Patients are dropped from the ambulance stretcher.

Patients are injured during the application of restraints.

These situations can typically be corrected with refresher training and written policies.

Many ambulance stretchers are not designed to be in the up position when patients are rolled long distances. The EMS service may need to invest in new stretchers or require that stretchers are in a down position when rolling patients; the latter policy eventually will lead to back injuries among medics.

Storm drain covers with inch-wide rectangular vents may potentially cause accidents. To reduce the chance that the EMS service and facility are sued over a patient injury, these storm drain covers need to be replaced with ones that will not trap stretcher wheels.

Allegations of theft from patients

This is a personnel matter, not a medical issue, and it should be handled by the administrative chain of command of the EMS system.

Substance abuse among medics

This problem requires action by the EMS system chain of command and medical director. The EMS agency must have personnel policies and procedures to address this situation. However, the medical director is responsible for appropriate use of all narcotic medications purchased by the EMS service under the drug enforcement agency (DEA) number of the medical director.

The medical director's responsibilities in these situations include the following:

Act as a patient advocate by protecting patients from the risk of a medic acting under an extension of the director's physician license while intoxicated.

Act in the best interest of the patients and medic involved.

Comply with legal requirements to report impaired medics to the state EMS licensing authority.

Work with the EMS agency's attorney during every step to ensure that the medic is treated fairly and to protect the director and EMS agency from lawsuit.

Realize that the potentially impaired health care professional is handled best by consulting with an expert in the areas of addiction to medicine and substance abuse.

Carefully handle the process of confrontation.

Be aware that most state medical societies are a valuable resource in these matters.

TRAINING

An EMS medical director should actively be involved in initial and recertification courses that are conducted by the agency. Generally, a training officer or course director will run the day-to-day mechanics of the program. The EMS medical director serves as the medical director for the course, helps arrange for lecturers, provides some direct instruction, and supervises testing. Many states require the medical director to personally certify, in writing, that each graduate of the training program clinically is prepared to practice prehospital care at the appropriate level of certification before the applicant is permitted to take the state EMT or paramedic examination.

The EMS medical director also must coordinate a regular, ongoing, training program for medics. It is effective to combine programs of general interest with refresher training that is targeted at areas of potential improvement. The medical director should do some teaching, occasionally recruit outside instructors, and encourage medics within the service to develop areas of expertise for peer instruction.

ON-LINE MEDICAL CONTROL

In an ALS, paramedics and other EMT-As make 99% of the requests for advice and orders; however, EMT-Bs also require the advice of a physician. Therefore, providers at all levels of certification must have access to on-line medical control. On-line medical control must be available 24 hours a day, 365 days a year.

The medical director designates a group of physicians to perform on-line medical control. Three basic ways to provide this service are as follows.

The on-duty emergency physician at the lead hospital for the EMS service (ie, the resource hospital) can serve as on-line medical control.

Alternatively, the on-duty emergency physician at the hospital that will receive the patient can be responsible for on-line medical control.

Finally, medical control can be provided by a small group of physicians at a centralized location.

In the third scenario, the medical control physician dedicates his full attention to this task and is not simultaneously responsible for patient care. This is practical in large EMS systems, and it is often coordinated with an emergency medicine residency program, such as exists in Pittsburgh and Milwaukee.

Advantages and Disadvantages

Advantages and disadvantages exist for each system. The first and third options of providing on-line medical control (mentioned above) use a smaller number of physicians, usually partners or residents of the medical director, which improves consistency and communication between the physicians. The second option, which is probably the most common nationwide, sacrifices consistency of medical control and makes it difficult to reach every medical control physician and disseminate changes to protocols.

Paramedics may dislike the inconsistency of the orders they receive when service is provided according to option 2. However, the second method has advantages. Paramedics and emergency physicians receive immediate feedback since the medic, physician, and patient arrive at the same place at the same time. Also, with option 2, the receiving physician can hardly be dissatisfied with the orders given, and may change those orders based on the situation at the receiving hospital (eg, withholding an order for prehospital thrombolytics if the cardiologist and catheterization lab team already are in the hospital). Overall, the second method is the easiest to set up but the hardest to do well.

Personnel Providing On-Line Medical control

At a minimum, any physician providing on-line medical control must be skilled in emergency medicine and familiar with the equipment and capabilities of the EMS system and the paramedics' training and protocols. A short base station training course for physicians, especially those without prior EMS experience, will greatly improve the quality of medical control. However, it often is hard to get physicians to attend. One possible solution is to incorporate a brief training program into a regular ED or physician group meeting.

Sometimes, nurses from the ED, physicians' assistants, or specially trained paramedics are permitted to provide on-line medical control. This is convenient in a busy ED, but medics prefer and patients may benefit from the physician's direct input. Of course, the designated on-line medical control physician is legally responsible for the orders given by others who are under his supervision.

Communication with Physician Verses Other ED staff

If the on-line medical control physicians feel that their time is taken unnecessarily by EMS calls, the medics may be speaking with the physician when physician guidance is not necessary. The first step to correct this problem is to ask medics to begin their call to the medical control hospital with the introduction of "report only" or "physician needed for orders." Any qualified ED staff member can take a report about a patient coming in. The physician is summoned only if the medic has a question or is requesting advice or orders for specific treatment changes. Emergency physicians at the receiving hospitals may be uncomfortable with this system at first but, in most cases, eventually prefer it.

If this is already part of the system and physicians still feel that too much of their time is occupied with by EMS calls, one of two things is happening; either the medics lack the confidence to independently carry out protocol orders or the protocols and standing orders have been structured to require an on-line physician order for tasks that the paramedics should be able to independently initiate. These problems should be recognized and addressed by the off-line medical director.

Forms of Communication

Although most medical control conversations use EMS radios, telephones (ie, land-based, cellular) possess advantages in clarity and confidentiality. EMS professionals should be encouraged to use the phone whenever practical and use the EMS radio only when the telephone is not available.

In the early days of EMS, medics in the field commonly transmitted cardiac rhythm strips via VHF radio for physician interpretation. This is time-consuming and the equipment often does not produce a readable strip at the receiving facility. Paramedics are trained to recognize and treat arrhythmias.

Today, rhythm strips rarely are transmitted for off-site interpretation. However, obtaining a 12-lead prehospital ECG to transmit over cellular phone lines to a receiver in the ED has some advantages. Medical directors and EMS system administrators should carefully consider the cost (eg, equipment, airtime, training, increased scene time) and benefits (eg, more rapid administration of thrombolytics in the receiving hospital, possible prehospital thrombolytics) of such a system.

Occasionally, questions arise about what was said and ordered during on-line medical control conversations. An accurate record of these conversations is useful in training, for quality assurance, and for medicolegal purposes. Tape recording, written record keeping, or both are used for this purpose.

Tape recording is more accurate but more expensive than keeping a written record. However, tape recording medical control conversations can inexpensively be accomplished through the dispatch center, which may already have a multichannel tape recorder in use to record incoming calls and radio traffic. If this technology is not available, recording devices must be attached to all radio and telephone lines at the medical control hospital(s) that are used for this purpose. The EMS system also must establish a procedure to securely catalog and store tapes.

Printing and distributing forms for written documentation of medical control conversations is easy, but this system has several shortfalls. It is difficult to simultaneously listen, analyze, and write down everything the medic says. On-line physicians tend to write less and think more. The result can be a very fragmented and incomplete record. Also, because of patient confidentiality concerns, the patient's name usually is not broadcasted over EMS communications systems. This creates a problem when trying to match the medical control record with a specific patient.

As digital cellular technology gradually replaces VHF radio, concerns about eavesdropping should lessen. Cataloging and storing on-line medical control reports is a challenge, especially when the patient is not transported to the hospital or when the medical control facility and receiving hospital are not the same.

Finally, many disputes and problems in on-line medical control arise from a misunderstanding between what the medic "knows" was said and what the physician "knows" was heard. A hastily scribbled record by the medical control physician almost never contains enough information to sort out the truth in these situations.

In general, the tape-recorded systems are the better choice for most EMS systems. The start-up costs are small, although not negligible, when compared to the cost of gasoline, insurance, salary, and other operating costs of an EMS system. Although setting up a tape-recording system initially requires more work than printing and distributing forms, the amount of work saved in the long run far exceeds the amount invested.

The off-line medical director may choose to review medical control records only when problems arise. However, random or focused reviews of medical control conversations are very useful for quality improvement and training purposes and a productive use of the medical director's time.

BIBLIOGRAPHY

Ossmann EW, Bartkus EA, Olinger ML: Prehospital pearls, pitfalls, and updates. Emerg Med Clin North Am 1997 May; 15(2): 283-301[Medline].

Storer DL, Dickinson ET III: Physician medical direction of EMS education programs: policy resource and education paper. American College of Emergency Physicians (ACEP) Emergency Medical Services (EMS) Committee, and the National Association of EMS Physicians (NAEMSP). Prehosp Emerg Care 1998 Apr-Jun; 2(2): 158-9[Medline].

Werman HA, ed: Medical Directory of Emergency Medical Services. American College of Emergency Physicians; 1993. NOTE:

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Medical Control excerpt

© Copyright 2005, eMedicine.com, Inc.

Hope this helps,

Ace844

[Ace844]

I'm kind of surprised at the lack of response to this thread...what with all of the medical einsteins we have here and soapbox philosophers proclaiming how we need this and that (myself included) but a surprisingly small number have the gumption to actually post solutions....Here's your chance...lets hear it folks!!

[actualparamedic]

I'm kind of surprised at the lack of response to this thread...what with all of the medical einsteins we have here and soapbox philosophers proclaiming how we need this and that (myself included) but a surprisingly small number have the gumption to actually post solutions

I'm not surprised at all.

Maybe a better way to move this thread along is to attack the issue from your local or regional point of view and share ideas. There is no silver bullet solution without a national EMS system to designate/regulate every facet of EMS provider design and practice. There will never be something like this that I can see on the horizon.

No one at this point has enough influence to unite EMS in a way which change can be affected uniformly on a nationwide basis without causing disruption to the daily flow of EMS. The National Scope of Practice Model is a good idea affecting only education, but has met with significant resistance from individual providers all the way up the chain to EMS associations and even state EMS offices.

There are so many factors which figure into why people train to and function at the EMS level they do. There are regional EMS delivery considerations, financial constraints, geographic factors, state EMS office requirements/regulations, local medical director biases, protocol restrictions, availability of EMS education venues and the ability of those training centers to educate EMS providers all the way up to EMT-P, public attitudes towards EMS, and the list goes on and on and on.

Here's a maddening example:

One of the largest fire departments in the US is comprised of approximately 60 volunteer and career stations. When a career ambulance company is assigned to a call, they go out the door as a paramedic unit (EMT-P) or medic unit (Cardiac Rescue Tech). In that same fire department, when a volunteer ambulance company is assigned to a call, it may go out the door as an ambulance unit (EMT-, IV unit (IV-Tech), medic unit (Cardiac Rescue Tech) or paramedic unit (EMT-P).

Volunteers are offered training to upgrade to the EMT-P level for free through the county fire academy. Yet the number of paramedics in the volunteer ranks stays constant, and every year a new crop of EMT-IV personnel appear in the volunteer ranks, rather than upgrade to EMT-P from EMT-B.

Why is this? Why does the county allow this? Why do the volunteer companies allow this? Why do the citizens allow this (especially when a EMT-IV volunteer unit is dispatched to your severe trouble breathing emergency --- you'll get an IV and albuterol nebulizer but no IV/IM meds and you'll like it!)? Wouldn't it make more sense from a staffing level, instructor commitment level, financial commitment level, and level of EMS service available to the community to eliminate all EMT-IV's and CRT's, going with either EMT-B or EMT-P staffed ambulances?

It all seems blatantly obvious to me...but it's just my opinion. There are obviously factors playing in to this which I can't understand, don't understand, am previously biased about or don't agree with, but it doesn't make my "brilliant" position more valid. I should also disclose that I was once part of this EMS system

Ace, this thread has great potential, but needs to be steered in a new direction.

[actualparamedic]

Whoever suggests eliminating I's is out of their minds. It's EMT-B's that need to be eliminated.

What? :shock:

I can only see this mindset as leading to the total collapse of EMS. OK, that's a little dramatic but...consider this:

In 1993, granted this is old data from Tom Scott, MA via EMS Universe, Emergency Care Information Center, Carlsbad, California, USA, the breakdown of EMS providers in the US went like this:

EMT-A or EMT-B - 506,000 (76.2%)

EMT-I or EMT-D - 79,400 (11.9%) - including AEMT-CC, Cardiac Technician, Cardiac Rescue Technician, and EMT-I

EMT-P 79,200 (11.9%)

Now announce nationwide to existing EMT-B's in 2005 that they must upgrade to and maintain EMT-I by 2009 and see how many downgrade to first responder or drop their EMS certification altogether rather than take on responsibility for more training.

A volunteer dominated state on the east coast went through this when bridging their EMT-A's to the new EMT-B in the mid 1990's: even with four years to make the transition a significant number of providers (primarily volunteers) dropped down to first responder rather than take the bridge course. I don't think anyone expected this type of attrition on such a large scale.

Seriously think about how eliminating EMT-B's through forced upgrades to EMT-I would gut volunteerism and essentially cripple delivery of EMS services in rural areas. There's already enough trouble maintaining the status quo.

Using numbers from 1993, imagine if 10% of those 506,000 EMT-B's decided to downgrade to first responder or drop EMT-B completely. That's 50,600 EMT-Basics off the street. Talk about sudden impact - that's 25,300 ambulances idled instead of running calls.

Just my $.02

[Ridryder 911]

Haven't heard response form mine.... of course this is holiday week too... & we know how those Gov'.t employees are :wink:

Be safe,

R/R 911