Medical Direction
Medical direction can be defined as a physician directing the medical care provided by others, such as Emergency Medical Services (EMS) personnel. This direction sometimes takes the form of “standing orders,” or protocols and procedures that can be followed at the discretion of the healthcare provider. It can also take the form of “on-line” medical direction, wherein the onsite provider calls the physician for permission to perform a particular procedure or advice on how to address a particular medical problem.
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HEALTHCARE PROVIDER RESOURCES
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EXAMPLE PRACTICES
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DATABASE SEARCHES
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FAMILY AND CAREGIVER RESOURCES American College of Emergency Physicians
More details about this and other family and caregiver resources |
HEALTHCARE PROVIDER RESOURCES
EMSC National Resource Center (NRC)
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EMSC State Partnership Performance Measures. To measure the effectiveness of federal grant programs, the Health Resources and Services Administration (HRSA) requires grantees to report on specific performance measures related to their grant funded activities. The measures are part of the Government Performance Results Act (GPRA). EMSC performance measures (PM) address operational capacity to provide pediatric emergency care, including the percent of prehospital provider agencies in the state/territory that have on- and/or off-line pediatric medical direction available from dispatch through patient to a definitive care facility (see PMs 71 and 72) . (Accessed April 2010).
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Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures. This NRC downloadable document contains additional information regarding the EMSC State Partnership performance measures, and includes best practices from state activities related to on- and off-line pediatric medical direction. (June 2009)
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Improving EMS Medical Direction for Pediatric Patients, An Internet Archive Webcast. This webcast, available through HRSA’s Maternal and Child Health Bureau’s online communications site, covers such topics as: performance measures in pediatric emergency care, on- and off-line medical direction, and pediatric prehospital protocols. This presentation is archived in video format, includes slides, and can also be accessed in transcript or audio-only formats. (August 2006)
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Model Pediatric Protocols. These model pediatric prehospital protocols, developed by the National Association of EMS Physicians in collaboration with EMSC, provide a basis for medical direction to create or refine existing protocols to meet local, regional, and state needs. They also set forth a standardized approach to pediatric treatment that can be employed by a wide variety of EMS systems. (2003)
American College of Emergency Physicians
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Direction of Prehospital Care at the Scene of Medical Emergencies. This American College of Emergency Physicians (ACEP) policy statement asserts that the direction of prehospital 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 prehospital emergency stabilization and transport. (April 2008)
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Role of Emergency Physicians in Emergency Medical Services for Children. ACEP here affirms that emergency physicians, as leaders in EMS, have a pivotal role in the integration of emergency medical services for children. They can achieve this goal, in part, by providing leadership in local, regional, and state EMS and EMSC systems through their involvement in the provision of medical direction, provider education, quality improvement, and legislative advocacy. (October 2006)
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Interfacility Transportation of the Critical Care Patient and Its Medical DirectionI. This ACEP document affirms that a patient’s condition and the potential for complications should dictate the level of services available during interfacility transportation. It further clarifies that transportation agency physician medical directors must have sufficient education, experience, and training in the management of critical care patients and in transportation medicine issues to ensure appropriate medical oversight and direction to the transportation or EMS agency and its personnel. (September 2005)
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Medical Direction for Staffing an Ambulance. This policy statement states the ACEP belief that the staffing of ambulances and other out-of-hospital emergency service vehicles should be subject to local EMS system physician medical direction. (September 2005)
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Medical Direction of Emergency Medical Services. All aspects of the organization and provision of basic (including first responder) and advanced life support emergency medical services require the active involvement and participation of physicians. In this statement, ACEP asserts that EMS agencies must have an identifiable physician medical director at the local, regional, and state level. (April 2005)
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As an adjunct to this policy statement, ACEP’s EMS Committee has also prepared a Policy Resource and Education Paper (PREP) titled Medical Direction of Prehospital Emergency Medical Services. (Accessed March 2010)
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Physician Medical Direction of EMS Education Programs. A joint policy statement between the College’s EMS Committee and the National Association of EMS Physicians’ Standards and Practice Committee, this paper discusses the role of the EMS education program medical director. It addresses this individual’s desirable qualifications, authority, and responsibility over all medical content related to patient care in EMS courses. (January 1997)
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Emergency Care for Children: Growing Pains. This Institute of Medicine (IOM) publication, part of a three-part series on the Future of Emergency Care in the United States, offers an analysis of: the role of pediatric emergency services as an integrated component of the overall health system; system-wide pediatric emergency care planning, preparedness, coordination, and funding; pediatric training in professional education; and research in pediatric emergency care. Among other recommendations, it suggests that experts from federal and nonfederal organizations should develop evidence-based model prehospital care protocols for the treatment, triage, and transport of pediatric patients. (June 2006)
National Association of EMS Physicians
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Medical Director of Air Medical Transport Programs. This National Association of EMS Physicians (NAEMSP) paper affirms the multifaceted and integral position of a medical director for both air medical transport programs and the EMS community at large. It also discusses guidelines for medical director education, performance, and experience to ensure patient care quality, safety, and cost-effectiveness. (December 2002)
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Medical Direction of Interfacility Transports. Developed by NAEMSP, this guide elucidates the role of medical direction in promoting safe and effective interfacility patient transfers (December 2000). For more information on this topic, access the EMSC NRC’s Interfacility Transfer Toolbox.
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Role of the State EMS Medical Director. In this piece, NAEMSP collaborates with ACEP and the National Association of State EMS Directors (NASEMSD) to address the role of the medical director in the delivery of emergency medical services. (January 2005)
National Association of State EMS Officials
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The Role of State Medical Direction in the Comprehensive Emergency Medical Services System. A joint endeavor from NASEMSD, NAEMSP, and ACEP, this document endorses the belief that physician medical directors at the state level are essential components of EMS systems. The state EMS medical director is thought to provide medical aspects of leadership, oversight, coordination, access to best practices, system quality management, and research in order to assure the best possible EMS functioning for patients. (2008)
National Highway Traffic Safety Administration
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Implementation Guide: EMS Agenda for the Future. This implementation guide is designed to establish priority objectives for EMS at the local, state, and national levels. It features an objective for medical direction within emergency medical services systems, with the long-term goal being a requirement that all EMS provider agencies maintain a formal documented relationship with a qualified medical director. (1998)
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North Carolina College of Emergency Physicians Standards for the Selection and Performance of EMS Medical Directors. This document demonstrates state standards and performance measures for EMS physician medical directors. (2009)
EXAMPLE PRACTICES
Maryland has both on and off-line pediatric medical direction available statewide through its two designated pediatric trauma and burn centers (referred to as the “pediatric” base stations.) The centers were selected as base stations because they met two primary criteria: each is designated as a pediatric specialty center, and each provides 24/7 coverage by boarded or board-eligible pediatric emergency medicine (PEM) attending physicians. The two pediatric base stations also serve as consultation centers for the state’s community hospitals.
The 30,000+ EMS providers in the state have radio access to the two pediatric base stations, as well as access to the 44 community hospital and trauma center (non-pediatric) base stations located in the state. Each pediatric and non-pediatric base station must comply with state regulations which include application, standardized base station course, and site visits on a five-year cycle.
All base stations and EMS providers utilize the same statewide EMS protocols (integrated ALS and BLS) for on-line medical direction. Protocol changes occur annually on July 1. All individuals using base station radio (EMS, physicians, and nurses) must take a protocol update course in person, on the web, or by DVD. Online medical direction for children can be provided simultaneously by both the pediatric base station and one of the local community base stations or the closest adult trauma center – all of which follow the same protocols.
The pediatric base stations are reached through the Maryland Institute of Emergency Medical Services Systems’ (MIEMSS) Emergency Medical Resource Center (EMRC) and System Communication Center (SYSCOM). Together, they provide statewide communication linkages to all BLS and ALS transport units, ALS engines, ALS chase cars, first response EMS units, and state police med-evac. Through the use of radio and microwave or high frequency electromagnetic wave technology, the statewide communication system links ambulances, helicopters, and hospitals, thereby allowing communication between all system components at all times.
The EMRC coordinates medical consultation between medic units and hospital physicians. SYCOM’s operators work with a Maryland state policy duty officer to dispatch and coordinate all Maryland state police med-evac missions. A separate communications center at MIEMSS also assists with medical communications from certain high volume EMS call areas.
For information about Maryland’s medical direction efforts and challenges, see the EMSC publication Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures.
Colorado Department of Public Health and Environment
Colorado’s Dept. of Public Health and Environment serves as an example of a state health department taking an active role in medical direction for EMS. All emergency medical technicians (EMTs) in Colorado are required by Board of Health and Colorado Board of Medical Examiners (CBME) rules to have a medical director involved if they are providing direct patient care in any setting. The CBME regulates this practice, which defines the roles and responsibilities of a medical director and the scope of practice for each of Colorado's levels of emergency medical technician. (Accessed March 2010)
Idaho Guidelines for Medical Direction of Prehospital EMS
Physician direction of prehospital emergency care may be accomplished through off-line and on-line medical direction using prospective, concurrent, and retrospective methods. This web site lists the responsibilities and qualifications of medical directors to optimize prehospital emergency medical services, authority for medical direction, and obligations of an EMS agency in Idaho. (Accessed March 2010)
Iowa Department of Public Health, Bureau of EMS
Rules and regulations pertaining to EMS providers performing under medical direction can be downloaded from this web site. A checklist is provided addressing the medical director’s responsibilities for protocols, continuous quality improvement, patient care report audits, and continuing education hours. The EMS Physician Medical Director Statement of Affirmation can be used as a model for other states requiring training of EMS medical directors. The Iowa prehospital emergency care protocols fully integrate pediatrics in all areas of medical care. (Accessed March 2010)
New York State Department of Health
Updating Policy Statement #95-01: Medical Control, the “Providing Medical Direction” section of the New York State Dept. of Health’s website assists Emergency Medical Services (EMS) agencies and physician medical directors in understanding medical direction at the agency level. It defines the roles and responsibilities of the service, the service medical director, the Regional EMS Council, and the Regional Emergency Medical Advisory Committee (REMAC) in relation to this topic. (Accessed March 2010)
West Virginia Office of Emergency Medical Services
The West Virginia Office of Emergency Medical Services provides a medical direction system for state EMS providers and the citizens they serve. The EMS Medical Direction System consists of the following components: State Medical Director, Regional Medical Directors, State Critical Care Committee, On-Line Medical Direction System, Regional Medical Command Centers, Communications System Infrastructure, Scope of Practice Development, Medical Practice Policy Formation, and Medical Advice on Issues. (Accessed March 2010)
FAMILY AND CAREGIVER RESOURCES
American College of Emergency Physicians
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Emergency Care of Children. This fact sheet answers questions that parents may have about emergency care for children, such as:
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Which local emergency department is best for your child?
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What role do pediatric emergency specialists play in the care of your child?
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What emergency physicians are doing to improve the care of children?
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How to make sure your child gets appropriate treatment in an emergency? (Accessed March 2010)
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