Miss. Code. tit. 15, pt. 12, subpt. 31, ch. 10, app 15-12-31-10-1
Medical Direction (pre-hospital Emergency Medical Services)
All aspects of the organization and provision of emergency medical services (EMS), including both basic and advanced life support, require the active involvement and participation of physicians. These aspects should incorporate design of the EMS system prior to its implementation; continual revisions of the system; and operation of the system from initial access, to pre-hospital contact with the patient, through stabilization in the emergency department. All pre-hospital medical care may be considered to have been provided by one or more agents of the physician who controls the pre-hospital system, for this physician has assumed responsibility for such care.
Implementation of this standard practice will insure that the EMS system has the authority, commensurate with the responsibility, to insure adequate medical direction of all pre-hospital providers, as well as personnel and facilities that meet minimum criteria to implement medical direction of pre-hospital services.
OFF-LINE (PROSPECTIVE AND RETROSPECTIVE) MEDICAL DIRECTION
Off-line medical direction includes the administrative promulgation and enforcement of accepted standards for out-of-hospital care. Off-line medical direction can be accomplished through both prospective and retrospective methods. Prospective methods include, but are not limited to, training, testing, and credentialing of providers, protocol development, operational policy and procedures development, and legislative activities. Off-line medical direction shall ensure the qualifications of out-of-hospital personnel involved in patient care and dispatch are maintained on an ongoing basis through education, testing, and credentialing as the local/state authorities have determined. Retrospective activities include, but are not limited to medical audit and review of care, (process improvement), direction of remedial education, and limitation of patient care functions if needed. Committees functioning under the medical director with representation from appropriate medical and provider personnel can perform various aspects of prospective and retrospective medical direction.
Each EMS agency providing pre-hospital care shall be licensed by the Mississippi State Department of Health, BEMS, and shall have an identifiable off-line Medical Director who after consultation with others involved and interested in the agency is responsible for the development, implementation and evaluation of standards for provision for medical care within the agency.
All pre-hospital providers (including EMT-Bs) shall be medically accountable for their actions and are responsible to the off-line Medical Director of the licensed EMS agency that approves their continued participation. All pre-hospital providers, with levels of certification EMT-B or above, shall be responsible to an identifiable physician who directs their medical care activity. The off-line Medical Director shall be appointed by, and accountable to, the appropriate licensed EMS agency.
The licensee's off-line medical director shall ensure that there is a capability and method to provide on-line medical control to EMS personnel on board any permitted unit at all times. If patient specific orders are written, there shall be a formal procedure to use them. In addition to on-line medical control capabilities, the licensee shall have a written plan, procedure, and resources in place for off-line medical control. This may be accomplished by use of comprehensive written, guidelines, procedures, or protocols.
Qualifications of a Medical Director
To optimize off-line medical direction of all out-of-hospital emergency medical services, these services should be managed by physicians who have demonstrated the following:
1. Mississippi licensed physician, M.D. or D.O.
2. Familiarity with the design and operation of out-of-hospital EMS systems.
3. Experience or training in the out-of-hospital emergency care of the acutely ill or injured patient.
4. Experience or training in medical direction of out-of-hospital emergency units.
5. Active participation or reasonable associated experience in the ED management of the acutely ill or injured patient.
6. Experience or training in the instruction of out-of-hospital personnel.
7. Active involvement in the training of pre-hospital personnel.
8. Experience or training in the EMS performance improvement process.
9. Active involvement in the medical audit, review and critique of medical care provided by pre-hospital personnel.
10. Knowledge of EMS laws and regulations.
11. Knowledge of EMS dispatch and communications.
12. Knowledge of local mass casualty and disaster plans including preparation for responding to terrorism and weapons of mass destruction.
13. By July 1, 2017, board certification in emergency medicine by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine. Substitutions may be approved by the State Medical Director.
14. Completion of an EMS Medical Directors training course. (Effective January, 2013)
15. Familiarity with base station operations where applicable, including communication with, and direction of, pre-hospital emergency units.
16. Knowledgeable of the administrative and legislative process affecting the local, regional and/or state pre-hospital EMS system.
17. Knowledgeable of laws and regulations affecting local, regional, and state EMS.
18. Approved by the State EMS Medical Director
Authority of an off-line Medical Director includes, but is not limited to:
Unless otherwise defined or limited by state or regional requirements, the medical director shall have authority over all clinical and patient care aspects of the EMS system including, but not limited to, the following:
1. Recommend certification, recertification, and decertification of non-physician out-of-hospital personnel to the appropriate certifying agency.
2. Establish, implement, revise, and authorize the use of system-wide protocols, policies, and procedures for all patient care activities from dispatch through triage, treatment, transport, and/or non-transport.
3. Establish criteria for determining patient destination in a non-discriminatory manner in compliance with state guidelines as appropriate.
4. Ensure the competency of personnel who provide on-line medical direction to out-of-hospital personnel including, but not limited to, physicians, EMTs, Advanced EMTs, Paramedics and nurses.
5. Establish the procedures or protocols under which non-transport of patients may occur.
6. Require education and testing to the level of proficiency approved for the following personnel within the EMS system:
a. EMTs
b. Advanced EMTs
c. Paramedics
d. Critical Care Paramedics
e. Nurses involved in out-of-hospital care
f. Dispatchers
g. Educational coordinators
h. On-line physicians
i. Off-line physicians
7. Implement and supervise an effective process improvement program. The medical director shall have access to all relevant records needed to accomplish this task.
8. Remove a provider from medical care duties for due cause, using an appropriate review and appeals mechanism.
9. Set or approve hiring standards for personnel involved in patient care.
10. Set or approve standards for equipment used in patient care.
11. Establishing system-wide medical and trauma protocols in consultation with appropriate specialists.
12. Recommending certification or decertification of non-physician pre-hospital personnel to the appropriate certifying agencies. Every licensed agency shall have an appropriate review and appeals mechanism, when decertification is recommended, to assure due process in accordance with law and established local policies. The Director shall promptly refer the case to the appeals mechanism for review, if requested.
13. Requiring education to the level of approved proficiency for personnel within the EMS system. This includes all pre-hospital personnel, EMTs at all levels, pre-hospital emergency care nurses, dispatchers, educational coordinators, and physician providers of on-line direction.
14. Suspending a provider from medical care duties for due cause pending review and evaluation. Because the pre-hospital provider operates under the license (delegated practice) or direction of the Medical Director, the Director shall have ultimate authority to allow the pre-hospital provider to provide medical care within the pre-hospital phase of the EMS system.
15. Establishing medical standards for dispatch procedures to assure that the appropriate EMS response unit(s) is dispatched to the medical emergency scene when requested, and the duty to evaluate the patient is fulfilled.
16. Establishing under which circumstances a patient may be transported against his will; in accordance with, state law including, procedures, appropriate forms, and review process.
17. Establishing criteria for level of care and type of transportation to be used in pre-hospital emergency care (i.e., advanced life support vs. basic life support, ground air, or specialty unit transportation).
18. Establishing criteria for selection of patient destination.
19. Establishing educational and performance standards for communication resource personnel.
20. Establishing operational standards for communication resource.
21. Conducting effective system audit and quality assurance. The Medical Director shall have access to all relevant EMS records needed to accomplish this task. These documents shall be considered quality assurance documents and shall be privileged and confidential information.
22. Insuring the availability of educational programs within the system and that they are consistent with accepted local medical practice.
23. May delegate portions of his/her duties to other qualified individuals.
24. The owner, manager, or medical director of each publicly or privately owned ambulance service shall inform the State Department of Health, Bureau of EMS of the termination of service in a licensed county or defined service area no less than 30 days prior to ceasing operations. This communication should also be sent by the owner, manager or medical director of each publicly or privately owned ambulance service to related parties and local governmental entities such as, but not limited to, emergencies management agency, local healthcare facilities, and the public via mass media.
25. Medical direction with concurrent and retrospective oversight supervision;
26. Standardized protocols;
27. Actively engaged in a continuous quality assurance, quality control, performance review, and when necessary, supplemental training.
Medical Direction (Online, Direct Medical Control)
On-line medical direction is the medical direction provided directly to out-of-hospital providers by the medical director or designee, as defined in the BEMS approved medical control plan, generally in an emergency situation, either on-scene or by direct voice communication. The mechanism for this contact may be radio, telephone, or other means as technology develops, but must include person-to-person communication of patient status, and orders to be carried out. Ultimate authority and responsibility for concurrent medical direction rests with the off-line medical director.
The practice of on-line medical direction shall exist and be available within the EMS system, unless impossible due to distance or geographic considerations. All credentialed pre-hospital providers shall be assigned to a specific on-line communication resource by a predetermined policy and this shall be included in the application for ALS licensure.
When EMS personnel are transporting patients to locations outside of their geographic medical control area, they may utilize recognized communication resources outside of their own area.
Specific local protocols shall exist which define those circumstances under which on-line medical direction is required.
On-line medical direction is the practice of medicine and all orders to which the pre-hospital provider shall originate from/or be under the direct supervision and responsibility of a physician.
The receiving hospital shall be notified prior to the arrival of each patient transported by the EMS system unless directed otherwise by local protocol.
Requirements of a Medical Director
1. This physician shall be approved to serve in this capacity by system (Off-Line) Medical Director.
2. This physician shall have received education to the level of proficiency approved by the off-line Medical Director for proper provision of on-line medical direction, including communications equipment, operation, and techniques. (January 2013) All Mississippi On-Line Medical Directors are encouraged to complete the Medical Director's course as prescribed by the Mississippi State Department of Health, Bureau of Emergency Medical Services and the Medical Direction, Training and Quality Assurance Committee.
3. This physician shall be appropriately trained in pre-hospital protocols, familiar with the capabilities of the pre-hospital providers, as well as local EMS operational policies and regional critical care referral protocols.
4. This physician shall have demonstrated knowledge and expertise in the pre-hospital care of critically ill and injured patients.
5. This physician assumes responsibility for appropriate actions of the pre-hospital provider to the extent that the on-line physician is involved in patient care direction.
6. The on-line physician is responsible to the system Medical Director (off-line) regarding proper implementation of medical and system protocols.
7. The licensee's off-line medical director shall ensure that there is a capability and method to provide on-line medical control to air medical personnel on board any of its air ambulance aircraft at all times. If patient specific orders are written, there shall be a formal procedure to use them. In addition to on-line medical control capabilities, the licensee shall have a written plan, procedure, and resources in place for off-line medical control. This may be accomplished by use of comprehensive written, guidelines, procedures, or protocols.
8. There must be - at all times - Medical direction with concurrent and retrospective oversight supervision; Standard Protocols; Continuing quality assurance, quality control, performance review, and when necessary, supplemental training.
Authority for Control of Medical Services at the Scene of Medical Emergency.
Authority for patient management in a medical emergency shall be the responsibility of the individual in attendance who is most appropriately trained and knowledgeable in providing pre-hospital emergency stabilization and transport.
When an advanced life support (ALS) squad, under medical direction, is requested and dispatched to the scene of an emergency, a doctor/patient relationship has been established between the patient and the physician providing medical direction.
The pre-hospital provider is responsible for the management of the patient and acts as the agent of medical direction.
Authority for Scene Management.
Authority for the management of the scene of a medical emergency shall be vested in appropriate public safety agencies. The scene of a medical emergency shall be managed in a manner designed to minimize the risk of death or health impairment to the patient and to other persons who may be exposed to the risks as a result of the emergency condition, and priority shall be placed upon the interests of those persons exposed to the more serious risks to life and health. Public safety personnel shall ordinarily consult emergency medical services personnel or other authoritative medical professionals at the scene in the determination of relevant risks.
Patient's Private Physician Present
The EMT should defer to the orders of the private physician. The base station should be contacted for record keeping purposes if on-line medical direction exists. The ALS squad's responsibility reverts back to medical direction or on-line medical direction at any time when the physician is no longer in attendance.
Intervener Physician Present and Non-Existent On-Line Medical Direction
When the intervener physician has satisfactorily identified himself as a licensed physician and has expressed his willingness to assume responsibility and document his intervention in a manner acceptable to the local emergency medical services system (EMSS); the pre-hospital provider should defer to the orders of the physician on the scene if they do not conflict with system protocol.
If treatment by the intervener physicians at the emergency scene differs from that outlined in a local protocol, the physician shall agree in advance to assume responsibility for care, including accompanying the patient to the hospital. In the event of a mass casualty incident or disaster, patient needs may require the intervener physician to remain at the scene.
Intervener Physician Present and Existent On-Line Medical Direction
If an intervener physician is present and on-line medical direction does exist, the on-line physician should be contacted and the on-line physician is ultimately responsible.
The on-line physician has the option of managing the case entirely, working with the intervener physician, or allowing him to assume responsibility.
If there is any disagreement between the intervener physician and the on-line physician, the pre-hospital provider should take orders from the on-line physician and place the intervener physician in contact with on-line physician.
In the event the intervener physician assumes responsibility, all orders to the pre-hospital provider shall be repeated to the communication resource for purposes of record-keeping.
The intervener physician should document his intervention in a manner acceptable to the local EMS system.
The decision of the intervener physician to accompany the patient to the hospital should be make in consultation with the on-line physician. Nothing in this section implies that the pre-hospital provider CAN be required to deviate from system protocols.
Communication Resource
A communication resource is an entity responsible for implementation of direct (on-line) medical control. This entity/facility shall be designated to participate in the EMS system according to a plan developed by the licensed ALS provider and approved by the system (off-line) medical director and the State Department of Health, BEMS.
The communication resource shall assure adequate staffing for the communication equipment at all times by health care personnel who have achieved a minimal level of competence and skill and are approved by the system medical director.
The communication resource shall assure that all requests for medical guidance assistance or advice by pre-hospital personnel will be promptly accommodated with an attitude of utmost participation, responsibility, and cooperation.
The communication resource shall provide assurance that they will cooperate with the EMS system in collecting and analyzing data necessary to evaluate the pre-hospital care program as long as patient confidentiality is not violated.
1. The communication resource will consider the pre-hospital provider to be the agent of the on-line physician when they are in communication, regardless of any other employee/employer relationship.
2. The communication resource shall assure that the on-line physicians will issue transportation instructions and hospital assignments based on system protocols and objective analysis of patient's needs and facility capability and proximity.
3. No effort will be made to obtain institutional or commercial advantages through use of such transportation instructions and hospital assignments.
4. When the communication resource is acting as an agent for another hospital, the information regarding patient treatment and expected time of arrival will be relayed to the receiving hospital in an accurate and timely fashion.
5. Communication resource shall participate in regular case conferences involving the on-line physicians and pre-hospital personnel for purposes of problem identification and provide continuing education to correct any identified problems.
6. If the communication resource is located within a hospital facility, the hospital shall meet the requirements listed herein and the equipment used for on-line medical direction shall be located within the emergency department.
Educational Responsibilities
Because the on-line and off-line medical directors allow the use of their medical licenses, specific educational requirements should be established. This is not only to insure the best available care, but also to minimize liability. All personnel brought into the system must meet minimum criteria established by state law for each level; however, the law should in no way preclude a medical director from enforcing standards beyond this minimum.
Personnel may come to the system untrained (in which case the medical director will design and implement the educational program directly or through the use of ancillary instructors), or they may have previous training and/or experience. Although the Department of Transportation has defined curricula for training, the curricula are not standardized nationally, and often are not standardized within a state or county. Certification or licensure in one locale does not automatically empower an individual to function as an EMT within another system. The medical director must evaluate applicants trained outside the system in order to determine their level of competence. Such evaluation may be made in the form of written examinations, but should also include practical skills and a field internship with competent peers and time spent with the medical director.
The educational responsibilities of the medical director do not end with initial training; skills maintenance must be considered. To insure the knowledge does not stagnate, programs should cover all aspects of the initial training curriculum on a cyclical basis. Continuing education should comprise multiple formats, including lectures, discussions, and case presentations, as well as practical situations that allow the EMT to be evaluated in action. The continuing education curriculum should also include topics suggested by audits, and should be utilized to introduce new equipment or skills.
Paramedics are allowed to administer any pharmaceutical that is approved in these Rules and Regulations; through any route that falls within the skill set taught consistent with the National Standard Curriculum; and approved by off line medical director.
Review and Audit
Personnel may be trained to the highest standards and many protocols may be written, but if critical review is not performed, the level of patient care will deteriorate. Review is intended to determine inadequacies of the training program and inconsistencies in the protocols. The data base required includes pre-hospital care data, emergency department and inpatient (summary) data, and autopsy findings as appropriate. The cooperation of system administrators, hospital
administrators, and local or state medical societies must be elicited. On occasion, the state legislature may be required to provide access to vital information.
The medical director or a designated person should audit pre-hospital run records, either randomly or inclusively. The data must be specifically evaluated for accuracy of charting and assessment; appropriateness of treatment; patterns of error, morbidity, and mortality; and need for protocol revision.
It cannot be assumed that all pre-hospital care will be supervised by on-line physicians. When proper or improper care is revealed by the audit process, prompt and appropriate praise or censorship should be provided by the medical director after consultation with the system administrator.
Individual Case Review.
Compliance with system rules and regulations is most commonly addressed by state and regional EMS offices. Audit by individual case review requires a more detailed plan. Each of the components defined in detail by the individual EMS system must be agreed on prior to the institution of any case review procedures. Case review may involve medical audit, including reviews of morbidity and mortality data (outcome-oriented review), and system audit, including compliance with rules and regulations as well as adherence to protocols and standing orders (process-oriented review). The personnel to be involved in a given case review process should include the off-line medical director; emergency department and critical care nurses; and EMS, technical and other support personnel who were involved in the specific cases.
The following must be written and agreed to in advance:
Procedural guidelines of how the individuals will interact during meetings.
Because considerations of medical malpractice may be present when issues concerning appropriateness of care and compliance with guidelines are raised, legal advice for procedural guidelines must be obtained prior to the institution of any medical audit program in order that medical malpractice litigation will neither result from nor become the subject of the meeting.
Confidentiality of case review in terms of local open meeting laws and public access to medical records and their distribution.
Format for recording the meeting and its outcome.
Access to overall system performance records, both current and historical, to allow comparison.
Overall outcome data (morbidity and mortality) and individual, unit-specific, and system-wide performance can be measured by the following means:
The severity of presentation of patients must be known, and a scale for that measurement must be agreed on, included in all EMT education, and periodically checked for reliability.
Appropriate treatment on scene and in transit should be recorded and subsequently evaluated for its effect on overall patient outcome.
At the emergency department, the severity of cases presenting (according to a severity scoring technique) and treatment needed should be recorded in detail.
An emergency department diagnosis and outcome in terms of admission to a general medical bed, critical care unit, or morgue must be known. The length of stay in the hospital, cost of stay, discharge status, and pathologic diagnosis should be made available.
Specialty Care Transport (SCT) Services
Specialty Care Transport (SCT) Services provide interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.
The off-line medical director for SCT agencies shall have access to consult with medical specialists for patient(s) whose illness and care needs are outside his/her area of practice. The medical director must have education experience in those areas of medicine that are commensurate with the mission statement of the medical transport service or utilize specialty physicians as consultants when appropriate.
Miss. Code. tit. 15, pt. 12, subpt. 31, ch. 10, app 15-12-31-10-1