Physician Oversight of EMS and Interface with Quality Processes

Roger M. Stone, M.D.,M.S., FAAEM, FACEPFaculty, Department of Emergency Medicine

University of Maryland School of MedicineMedical Director, Montgomery Co Fire & Rescue

Associate Medical Director, Carroll County Emergency Services Association

UMBC / UMBEMS Fellowship

Objectives Definitions and terminology relating to

physicians in EMS– History– Stages of input: Prospective, Immediate, Retrospective

Understand focus on medical quality process Quality as primary mission of Medical Director Describe roles in on-line medical oversight Describe potential role in peer review Typical types of calls requiring direction

Brief History Important: Genesis of BLS

The Institute of Medicine’s “White Paper” Accidental Death and Disability: The Neglected Disease

of Modern Society (1966)

BLS previous to the White Paper Hearses or loose tiered ambulances, scoop & run Variable training in First Aid, little physician input

After the EMS Act of 1973 Monies available to create systems, including training Formal BLS was born from this

History of ALS Genesis: CPR in Baltimore

Dr. Peter Safar (JHU 1950s)

St Vincent’s Mobile CCU in NYC Dr. William Grace and CCU Fellows~ 1969

Seattle Medic One Dr. Leonard Cobb (U Washington 1970)

Miami Fire Department Rescue One Dr. Eugene Nagel (U Miami 1969)

History of Physicians in EMS Medical Command/Control (50’s-70’s) Medical Direction in late 80’s to early 90’s

– EMS got more autonomous

“EMS Physician” was born (circa 1986-90)– origin: Nat’l Assoc EMS Physicians (NAEMSP)– Position Paper on Medical Oversight (1998)

Medical Oversight– most modern terminology

– Source: Prehospital Care and Medical Oversight (NAEMSP)

Definitions of Medical Oversight

The responsibility of physicians to direct the prehospital system and providers in the overall clinical management of patients E. Racht

The result of the legal, moral and medical authority responsible for the provision of pre-hospital care by physician extenders

A process whereby a physician director insures that care provided to patients by the EMS system is both appropriate and beneficial - R. Bass

The implementation & supervision by a physician of the medical aspects of a system designed to deliver emergency patient care in the out of hospital setting– R. Stone

Stages of Medical Input

Stages of Input– Retrospective– Immediate– Prospective

Retrospective Input

Results from the review of individual calls and collected data – to determine if the system is working…not!

Assesses that appropriate skills were used and maintained (ex IVs, ETT)

Proactive problem solving & QI possible Peer review if individual personnel err

Prospective Input

Involvement prior to actual events– training of providers– patient care guidelines/standards/protocols– equipment selection and approval– appropriate credentialing of providers

Quality measures in place in advance

Immediate Input

Also referred to as On-Line Oversight Only 2 major mechanisms

– Radio Communication

– On scene physician (3 types) System EMS physician Patient’s physician Stranger/Samaritan/Passer-by

Levels of Care

1st Responder Emergency medical Technician-Basic Emergency Medical Technician-

Intermediate (300+ hours) Emergency Medical technician-

Paramedic (600-900 hours)

What should Residents know about EMS quality systems?

Need existence of state law enabling EMS Regulations: Guide Local and State QI Ability to query data in order to improve Inquiry process & peer review mechanism MD subtitles guide all aspects of EMS

02:Providers;03:Programs;04:Education 05: Regions; 06:AED; 07:Syscom; 08:Centers

– Source Maryland COMAR Title 30

Base Stations

Cornerstone of on-line direction Source COMAR Title 30, Subtitle 03, Chapter 06

Surrogate for the medical director’s inability to be everywhere all the time

Residency trained front line EPs, 24h/7d

Has a mandate for quality consultations

What should EM residents know about the medical director?

The medical director is hybrid:– Independent voice of off-line direction

Not an agent of either management or rank and file Not agent of State, but subject to laws or regulations Works with leaders, but nurtures rank & file Looked upon as a mentor on the medicine

Future EM graduates may be asked:– “Doc, could you be our medical director?”

Task Areas: Scope of Medical Practice

! Authority to impact quality of care

Medical decisions about assessment & treatment protocols, as well as equipment

Medical support for dispatch protocols Medical consultant for training programs Authority to locally credential providers

Medical liaison to all physicians in the community Link EMS to academic ties within emergency medicine Linkage of EMS to Public Health initiatives Oversight of any medical aspect of each service subsystem ICS: physician @ MCIs, drills, mass gatherings, multiple alarms

The Medical Review Process Physicians help adopt a QA Process

Maryland mandates MRC in each county

The physician may have various roles in such a process– Committee may report to him/her– Doc may sit on a committee, or be staff– Provides a buffer panel to avoid extremes of

personal opinion, avoid unfairness

Low and High Profile Case Key step is appropriate fact finding/investigation

Routine case: Mild shortcoming or bad habit System or an educational mentoring fix

Most states require absolute protection of public in high profile cases

Consider suspending privileges if serious Medical duties may still include remediation

MD Title 30 requires submission of plans to fix

EMS “Treat and Release” programs are risky 10 studies presented at NAEMSP 2003

In Maryland, study found 2000 ICD-9 codes were encountered by medics in Baltimore

The best under triage rate for treat & release 10%

So why do we need ALS as a means to decide not to transport?

Prehosp Emerg Care. 1999 Apr-Jun;3(2):140-9. “Change the scope of practice of paramedics?

An EMS/public health policy perspective” 5259 patients transported by city ambulance ED records available for 3329 (63%) Top 51 diagnoses accounted for 53.56%

– 82.5% of these involve infections, general patient evaluations, and injuries

– Each additional diagnosis accounts for less than one-third of 1% of cases

“The sheer breadth of diagnoses demonstrated a complexity beyond the grasp of any provider without numerous laboratory, diagnostic, and treatment resources.”

How can an EMS provider at any level identify the benign amongst such a high number of illnesses without more training?

(Stone ’05)

Prehosp Emerg Care. 2001 Oct-Dec;5(4):360-5

Can basic life support personnel safely determine that advanced life support is not needed?

Questions whether BLS can always judge the lack of need for ALS

N=69; 52 thought not to need ALS;40 needed ALS; 39 high risk CC’s;16 admitted

One of the most debated issues

N Engl J Med. 2004 Aug 12;351(7):647-56. Stiel et all

EMT-D programs impact cardiac arrests as much as the average EMT-P

Advanced cardiac life support in out-of-hospital cardiac arrest

“OPALS” Study presented at NAEMSP 2004

The addition of full ALS no better in cardiac arrest than adding AED to EMT-B

ALS valuable in the deteriorating Priority 1 patient

BLS waives off ALSBLS waives off ALS ALS on scene derails BLS plan to transportALS on scene derails BLS plan to transport ALS downgrades a call inappropriately ALS downgrades a call inappropriately ALS wishes to stop resuscitation early onALS wishes to stop resuscitation early on

People rely on only one medic who is the errant one

Have a common themeHave a common theme

Doctor, can I give this to the EMT’s? Doc, can I get a “priority 4-stop CPR”? Can you take this “mild trauma” patient? Doc, I gave him sugar and he woke up;

permission for non-transport? Can I have an order for CPAP? “A medic was there and said it was OK!”