EIIC: Emergency Medical Services for Children | Innovation and Improvement Center

Medical Direction Toolbox

Medical direction for emergency medical services (EMS) systems encompasses all aspects of physician oversight for medical care provided in the prehospital setting. Direct medical oversight, or online medical direction, involves real-time communications with EMS providers caring for a patient on an emergency scene or en route to the destination facility. Most commonly, physician medical directors (and sometimes mid-level providers, nurses, or paramedics with special training) consult with field EMS providers to direct patient care via cellular phone or two-way radio. Increasingly, video telemedicine capabilities are being incorporated into prehospital emergency care, providing opportunities for even more direct interaction between the physician medical director, EMS provider, and the patients they serve. Indirect medical direction, or offline medical direction, involves every other aspect of oversight for prehospital medical care, including development and implementation of protocols and patient care guidelines, provider training, EMS system design and evaluation, and quality assurance and improvement.

In 2006, the Institute of Medicine reported that “a lack of initial and continuing pediatric education, coupled with the low frequency with which EMT’s encounter critical pediatric patients, results in a lower level of care than should be expected of the nation’s prehospital emergency care system.” Additionally, studies have shown that prehospital providers are less comfortable with providing emergency care for pediatric patients, particularly infants. Therefore, the assurance of high quality online and offline medical direction for pediatric patients is of utmost importance.

The purpose of this toolkit is to guide EMSC program managers, physician medical directors, and EMS administrators on the roles and responsibilities of the EMS medical director and the incorporation of pediatrics into EMS medical oversight.

Healthcare Provider Resources

EMSC National Resource Center

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) 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 November 2013). 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)

American College of Emergency Physicians

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) Interfacility Transportation of the Critical Care Patient and Its Medical Direction 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) 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. (Reaffirmed April 2012) 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)

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 November 2013)

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) Role of State EMS Medical Director This joint statement by ACEP, the National Association of EMS Physicians (NAEMSP), and the National Association of State EMS Officials (NASEMSO) defines the role and basic qualifications of a state EMS medical director and strongly encourages the establishment of a regular, full-time position for a state EMS medical director in every U.S. state and territory. Qualified medical direction is identified as a fundamental element of the emergency medical services system. (April 2009) 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)

Critical Illness and Trauma Foundation

Guide for Preparing Medical Directors This course is an entry level orientation for medical directors covering the essentials for emergency medical services (EMS) oversight and direction. These materials were adapted from the National Highway Traffic Safety Administration’s (NHTSA) Guide for Preparing Medical Directors developed originally by NAEMSP and ACEP. Although designed to serve as an orientation for rural EMS medical directors, this course may also be beneficial to the medical director of EMS in a suburban or urban area who has not taken a medical directors course. (Accessed November 2013)

Federal Emergency Management Administration

HANDBOOK FOR EMS MEDICAL DIRECTORS Medical directors provide critical oversight and medical direction to ensure that effective emergency medical care is provided to millions of patients throughout the U.S. In addition to providing medical oversight and direction, EMS medical directors support EMS personnel and first responders through training, protocol development, and resource deployment advice. This handbook provides a baseline overview of key roles and responsibilities to assist current and prospective medical directors in performing their important missions. (March 2012)

Institute of Medicine

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

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) Medical Control of Emergency Medical Services (Hindmand, R. & Maggiore, W., 2011). NAEMSP highlights this article in the Journal of Health and Life Sciences Law. The authors provide an overview of the legal issues that may arise in the relationship between EMS medical directors and the EMTs providing care under their supervision, the legal structure of medical direction within the EMS systems, and the qualifications and responsibilities of EMS medical directors. (February 2011) Medical Oversight of EMS Systems This PowerPoint presentation provides an overview of EMS medical direction intended for EMS subspecialty certification candidates. It includes discussion on the definition and perspectives of indirect and direct medical oversight, distinct features of the medical practice of EMS systems, specialized proficiencies required by the practice of EMS, time dependency of immediate treatment of some conditions, and other essentials of understanding for the practice of medicine in the EMS environment. (May 2013)

National Association of State EMS Officials

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 EMS Advisory Council, Medical Oversight and Research Committee

The Next Steps for Prehospital Care Evidence-Based Guidelines The National EMS Research Agenda, published by NHTSA in 2001, and the report on the Future of Emergency Care in the United States, published by IOM in 2006, set forth recommendations to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients, including children. In response to these recommendations, in September 2008, the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC) cosponsored a national meeting, funded by NHTSA, to educate EMS leaders on the role of prehospital care evidence-based guidelines (EBGs) and to draft a National EBG Model Process (Appendix A) for the development, implementation, and evaluation of EMS guidelines.

National Highway Traffic Safety Administration

Emergency Medical Services Agenda for the Future This landmark agenda was developed to determine the most important directions for the future of EMS development. It continues to provide the guiding principles for the continued evolution of EMS, focusing on out-of-hospital aspects of the system. The Agenda describes medical direction (see page 29), the vision for the future of EMS medical direction, and the necessary actions to achieve that vision. (1995) Evidence-Based Guidelines for Prehospital Care Since 2008, NHTSA’s Office of Emergency Medical Services and the federal EMSC Program have been fortunate to work with EMS stakeholders to create and pilot test a model for developing and implementing evidence-based guidelines (EBGs) for prehospital emergency care. In this publication, NHTSA details the progress (Appendix A) of the project with the EMS community. (January 2013) 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)

North Carolina Office of EMS

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 EMSC

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.

Idaho EMS Medical Supervision Development Guide

In Idaho, licensed EMS providers are only able to provide emergency medical services under the supervision of a designated medical director. Providers are individually licensed at four levels of care: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), and Paramedic. This guide will provide an overview of medical direction for EMS agencies in Idaho and serve as an introduction into this important healthcare role. (2012)

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

Policy 11-03: Providing Medical Direction. This section of the New York State Dept. of Health’s website assists EMS agencies and physician medical directors in understanding medical direction for patients of all ages. 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. (March 2011)

Texas EMSC State Partnership

Pediatric Protocol Resource Tool Kit (PPR Tool Kit). This is a one-of-a-kind resource for EMS agencies and their medical directors, EMS professionals, and prehospital research personnel. Tools in the PPR Tool Kit include links to local, regional, and national resources, recently-developed evidence-based (EB) prehospital pediatric protocols, EB-summaries, model protocols, and a reference library.

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, and Scope of Practice Development. (Accessed November 2013)

Family And Caregiver Resources

American College of Emergency Physicians

Emergency Care of Children

This fact sheet answers questions that parents may have about emergency care for children, such as:

  • Which local emergency department is best for your child?
  • What role do pediatric emergency specialists play in the care of your child?
  • What emergency physicians are doing to improve the care of children?
  • How to make sure your child gets appropriate treatment in an emergency? (Accessed November 2013)