Medical Control and Oversight

Bureau of EMS Policy Statement
Policy Statement # 11-05
Date June 28, 2011
Subject Medical Control and Oversight
Supercedes/Updates 95-01

Purpose

This policy was developed by the State Emergency Medical Advisory Committee (SEMAC) and the Department to better define the statutory authority, roles and responsibilities, the development of treatment protocols, credentialing, provision of medical control and oversight to the prehospital community. It was approved by the State EMS Council at its March, 2011 meeting and is authorized by the Department.

DEFINITIONS:

1. "State Emergency Medical Advisory Committee" (SEMAC) means the New York State Emergency Medical Advisory Committee formed pursuant to Public Health Law Section 3002-a.

2. "Regional Emergency Medical Advisory Committee" (REMAC) As defined in section 3001.16 means a group of five or more physicians, and one or more non-voting individuals representative of each of the following; hospitals, basic life support providers, advanced life support providers and emergency medical services training sponsor medical directors approved by the affected regional emergency medical services councils.

3. "Medical control" (3001.15) means:

  1. (a) advice and direction provided by a physician or under the direction of a physician to certified first responders, emergency medical technicians or advanced emergency medical technicians who are providing medical care at the scene of an emergency or en route to a health care facility and
  2. (b) indirect medical control including the written policies, procedures, and protocols for prehospital emergency medical care and transportation developed by the state emergency medical advisory committee, approved by the state council, the commissioner and implemented by regional medical advisory committees.

4. "Under the direction of a physician" shall mean a Physician, Physician Assistant, Nurse Practitioner, or Registered Professional Nurse that meets or exceeds those requirements as established in NYCRR Title 10, Section 405.19 - Emergency Services. Registered Professional Nurses must have completed the educational requirements within one year as stated in Section 405.19. Per Section 405.19 the following education requirements are:

Title Required Training
Physician ACLS and ATLS
Physician Assistant ACLS and ATLS
Nurse Practitioner ACLS and ATLS
Registered Professional Nurse ACLS

5. "Course sponsor medical director" means a physician licensed in the State of New York, identified by an approved training course sponsor and approved by the Department as having sufficient knowledge and experience required by the Department to fulfill the educational needs of Department certification courses.

6. "On-line (direct) medical control" means the advice and direction provided by a physician or under the direction of a physician, operating under guidelines approved by a REMAC, to certified EMS personnel who are providing medical care at the scene of an emergency or en route to a health care facility.

On-line medical control must be made directly between the on-line medical control personnel (Physician, Physician Assistant, Nurse Practitioner or Registered Professional Nurse1) and certified EMS field personnel and be in real time. Physician and Non-physician on-line medical control personnel must successfully complete a REMAC approved on-line medical control program. The physician on-line medical director or the REMAC will be responsible for conducting quality assurance review of the hospital or regional on-line medical control programs and personnel.

7. "Medical control location" means a place which has been approved by one or more REMAC(s) as having met their policies and procedures to provide on-line medical control.

8. "Regional EMS system" means the provision of emergency medical service, in an organized manner, by one or more EMS services or EMS systems, utilizing certified EMS personnel, in accordance with the medical control policies of the REMAC.

9. "EMS system" means one or more EMS services organized to provide emergency medical service in an area served by one or more Regional EMS Councils. An EMS system must have a system medical director and have been approved by each REMAC as having met the medical standards of the REMAC in each Region within which the system will provide care.

10. "Regional medical director" means a physician member of a REMAC, who has been approved by the REMAC as having met its credentialing policies and procedures and who may be appointed by a REMAC with specific duties and responsibilities.

11. "System medical director" means a physician identified by an EMS system who has been approved by one or more REMAC(s) as having met their credentialing policies and procedures and who oversees the medical care provided by all EMS services within the EMS System.

12. "Service medical director" means a physician identified by an EMS service who has been approved by one or more REMAC(s) as having met their credentialing policies and procedures, who is directly responsible for the medical care provided by the certified EMS personnel of that EMS service, and who provides and participates in the EMS service's quality improvement program. No physician may act as service medical director for more than 10 EMS Services. A ratio of physician to certified EMS personnel supervision must be provided as follows; a) 500:1 for certified EMS personnel who provide Automated External Defibrillation, b) 100:1 for certified EMS personnel who provide advanced life support; provided that the maximum number of personnel to be supervised by an individual physician may not exceed 500 AED or 100 ALS personnel2.

13. "Certified EMS personnel" means certified first responders, emergency medical technicians or advanced emergency medical technicians currently certified by the Department.

MEDICAL CONTROL

Medical control is accomplished through physician participation and direction at the state, regional, system and service levels.

State Emergency Medical Advisory Committee (SEMAC)

The state emergency medical advisory committee (SEMAC) shall:

  1. develop minimum standards for:
    • medical control,
    • triage, treatment, and transportation protocols,
    • protocols for invasive procedures,
    • protocols for infection control,
    • the administration of drugs, by certified EMS personnel,
    • the use of regulated medical devices by certified EMS personnel,
    • equipment, staffing and documentation requirements for medical control locations,
    • the approval of EMS systems,
    • qualifications and responsibilities for regional, system, service and course sponsor medical directors,
    • operational aspects of the provision of EMS related to improving patient care or outcome.
  2. issue, with the consent of the Commissioner, statewide advisory guidelines that include, but are not limited to:
    • medical standards for the establishment and approval of EMS services,
    • criteria for regional approval of dispatch, triage, treatment and transportation protocols,
    • criteria for statewide, regional, system and service quality improvement programs,
    • responsibilities of service medical directors,
    • inter regional ALS protocol coordination and use,
    • patient destination protocols,
    • policies to be utilized when no patient is found and/or a patient refuses services,
    • criteria for transfer of patient care between non-physician providers,
    • criteria for appropriate utilization of air medical transportation resources,
    • medical aspects of disaster and multiple casualty incidents and mutual aid,
    • any subject in section 1.
  3. issue minimum statewide guidelines, in compliance with all Federal and State rules, for inter-facility transfers including:
    • acceptance of any patient by the transferring crew,
    • authorization and responsibility of the sending hospital and physician,
    • required documentation, by the transferring physician, of the level of care to be provided during the transfer,
    • responsibilities of the receiving facility,
    • use of pre hospital protocols and medical control intervention,
    • use of medical modalities outside the regional prehospital protocol set that require special or additional training,
    • documentation and transmission of medical orders.
  4. review and approve protocols developed and/or implemented by REMAC's;
  5. review and make recommendations to the SEMSCO and the Commissioner regarding demonstration projects developed pursuant to 10 NYCRR Part 800.19;
  6. develop procedures for the review and approval of prehospital EMS research/evaluation activities;
  7. report to the SEMSCO on all issues brought before it.

Regional Emergency Medical Advisory Committee (REMAC)

Although by law a REMAC is given independent authority to decide EMS medical issues within its region, it must work cooperatively and with one common purpose with its Regional EMS Council (REMSCO) and the EMS community so that the system operates smoothly and effectively. For that to happen, the REMAC and the REMSCO need to establish joint operating procedures to ensure effective communications that produces a partnership of shared responsibilities that assures the provision of quality EMS services within the region. Toward this common objective the following goals for a REMAC are:

  • To establish prehospital medical standards for a region consistent with the current practice of emergency medicine.
  • To provide medical leadership, education, guidance, quality assurance and appropriate remediation to all participants in the regional EMS system
  • To ensure and participate in regional and agency level quality assurance activities.
  • To educate and credential physicians to provide on-line medical control.
  • To educate and credential NYS certified EMS prehospital care providers.
  • To ensure the availability and quality of educational programs for all pre-hospital care providers.
  • To coordinate the development of the regional medical control system.
  • To define roles and responsibilities of the REMAC physicians within the Regional EMS System.
  • To encourage broad medical participation and a diverse representative constituency in the development of medical control policies and procedures, as well as dispatch, triage, treatment, and transportation protocols which are consistent with the standards of the SEMAC and which address specific local conditions.
  • To develop a methodology by which both the REMSCO and REMAC will review, approve/disapprove, and forward recommendations to the appropriate regional and State committees regarding pre-hospital demonstration projects.
  • To receive patient outcome information from hospitals and pre-hospital EMS services and coordinate quality assurance/improvement activities for the purpose of assessing pre-hospital care concerns.
  • To encourage and review pre-hospital research/evaluation.

Each REMAC, within the standards and guidelines established by the SEMAC:

  1. shall develop, review and/or implement dispatch, treatment, triage and transportation protocols, specific to the needs of its region(s). Such protocols shall delineate care to be provided under standing orders and/or on-line medical control,
  2. may develop protocols, including but not limited to the following:
    • determining patient destination;
    • procedures to be followed when a patient refuses and/or no transport of a patient occurs;
    • circumstances under which care may be transferred from one level of non-physician provider to another;
    • utilization of air medical transportation resources.
  3. may develop policies and procedures, to optimize medical control of all pre-hospital patient care activities for all EMS services providing care within its region. Such policies and procedures shall include, but are not limited to,
    • the initial and continuing qualifications for physicians providing on-line medical control,
    • minimum staffing, equipment and documentation requirements for medical control locations,
    • qualifications and responsibilities for the regional, system, service and course sponsor medical directors,
    • approval of EMS services, indicating they have met the requirements of the REMAC to provide a level of care, upon initial application and any subsequent changes in the level of service offered;
    • guidelines for inter-facility transfers,
    • the initial credentialing and continuing medical and educational qualifications of all pre-hospital care providers in the region;
    • process for disciplinary action against EMS providers;
    • medical requirements for and approval of EMS systems and services,
    • approval and use of inter regional protocols,
    • operational aspects of the provision of EMS related to improving patient care or outcome,
  4. may develop, implement and shall participate in a region wide quality improvement plan which addresses regional and system wide issues, and which facilitates the integration of emergency medical service with hospital quality improvement activities,
  5. shall review and make recommendations to the REMSCO for any demonstration projects developed pursuant to Section 800.19 of this Part.
  6. may designate, if appropriate, a member to act as regional medical director, who if appointed shall have written duties, authorities and responsibilities defined by the REMAC.
  7. may develop procedures for the review and approval of prehospital EMS research/evaluation activities.
  8. shall address all issues brought before it by the REMSCO or any provider or other interested party.

Footnotes

1 Meeting the requirements of Title 10 NYCRR part 405.19 (d) Staffing, sections (1) Emergency Service Physician and (3) Registered Physicians Assistants, Nurse Practitioners and Registered Professional Nurses.

2 10 NYCRR Part 80.136 (a)(2)...The medical director of any advanced life support system with 10 or more advanced life support agencies and/or 100 or more advanced emergency medical technicians (AEMTS) shall designate associate physicians...

RESOURCE INFORMATION

11-03 Providing Medical Direction

http://www.health.state.ny.us/professionals/ems/policy/11-03.htm

American College of Emergency Physicians

http://www.acep.org

National Association of EMS Physicians

http://www.naemsp.org

Approved by Lee Burns, Acting Director