Developments of EMS Medical Direction

During a Disaster in TexasSTRAC Emergency Healthcare Systems Conference

May 6, 2014

Craig Cooley, MD, MPH, EMT-P, FACEP

Assistant Professor, UT Health Science Center San Antonio

Interim Assistant Medical Director, San Antonio Fire Department

Emily Kidd, MD

Assistant Professor, UT Health Science Center, San Antonio

Interim Medical Director, San Antonio Fire Department

� Understand scope of practice as it pertains to EMS

and other health personnel during a disaster

� Understand potential differences in scope of practice

and skill of responders from different jurisdictions

� Understand Texas regulations concerning EMS

Medical Direction and Medical Direction in a disaster

� Understand the different roles and issues for the

local EMS Medical Director during a disaster

�Discuss Texas specific programs and initiatives for

EMS during a disaster

OBJECTIVES

Dr. Craig

Cooley

SCOPE OF PRACTICE IN

EMS

“SCOPE OF PRACTICE”

�Legal descriptionLegal descriptionLegal descriptionLegal description

�Distinguishes between licensed health care

personnel and the lay public

�Distinguishes between different licensed

health care professionals

�Exclusive or overlapping domains of practice

�EMS—depends on definition of “pre-hospital”

�May be written or interpreted narrowly

�Paramedics in EDs

SCOPE OF PRACTICE

�Describes authority, vested by a state, in

licensedlicensedlicensedlicensed individuals practicing within that

state

�Statute, rules, or regulations

�Precedent

�Licensure board interpretation

�Establishes which activities and procedures

represent illegal activity if performed without

a license

SURVEY

�How many Licensed Paramedics?

�How many Certified Paramedics?

CONFUSION“LICENSED PARAMEDIC”

CertificationCertificationCertificationCertification

� Time-limited recognition and use of a credential to an individual after verifying that he/she has met predetermined and standardized criteria� National Registry

� Licensed before ABEM

� USMLE before license

� Statutory—allows for government regulation when activity is not prohibited by law� Teachers, librarians

LicensureLicensureLicensureLicensure

� Time-limited government permission given to an individual to engage in a given activity after verification of predetermined and standardized criteria

� Illegal to perform without approval

� All EMS providers are functionally licensed

� Nothing to do with “independence” of practice

SCOPE OF PRACTICE

�Tasks and roles legally authorized to perform

�DOES NOT:DOES NOT:DOES NOT:DOES NOT:

�Define standard of care

�Establish a practice guideline or protocol

�Protocols may “define” scope of practice

�Vary based on circumstances

�Regulate knowledge

SCOPE VS STANDARD

Scope of PracticeScope of PracticeScope of PracticeScope of Practice

1. “Are/were you allowed to do it?”

2. Act of commission if unlicensed—criminal offense

3. Varies level to level, but NOT based on circumstances

4. From statute, rules, regulations, etc

5. Can’t really regulate knowledge through scope of practice

Standard of CareStandard of CareStandard of CareStandard of Care

1. “Did you do the right thing and did you do it properly?”

2. Act of commission or omission may lead to civil l iability (negligence)

3. Situational—depends on many variables

4. Determined by scope of practice, l iterature, expert witnesses and juries

5. Used to evaluated professional judgment

IF YOU’VE SEEN ONE

EMS SYSTEM, YOU’VE

SEEN ONE EMS SYSTEM

“PARAMEDIC”

�What does that mean?

�No universal definition

�Varies by state and regions within Texas

�Delegated authority (more later)

�Wide range of skills and training

�Two providers standing next to each other may

not have the same capabilities

�Why??

SCOPE OF PRACTICE

�States highly variable

�Listed in state law

�May be constraining

�Deferred to state level EMS authority

�Combination of elements

�Vague language

�Examples…

PENNSYLVANIA SCOPE OF PRACTICE LAW

� A i r w a y — N o n s u r g i c a l A l t e r n a t i v e / R e s c u e A i r w a y — C o m b i T u b e T M , K i n g L T - D A i r w a y T M o r K i n g L T S - D A i r w a y

� A i r w a y — o r a l & n a s a l

� A i r w a y — p h a r y n g e a l t r a c h e a l l u m e n ( P T L )

� B a g - v a l v e - E T T / N o n s u r g i c a l a l t e r n a t i v e a i r w a y v e n t i l a t i o n

� B a g - v a l v e - m a s k — w i t h i n - l i n e s m a l l - v o l u m e n e b u l i z e r

� B a g - v a l v e - m a s k ( B V M ) v e n t i l a t i o n

� C h e s t d e c o m p r e s s i o n — n e e d l e

� C P A P / B i P A P 5— d e m o n s t r a t e a p p l i c a t i o n o f

� C r i c o i d p r e s s u r e ( S e l l i c k m a n e u v e r )

� C r i c o t h y r o t o m y — n e e d l e

� C r i c o t h y r o t o m y — o p e n / s u r g i c a l

� C r i c o t h y r o t o m y — o v e r w i r e ( S e l d i n g e r ) t e c h n i q u e

� E n d t i d a l C O 2 m o n i t o r i n g / c a p n o g r a p h y

� E s o p h a g e a l o b t u r a t o r a i r w a y ( E O A ) / e s o p h a g e a l g a s t r i c t u b e a i r w a y ( E G T A )

� E x t u b a t i o n

� F l o w r e s t r i c t e d o x y g e n p o w e r e d v e n t i l a t i o n d e v i c e ( d em a n d v a l v e )

� G a s t r i c d e c o m p r e s s i o n — O G 5 & N G 5 t u b e ( s u c t i o n )

� G a s t r i c t u b e i n s e r t i o n — n a s a l & o r a l

� H e a d - t i l t / c h i n - l i f t

� I n s p i r a t o r y I m p e d a n c e T h r e s h o l d D e v i c e ( I T D )

� I n t u b a t i o n — d i g i t a l & l i g h t e d s t y l e t

� I n t u b a t i o n — e n d o t r a c h e a l t u b e

� I n t u b a t i o n — m e d i c a t i o n p a r a l y t i c s a s s i s t e d ( R S I 5 )

� I n t u b a t i o n — n a s o t r a c h e a l & o r o t r a c h e a l

� I n t u b a t i o n — r e t r o g r a d e

� I n t u b a t i o n — t r a n s i l l u m i n a t i o n / l i g h t e d s t y l e t

� J a w t h r u s t & m o d i f i e d j a w t h r u s t ( t r a um a )

� L a r y n g e a l m a s k a i r w a y ( L M A )

� Mo u t h - t o - m o u t h , n o s e , s t o m a , b a r r i e r & p o c k e t m a s k

� O b s t r u c t i o n — d i r e c t l a r y n g o s c o p y ( r e m o v e w i t h f o r c e p s )

� O b s t r u c t i o n — m a n u a l ( H e i m l i c h , f i n g e r s w e e p , c h e s t t h r u s t s ) u p p e r a i r w a y

� O x y g e n t h e r a p y — b l o w - b y d e l i v e r y

� O x y g e n t h e r a p y — h u m i d i f i e r s

� O x y g e n t h e r a p y — n a s a l c a n n u l a

� O x y g e n t h e r a p y — n o n - r e b r e a t h e r m a s k

� O x y g e n t h e r a p y — p a r t i a l r e b r e a t h e r

� O x y g e n t h e r a p y — r e g u l a t o r s

� O x y g e n t h e r a p y — s i m p l e f a c e m a s k

� O x y g e n t h e r a p y — V e n t u r i m a s k

� P e a k e x p i r a t o r y f l o w a s s e s s m e n t

� P u l s e o x i m e t r y

� S u c t i o n i n g — m e c o n i u m a s p i r a t i o n

� S u c t i o n i n g — s t o m a / t r a c h e o s t o m y

� S u c t i o n i n g — t r a c h e o b r o n c h i a l

� S u c t i o n i n g — u p p e r a i r w a y ( n a s a l )

� S u c t i o n i n g — u p p e r a i r w a y ( o r a l )

� T r a n s t r a c h e a l j e t v e n t i l a t i o n

� V e n t i l a t o r s — a u t o m a t e d t r a n s p o r t ( A T V )

� V e n t i l a t o r s — t r a n s p o r t

� G l a s g o w C o m a S c a l e ( G C S )

� L e v e l o f c o n s c i o u s n e s s ( L O C )

� P a t i e n t a s s e s s m e n t s k i l l s i d e n t i f i e d i n t h e N S C 5

� V i t a l s i g n — b o d y t e m p e r a t u r e

� V i t a l s i g n — p u l s e

� V i t a l s i g n — p u p i l s

� V i t a l s i g n — r e s p i r a t i o n s

� V i t a l s i g n — s k i n c o l o r / t e m p e r a t u r e & c o n d i t i o n ( C T C )

� B l o o d p r e s s u r e — a u s c u l t a t i o n

� B l o o d p r e s s u r e — e l e c t r o n i c n o n - i n v a s i v e

� B l o o d p r e s s u r e — p a l p a t i o n

� C a r d i a c m o n i t o r i n g — a p p l y e l e c t r o d e s

� C a r d i a c m o n i t o r i n g — m u l t i l e a d

� C a r d i a c m o n i t o r i n g — s i n g l e l e a d ( i n t e r p r e t i v e )

� C a r d i o p u l m o n a r y r e s u s c i t a t i o n ( C P R ) a d u l t , i n f a n t , c h i l d , o n e & t w o p e r s o n

� C a r d i o v e r s i o n — s y n c h r o n i z e d

� C a r o t i d m a s s a g e ( v a g a l m a n e u v e r s )

� D e f i b r i l l a t i o n — C o u n t e r s h o c k —m a n u a l

� D e f i b r i l l a t i o n — a u t o m a t e d e x t e r n a l d e f i b r i l l a t o r ( A E D )

� H em o d y n a m i c m o n i t o r i n g / a s s i s t ( S w a n G a n z , a r t e r i a l , c e n t r a l v e n o u s l i n e s )

� I n t r a - a o r t i c b a l l o o n p um p m o n i t o r i n g / a s s i s t

� M e c h a n i c a l C P R d e v i c e

� T h r o m b o l y t i c t h e r a p y — i n i t i a t i o n

� T h r o m b o l y t i c t h e r a p y — m o n i t o r i n g

� T r a n s c u t a n e o u s p a c i n g

� U s e a ( c a r d i a c ) m a g n e t t o a l t e r t h e m o d e o f a n A I C D 5 o r p a c em a k e r

� V e r b a l p a t i e n t r e p o r t t o r e c e i v i n g p e r s o n n e l

� C ommu n i c a t i o n s w i t h P S A P s 5 , h o s p i t a l s , m e d i c a l c o mm a n d f a c i l i t i e s

� O u t - o f - H o s p i t a l D o N o t R e s u s c i t a t e ( D N R ) o r d e r s ( A c t # 5 9 )

� P a t i e n t C a r e R e p o r t c o m p l e t i o n

� C o n t am i n a t e d e q u i p m e n t d i s p o s a l ( s h a r p s & P P E 5 )

� D e c o n t a m i n a t i o n

� D i s i n f e c t i o n

� P P E 5 ( p e r s o n a l p r o t e c t i o n e q u i p m e n t ) u s e

� S p i n a l i mm o b i l i z a t i o n — h e l m e t s t a b i l i z a t i o n o r r e m o v a l

� S p i n a l i mm o b i l i z a t i o n — l o n g b o a r d w / p t s u p i n e & s t a n d i n g

� S p i n a l i mm o b i l i z a t i o n — m a n u a l s t a b i l i z a t i o n & c e r v i c a l c o l l a r

� S p i n a l i mm o b i l i z a t i o n — r a p i d e x t r i c a t i o n

� S p i n a l i mm o b i l i z a t i o n — s e a t e d p a t i e n t ( K E D 5 , e t c . )

� S p l i n t i n g — m a n u a l , r i d g e d , s o f t , v a c u um

� S p l i n t i n g — t r a c t i o n

� C e n t r a l v e n o u s c a n n u l a t i o n ( f e m o r a l v e i n o n l y )

� C e n t r a l v e n o u s l i n e — a c c e s s o f e x i s t i n g c a t h e t e r s

� C l e a n t e c h n i q u e

� E x t e r n a l j u g u l a r v e i n c a n n u l a t i o n

� H e p a r i n / s a l i n e l o c k i n s e r t i o n s a s n o - f l o w I V

NEW YORK SCOPE OF PRACTICE LAW

� New York City!!...(actually, not NYC—FDNY does what

it wants)

� “New York State does not have a specific scope of

practice document for the CFR/EMT/AEMT. Instead,

in NYS, scope of practice for the CFR/EMT/AEMT is

defined by curriculum, protocol, and physician

medical direction at the EMS agency, region, and

State levels. In order to determine whether a

particular skill falls within the EMS provider's scope

of practice, one would need to refer to the

appropriate curriculum and protocol.”

TEXAS SCOPE OF PRACTICE LAW

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“DELEGATED AUTHORITY”

�Only state with this

�EMS personnel work “under the physician’s

license”

�Hear this across the country—only really true

here

�“Paramedics can do heart surgery on the side

of the road if their Medical Director allows it”

�Technically true, but reality is fuzzier

SCOPE OF PRACTICE IN TEXAS

�State law does define EMS levels with specific

skills listed

�Very limited

�No direct authority by DSHS to define scope of

practice…

�Texas Medical Board would have a say about

the physician's license if extreme procedures

were allowed

REALITY

�Combination of legal authority to practice with

training, accepted standard of care, and local

authority (Medical Director)

�Allows for systems to individualize to meet

local needs

�Neighboring systems may have significant

differences in capabilities of providers

TEXAS EMT (SEC 773.047)

�An individual qualifies as an emergency

medical technician if the individual is certified

by the department as minimally proficient to

perform emergency prehospital care that is

necessary for basic life support and that

includes cardiopulmonary resuscitation cardiopulmonary resuscitation cardiopulmonary resuscitation cardiopulmonary resuscitation and

the control of hemorrhagingcontrol of hemorrhagingcontrol of hemorrhagingcontrol of hemorrhaging.

TEXAS EMT-I

�An individual qualifies as an emergency

medical technician-intermediate if the

individual is certified by the department as

minimally proficient to provide emergency

prehospital care by initiating under medical

supervision certain procedures, including

intravenous therapy and endotrachealendotrachealendotrachealendotracheal or

esophageal intubation.

TEXAS PARAMEDIC

� An individual qualifies as an emergency medical

technician-paramedic if the individual is certified by

the department as minimally proficient to provide

advanced life support that includes initiation under

medical supervision of certain procedures, including

intravenous therapy, endotracheal or esophageal

intubation, electrical cardiac defibrillation or

cardioversion, and drug therapy.

� LicensedLicensedLicensedLicensed Paramedic

� In addition, a licensed paramedic must complete a

curriculum that includes college-level course work in

accordance with rules adopted by the board.

OTHER STATE DEFINITIONS

�Highly variable

�EMT, EMT-I, EMT-CC, EMT-CT, EMT-P, etc

�> 40 different “levels”

�Even more if you count scope of practice and

credentialing differences

�How do we fix this??

IS THERE A SOLUTION?

NATIONAL EMS SCOPE OF PRACTICE

� The National EMS Scope of Practice Model supports a system of licensure common in other allied health professions. Such a system offers the following benefits:

�establishes national standards for the minimum psychomotor skills and knowledge for EMS personnel;

� improves consistency among States’ scopes of practice;

� facilitates reciprocity;

� improves professional mobility;

�promotes consistency of EMS personnel titles;

�and improves the name recognition and public understanding of EMS personnel

NATIONAL EMS SCOPE OF PRACTICE

�Education

�National EMS Education Standards

�Certification

�State level

�National Registry

�Licensure

�State level

�Credentialed

�Medical Director

NATIONAL EMERGENCY MEDICAL SERVICES

EDUCATION STANDARDS

� “…minimal minimal minimal minimal terminal objectives for entryterminal objectives for entryterminal objectives for entryterminal objectives for entry ----level level level level EMS EMS EMS EMS

personnel personnel personnel personnel to achieve within the parameters outlined

in the National EMS Scope of Practice Model.”

� “Although educational programs must adhere to the

Standards, its format will allow will allow will allow will allow diverse diverse diverse diverse

implementation methods to meet local needs and implementation methods to meet local needs and implementation methods to meet local needs and implementation methods to meet local needs and

evolving educational practicesevolving educational practicesevolving educational practicesevolving educational practices. The less prescriptive

format of the Standards will also allow for ongoing

revision of content consistent with scientific

evidence and community standards of care.”

NATIONAL EMS CORE CONTENT

� “Core Content defines the entire domain of out-of-

hospital practice and identifies the identifies the identifies the identifies the universal universal universal universal body of body of body of body of

knowledge and skills for emergency medical services knowledge and skills for emergency medical services knowledge and skills for emergency medical services knowledge and skills for emergency medical services

providers providers providers providers who do not function as independent

practitioners.”

� “Core Content does not represent a minimum level of

knowledge and competency. The National National National National Scope of Scope of Scope of Scope of

Practice Model will determine the minimum level of Practice Model will determine the minimum level of Practice Model will determine the minimum level of Practice Model will determine the minimum level of

knowledge knowledge knowledge knowledge and competencyand competencyand competencyand competency for various levels of EMS

providers.”

NATIONAL EMS SCOPE OF PRACTICE

�Floor capabilities for different levels

�Emergency Medical Responder (EMR)

�Emergency Medical Technician (EMT)

�AEMT (Advanced EMT)

�Paramedic

�Allows for more aggressive scope in different

states

PARAMEDIC

�Combination of:

�Education

�National EMS Education Standards

�State license

�Combination of different elements

�Certification

�National EMS Scope of Practice Model

�Credentialing

�National EMS Core Content

ELEMENTS REQUIRED

�Educated

�Learned it

�Paramedic school

�Certified

�Passed it

�National Registry

�Or state test

� Licensed� Paid it

� State requirements� At least 18 years old

� Complete high school or GED certificate

� Successful completion of a DSHS approved EMS training course

� Submit EMS Personnel Certification Application and fee

� Pass National Registry exam

� Fingerprints

� Credentialed� Got it checked off

� Medical Director

NATIONAL EMS SCOPE OF PRACTICE MODEL

I ’m a

Paramedic

and I’m

here to

help!

RELEVANCE IN A

DISASTER

FEDERAL PLAN

�No specific federal requirements

�Refers to states

�Relies on adoption of the National Scope of

Practice

�Potential for variable capabilities of

responders

�Potential for confusion

NIMS

�“The terms “credentialed‟ and “credentialing‟

mean having provided, or providing,

respectively, documentation that identifies documentation that identifies documentation that identifies documentation that identifies

personnel and authenticates and verifies the personnel and authenticates and verifies the personnel and authenticates and verifies the personnel and authenticates and verifies the

qualifications qualifications qualifications qualifications of such personnel of such personnel of such personnel of such personnel by ensuring

that such personnel possess a minimum

common level of training, experience, physical

and medical fitness, and capability

appropriate for a particular position…”

FEMA PARAMEDIC CRITERIA

� Completion Completion Completion Completion of a stateof a stateof a stateof a state----approved paramedic program approved paramedic program approved paramedic program approved paramedic program based on NHTSA National Standard Curriculum*. � NHTSA National EMS Education Standards are a component of the EMS Education Agenda for the Future: A System Approach, a comprehensive plan for a national EMS education system.

� The state equivalent to EMRs, EMTs, Advanced EMTs and paramedics are expected to transition to these educational standards as they are implemented.

� Completion of the following courses/curricula: � 1. ICS-100: Introduction to ICS.

� 2. IS-700.A: NIMS, An Introduction.

� 3. IS-800.B: NRF, An Introduction.

� 4. HazMat Awareness Training or equivalent basic instruction consistent with: …

� Ongoing, active participation with an EMS-providing entity, organization, or agency.

� Successful completion of a state-approved program at this level or NREMT certification at this level.

� Active status of legal authorityActive status of legal authorityActive status of legal authorityActive status of legal authority to function as a paramedic granted by a state, the District of Columbia, or U.S. territory.

STATE PLAN

�TDEM

�EMTF

�Ambulance Strike Teams

�AMBUS

�MMU

�RAC (STRAC)

�Regional coordination of assets

RESPONDERS

�Will have been vetted

�Background check

�“Credentialed” to respond and work at their

level of state authority

�Some understanding of ICS and disaster

response plans

RESPONDERS

�Variable medical capability

�May be credentialed for more or fewer skills

than local system

�Increased confusion with “mixed” teams

�Communication is key

�Discussion between local and sending EMS

Medical Directors

FINAL THOUGHTS

�EMS providers are not created equal

�All formal responders will be licensed and

authorized to see patients

�Beware of “self-responders”

�Responders may have variable capabilities

when treating patients

�And with that…

Dr. Emily

Kidd

EMS MEDICAL

DIRECTION IN A

DISASTER

WHAT IS AN EMS MEDICAL DIRECTOR?

� Texas Health and Safety Code, Chapter 773Texas Health and Safety Code, Chapter 773Texas Health and Safety Code, Chapter 773Texas Health and Safety Code, Chapter 773

� Sec. 773.007. SUPERVISION OF EMERGENCY PREHOSPITAL CARE. Sec. 773.007. SUPERVISION OF EMERGENCY PREHOSPITAL CARE. Sec. 773.007. SUPERVISION OF EMERGENCY PREHOSPITAL CARE. Sec. 773.007. SUPERVISION OF EMERGENCY PREHOSPITAL CARE.

(a) The provision of advanced life support must be under medical provision of advanced life support must be under medical provision of advanced life support must be under medical provision of advanced life support must be under medical

supervision and a licensed physician's control.supervision and a licensed physician's control.supervision and a licensed physician's control.supervision and a licensed physician's control.

(b) The provision of basic life support may be under medical

supervision and a licensed physician's control.

� Sec. 773.0571. REQUIREMENTS FOR PROVIDER LICENSE. Sec. 773.0571. REQUIREMENTS FOR PROVIDER LICENSE. Sec. 773.0571. REQUIREMENTS FOR PROVIDER LICENSE. Sec. 773.0571. REQUIREMENTS FOR PROVIDER LICENSE. The

department shall issue to an emergency medical services provider

applicant a license that is valid for two years if the department is

satisfied that….

(6) the applicant employs a medical directorthe applicant employs a medical directorthe applicant employs a medical directorthe applicant employs a medical director; and

� Sec. 773.114. SYSTEM REQUIREMENTS. Sec. 773.114. SYSTEM REQUIREMENTS. Sec. 773.114. SYSTEM REQUIREMENTS. Sec. 773.114. SYSTEM REQUIREMENTS. (a) Each emergency medical

services and trauma care system must have:

(1) local or regional medical control local or regional medical control local or regional medical control local or regional medical control for all field care and transportation,

consistent with geographic and current communications capability;

(2) triage, transport, and transfer protocolsprotocolsprotocolsprotocols; and

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Occupations Code, Title 3, Subtitle B, Chapter 157Texas Occupations Code, Title 3, Subtitle B, Chapter 157Texas Occupations Code, Title 3, Subtitle B, Chapter 157Texas Occupations Code, Title 3, Subtitle B, Chapter 157

� SecSecSecSec. 157.001. GENERAL AUTHORITY OF PHYSICIAN TO DELEGATE. . 157.001. GENERAL AUTHORITY OF PHYSICIAN TO DELEGATE. . 157.001. GENERAL AUTHORITY OF PHYSICIAN TO DELEGATE. . 157.001. GENERAL AUTHORITY OF PHYSICIAN TO DELEGATE.

(a) A physician may delegate to a qualified and properly trained person physician may delegate to a qualified and properly trained person physician may delegate to a qualified and properly trained person physician may delegate to a qualified and properly trained person acting

under under under under the physician's supervision the physician's supervision the physician's supervision the physician's supervision any medical act that a reasonable and

prudent physician would find within the scope of sound medical judgment to

delegate if, in the opinion of the delegating physician:

(1) the act:

(A) can be properly and safely per formed by the person to

whom the medical act is delegated;

(B) is per formed in i ts customary manner; and

(C) is not in violation of any other statute; and

(2) the person to whom the delegation is made does not represent to

the public that the person is authorized to practice medicine.

(b) The delegating physician remains responsible for the medical acts

of the person per forming the delegated medical acts.

� Sec. 157.003. EMERGENCY CARE. Sec. 157.003. EMERGENCY CARE. Sec. 157.003. EMERGENCY CARE. Sec. 157.003. EMERGENCY CARE. The authority to delegate medical acts to a

properly qualified person as provided by this subchapter applies to emergency applies to emergency applies to emergency applies to emergency

care provided by emergency medical personnelcare provided by emergency medical personnelcare provided by emergency medical personnelcare provided by emergency medical personnel certified by the Texas

Department of Health.

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administrative Code Title 22, Part 9, Chapter 197, Rule Texas Administrative Code Title 22, Part 9, Chapter 197, Rule Texas Administrative Code Title 22, Part 9, Chapter 197, Rule Texas Administrative Code Title 22, Part 9, Chapter 197, Rule §§§§197.2197.2197.2197.2

� (4) Delegated practiceDelegated practiceDelegated practiceDelegated practice-----Permission given by a physician licensed by the board,

either in person or by treatment protocols or standing orders to a specific

prehospital provider to provide medical care.

� (5) Direct medical controlDirect medical controlDirect medical controlDirect medical control-----Immediate and concurrent clinical direction either

on-scene or via electronic communication from a physician licensed by the

board and designated by the EMS medical director. If an EMS system does not

have an EMS Medical Director, then such designation should be by a physician

advisor, or in his or her absence, the director of the EMS system.

� (12) ProtocolsProtocolsProtocolsProtocols--Written instructions providing prehospital personnel with a

standardized approach to commonly encountered problems in the out-of-

hospital setting, typically in regard to patient care. Protocols may include

standing orders to be implemented prior to, or in lieu of, establishing

communication with direct medical control.

� (13) Standing delegation ordersStanding delegation ordersStanding delegation ordersStanding delegation orders-----Instructions or orders provided by the EMS

medical director to EMS personnel, directing them to perform certain medical

care in the absence of any communication with direct medical control.

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule §§§§197.3197.3197.3197.3

(a) An off-line medical director shall be:

(1) a physician licensed to practice in Texas physician licensed to practice in Texas physician licensed to practice in Texas physician licensed to practice in Texas and shall be registered registered registered registered as an as an as an as an EMS medical directorEMS medical directorEMS medical directorEMS medical director with the Texas Department of State Health Services;

(2) familiar with the design and operation of EMS systems;

(3) experienced in experienced in experienced in experienced in prehospitalprehospitalprehospitalprehospital emergency care and emergency emergency care and emergency emergency care and emergency emergency care and emergency management management management management of ill and injured patients; of ill and injured patients; of ill and injured patients; of ill and injured patients;

(4) actively involved actively involved actively involved actively involved in:

(A) the training and/or continuing education of EMS personnel, under

his/her direct supervision, at their respective levels of certification;

(B) the medical audit, review, and critique of the performance of

EMS personnel under his or her direct supervision;

(C) the administrative and legislative environments affecting regional and/or state prehospital EMS organizations;

(5) knowledgeable about local multiknowledgeable about local multiknowledgeable about local multiknowledgeable about local multi----casualty plans; casualty plans; casualty plans; casualty plans;

(6) familiar with dispatch and communications operations of prehospitalemergency units; and

(7) knowledgeable about laws and regulations affecting local, regional, and state EMS operations.

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule Texas Administrative Code Tit le 22, Par t 9, Chapter 197, Rule §§§§197.3197.3197.3197.3

(b) The off-line medical director shall be required to:

(1) approve the level of approve the level of approve the level of approve the level of prehospitalprehospitalprehospitalprehospital care which may be rendered care which may be rendered care which may be rendered care which may be rendered locally by each of the EMS personnel employed by and/or volunteering with the EMS under the medical director's supervision, regardless of the level of state certification or licensure, before the certificant or licensee is permitted to provide such care to the public;

(2) establish and monitor compliance with field performance guidelines compliance with field performance guidelines compliance with field performance guidelines compliance with field performance guidelines for EMS personnel;

(3) establish and monitor compliance with training guidelines compliance with training guidelines compliance with training guidelines compliance with training guidelines which meet or exceed the minimum standards set forth in the Texas Department of State Health Services EMS certification regulations;

(4) develop, implement, and revise protocolsdevelop, implement, and revise protocolsdevelop, implement, and revise protocolsdevelop, implement, and revise protocols and/or standing delegation orders, if appropriate, governing prehospital care and medical aspects of patient triage, transport, transfer, dispatch, extrication, rescue, and radio-telephone-telemetry communication by the EMS;

(5) direct an effective system audit and quality assurance program; quality assurance program; quality assurance program; quality assurance program;

(6) determine standards and objectives for all medically related aspects of determine standards and objectives for all medically related aspects of determine standards and objectives for all medically related aspects of determine standards and objectives for all medically related aspects of operation operation operation operation of the EMS of the EMS of the EMS of the EMS including the inspection, evaluation, and approval of the system's performance specifications;

(7) function as the primary liaison between the EMS administration and the primary liaison between the EMS administration and the primary liaison between the EMS administration and the primary liaison between the EMS administration and the local local local local medical communitymedical communitymedical communitymedical community, ascertaining and being responsive to the needs of each;

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administ rat ive Code T i t le 22 , Par t 9 , Chapter 197, Rule Texas Administ rat ive Code T i t le 22 , Par t 9 , Chapter 197, Rule Texas Administ rat ive Code T i t le 22 , Par t 9 , Chapter 197, Rule Texas Administ rat ive Code T i t le 22 , Par t 9 , Chapter 197, Rule §§§§197.3197.3197.3197.3

(b) The off-line medical director shall be required to:

(8) develop a letter or agreement or contract between the medical director(s) and the EMS administration outlining the specific responsibilities and authority of each. The agreement should describe the process or procedure by which a medical director may withdraw responsibility for EMS personnel for noncompliance with the Emergency Medical Services Act, the Health and Safety Code, Chapter 773, the rules adopted in this chapter, and/or accepted medical standards;

(9) take or recommend appropriate remedial or corrective measures for EMS personnel,take or recommend appropriate remedial or corrective measures for EMS personnel,take or recommend appropriate remedial or corrective measures for EMS personnel,take or recommend appropriate remedial or corrective measures for EMS personnel, in conjunction with local EMS administration, which may include, but are not limited to, counseling, retraining, testing, probation, and/or field preceptorship;

(10) suspend a certified EMS individual from medical care duties for due cause pending review suspend a certified EMS individual from medical care duties for due cause pending review suspend a certified EMS individual from medical care duties for due cause pending review suspend a certified EMS individual from medical care duties for due cause pending review and and and and evaluation; evaluation; evaluation; evaluation;

(11) establish the circumstances under which a patient might not be transported; establish the circumstances under which a patient might not be transported; establish the circumstances under which a patient might not be transported; establish the circumstances under which a patient might not be transported;

(12) establish the circumstances under which a patient may be transported against his or her establish the circumstances under which a patient may be transported against his or her establish the circumstances under which a patient may be transported against his or her establish the circumstances under which a patient may be transported against his or her will will will will in accordance with state law,in accordance with state law,in accordance with state law,in accordance with state law, including approval of appropriate procedures, forms, and a review process;

(13) establish criteria for selection of a patient's destinationpatient's destinationpatient's destinationpatient's destination;

(14) develop and implement a comprehensive mechanism for management of patient care incidents, including patient complaints, allegations of substandard care, and deviations from established protocols and patient care standards;

(15) only approve care or activity that was provided at the time the medical director was employed, contracted or volunteering as a medical director;

(16) notify the board at time of licensure registration under §166.1 of this title (relating to Physician Registration) of the physician's position as medical director and the names of all EMS providers for whom that physician holds the position of off-line medical director;

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administrative Code Title 22, Part 9, Chapter 197, §Rule 197.4

(a) The EMS medical director shall assign the prehospital provider under his or her direction to a specific on-line communication resource by a predetermined policy.

(b) Specific local protocols shall define the circumstances under which on-line medical direction is required.

(c) A physician providing or delegating on-line medical direction ("on-line physician") shall be appropriately trained in the use of prehospital protocols.

(d) A physician providing or delegating on-line medical direction shall have personal expertise in the emergency care of ill and injured patients.

(e) A physician providing or delegating on-line medical direction for particular patients assumes responsibility for the appropriateness of prehospital care provided under his or her direction by EMS personnel.

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administrative Code Title 22, Part 9, Chapter 197, Texas Administrative Code Title 22, Part 9, Chapter 197, Texas Administrative Code Title 22, Part 9, Chapter 197, Texas Administrative Code Title 22, Part 9, Chapter 197, §§§§Rule 197.5Rule 197.5Rule 197.5Rule 197.5

(a) Control at the scene of a medical emergency shall be the responsibi l i ty of the indiv idual in attendance who is

most appropr iately t rained and knowledgeable in providing pre-hospital emergency stabi l izat ion and transport .

(b) The prehospital provider on the scene is responsible for the management of the pat ient(s) and acts as the agent

of the physic ian providing medical direct ion.

(c) I f the pat ient 's personal physic ian is present and assumes responsibi l i ty for the pat ient 's care, the prehospital

provider should defer to the orders of said physic ian unless those orders confl ict with establ ished protocols . The

pat ient 's personal physic ian shall document in his or her orders in a manner acceptable to the EMS system. The

physic ian providing on- l ine medical direct ion shall be not if ied of the part ic ipat ion of the pat ient 's personal

physic ian.

(d) I f the medical orders of the pat ient 's personal physic ian confl ict with system protocols , the personal physic ian

shall be placed in communicat ion with the physic ian providing on- l ine medical direct ion. I f the personal

physic ian and the on- l ine medical director cannot agree on treatment, the personal physic ian must e ither

cont inue to provide direct pat ient care and accompany the pat ient to the hospital or must defer al l remaining

care to the on- l ine medical director .

(e) The system's medical director or on- l ine medical control shal l assume responsibi l i ty for direct ing the act iv it ies of

prehospital providers at any t ime the pat ient 's personal physic ian is not in attendance.

(f ) I f an intervenor physic ian is present at the scene and has been sat isfactor i ly ident if ied as a l icensed physic ian

and has expressed his or her wil l ingness to assume responsibi l i ty for care of the pat ient , the on- l ine physic ian

should be contacted. Once the on- l ine physic ian is contacted, he or she is ult imate ly responsible for the care of the

pat ient unless or unt i l the on- l ine physic ian al lows the intervenor physic ian to assume responsibi l i ty for the pat ient .

(g) The on- l ine physic ian has the opt ion of managing the case exclusively , working with the intervenor physic ian, or al lowing

the intervenor physic ian to assume complete responsibi l i ty for the pat ient .

(h) I f there is any disagreement between the intervenor physic ian and the on- l ine physic ian, the prehospital provider shall be

responsible to the on- l ine physic ian and shall p lace the intervenor physic ian in contact with the on- l ine physic ian.

( i ) I f the intervenor physic ian is author ized to assume responsibi l i ty , al l orders to the prehospital provider by the intervenor

physic ian shall also be repeated to medical control for recordkeeping purposes.

( j ) The intervenor physic ian must document his or her intervent ion in a manner acceptable to the local EMS.

(k) The decis ion of the intervenor physic ian not to accompany the pat ient to the hospital shal l be made with the approval of

the on- l ine physic ian.

( l ) Nothing in this sect ion implies that the prehospital provider can be required to deviate from standard protocols .

TEXAS LAW ON EMS MEDICAL DIRECTION

� Texas Administrative Code Title 22, Part 9, Chapter 197, Texas Administrative Code Title 22, Part 9, Chapter 197, Texas Administrative Code Title 22, Part 9, Chapter 197, Texas Administrative Code Title 22, Part 9, Chapter 197, §§§§Rule 197.6Rule 197.6Rule 197.6Rule 197.6

(a) The medical director has the authority to design research projects and

educational studies. Such studies should be approved by:

(1) EMS administrative officials; and

(2) an independent review panel if the project/study may have a

differential impact on patient care.

(b) The results of the study should be made available through publications

to the EMS community.

TEXAS LAW ON EMS MEDICAL DIRECTION

An EMS Medical Director in Texas:An EMS Medical Director in Texas:An EMS Medical Director in Texas:An EMS Medical Director in Texas:

� Delegates the practice of emergency care to EMS providers

� Credentials and/or de-credentials each EMS provider providing care

under his/her practice

� Remains responsible for that medical care

� Provides standing orders

� Provides real-time (on-line) direction to EMS providers

� Writes and maintains protocols for medical care

� Stays actively involved in and directs education and

continuing education of EMS personnel

� Is responsible for the Quality Assurance / Performance

Improvement of medical care of an EMS System

� Acts as a liaison between the EMS Administration and the

local medical community

SUMMARIZE, PLEASE!

Some specifics:Some specifics:Some specifics:Some specifics:

� Determines any remediation needed for EMS providers

� Determines where EMS patients are transported (destination)

� Determines when a patient will not be transported

� Determines when a patient will be transported against his/her

will

� Provides real time (on-scene or on-line) direction as needed

� Determines when other physicians on the scene of an emergency

can provide direction to EMS personnel

SUMMARIZE, PLEASE!

NAEMSP recommendations:NAEMSP recommendations:NAEMSP recommendations:NAEMSP recommendations:

EMS should take the lead in local disaster medical response.EMS should take the lead in local disaster medical response.EMS should take the lead in local disaster medical response.EMS should take the lead in local disaster medical response.

� Establish Establish Establish Establish competencycompetencycompetencycompetency ----based core curricula and regular training based core curricula and regular training based core curricula and regular training based core curricula and regular training in disaster responsein disaster responsein disaster responsein disaster response

� Development of metrics to measure competency in disaster Development of metrics to measure competency in disaster Development of metrics to measure competency in disaster Development of metrics to measure competency in disaster responseresponseresponseresponse

� Establish MOU’s / MOA’s for mutual aidEstablish MOU’s / MOA’s for mutual aidEstablish MOU’s / MOA’s for mutual aidEstablish MOU’s / MOA’s for mutual aid

� Plan for l icensure and l iability Plan for l icensure and l iability Plan for l icensure and l iability Plan for l icensure and l iability issuesissuesissuesissues

� EMS and EMS Medical Directors should participate in Unified EMS and EMS Medical Directors should participate in Unified EMS and EMS Medical Directors should participate in Unified EMS and EMS Medical Directors should participate in Unified Command structureCommand structureCommand structureCommand structure

� Establish triage processes and trainingEstablish triage processes and trainingEstablish triage processes and trainingEstablish triage processes and training

� Have Have Have Have processsesprocesssesprocesssesprocessses in place to increase scope of practice and in place to increase scope of practice and in place to increase scope of practice and in place to increase scope of practice and decrease need for direct medical controldecrease need for direct medical controldecrease need for direct medical controldecrease need for direct medical control

� EMS providers should have involvement in expanded community EMS providers should have involvement in expanded community EMS providers should have involvement in expanded community EMS providers should have involvement in expanded community medical care rolesmedical care rolesmedical care rolesmedical care roles

� Advocate for resiliency and recovery of EMS responders after a Advocate for resiliency and recovery of EMS responders after a Advocate for resiliency and recovery of EMS responders after a Advocate for resiliency and recovery of EMS responders after a disasterdisasterdisasterdisaster

SO….WHAT ABOUT DURING A DISASTER?

� TriageTriageTriageTriage

�Destination decisions Destination decisions Destination decisions Destination decisions –––– change?change?change?change?

�Altered treatment decisions / standards of careAltered treatment decisions / standards of careAltered treatment decisions / standards of careAltered treatment decisions / standards of care

�No transport / Altered transportNo transport / Altered transportNo transport / Altered transportNo transport / Altered transport

�No send / Delayed responseNo send / Delayed responseNo send / Delayed responseNo send / Delayed response

� Jurisdictional boundariesJurisdictional boundariesJurisdictional boundariesJurisdictional boundaries

�EMS functioning in alternate settingsEMS functioning in alternate settingsEMS functioning in alternate settingsEMS functioning in alternate settings

�Altered scope of practiceAltered scope of practiceAltered scope of practiceAltered scope of practice

�EMS participation in state responseEMS participation in state responseEMS participation in state responseEMS participation in state response

�Responder health and safetyResponder health and safetyResponder health and safetyResponder health and safety

�LiabilityLiabilityLiabilityLiability

SO….WHAT ABOUT DURING A DISASTER?

�Need to prioritize patients

�Most good for the most patients

�Which patients go where?

�Which system to use?

�START START START START (Simple Triage and Rapid

Transport)

�MASS (Move, Assess, Sort, SendMASS (Move, Assess, Sort, SendMASS (Move, Assess, Sort, SendMASS (Move, Assess, Sort, Send))))

�SALTSALTSALTSALT (Sort, Assess, Life-saving

interventions, Treatment/

Transport)

TRIAGE

� Increased front-end

triage of calls

�Nursing hotlines

�Triage of call order

�Alternate resources

sent

�Treat-and-release

protocols

�No-send criteria

ALTERED DISPATCH

San Antonio Express News

�Change in staffing of ambulances

�Change in protocols for treatment

�Save resources

�Save time

�Altered documentation requirements

�Alteration of transport vehicles

ALTERED TREATMENT DECISIONS /

ALTERED STANDARD OF CARE

� Closest appropriate facility

� Closest hospital vs.

hospitals at a distance

� Utilizing all emergency

departments

� Alternate Care Sites

� Clinics

� Shelters

� Mobile medical units

DESTINATION DECISIONS

�Shelter care

�Alternate care sites

�Vaccination delivery

ALTERNATE SETTINGS /

ALTERED SCOPE OF PRACTICE

Photo by Jocelyn Augustino, FEMA

Photo by Chief David Almaguer, HFD

�PPE

�Vaccinations

�Pre- and post-incident health screenings

�Mental health support

�Deployment in austere environments

RESPONDER HEALTH AND SAFETY /

LIABILITY ISSUES

�Ambulance Strike Teams

�Ambulance Utilization Criteria

�ALS Buses

�Ambuses

�Mobile Medical Units

� Incident EMS Medical Directors

STATE RESPONSE /

OUTSIDE JURISDICTIONAL BOUNDARIES

� Institutes of Medicine

�Recommendations for states to develop robust

CSC plans and guidelines

�Must include:

�Utilizing NIMS compliant ICS

�Adhering to ethical norms and principles

�Providing palliative care services

�Addressing the needs of at-risk populations

�Mobilizing mental health services

CRISIS STANDARDS OF CARE

�Establish consistent triggers and thresholds for CSC

�Modifying protocols

�Transferring protocols

�Authorization of the use of CSC protocols/plans

�Provide liability protection for providers

�Coordination of regional and state emergency

operations and CSC planning

�Reimbursement issues

�Liability protection for altered modes of

transportation and care

CRISIS STANDARDS OF CARE

� Texas Health and Safety Code, Chapter 773

� Texas Occupations Code, Title 3, Subtitle B, Chapter 157

� Texas Administrative Code Title 22, Part 9, Chapter 197

� National Association of EMS Physicians. Special Operations

Medical Support . Kendall Hunt Professional; 2009.

� Institute of Medicine of the National Academies. Crisis

Standards of Care: A systems framework for catastrophic

disaster response – Volume 3: EMS. Washington D.C. The

National Academies Press; 2012.

� Catlett CL, Jenkins JL, MG Millin . Role of emergency medical

services in disaster response: Resource document for the

National Association of EMS Physicians Position Statement.

Prehosp Emerg Care 2011;15:420-425.

REFERENCES