1、Designation: F 1149 93 (Reapproved 2003)Standard Practice forQualifications, Responsibilities, and Authority of Individualsand Institutions Providing Medical Direction of EmergencyMedical Services1This standard is issued under the fixed designation F 1149; the number immediately following the design
2、ation indicates the year oforiginal adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon (e) indicates an editorial change since the last revision or reapproval.1. Scope1.1 This practice covers the qualif
3、ications, responsibilities,and authority of individuals and institutions providing medicaldirection of emergency medical services.1.2 This practice addresses the qualifications, authority, andresponsibility of a Medical Director (off-line) and the relation-ship of the EMS (Emergency Medical Services
4、) provider tothis individual.1.3 This practice also addresses components of on-linemedical direction (direct medical control) including the quali-fications and responsibilities of on-line medical physicians andthe relationship of the prehospital provider to on-line medicaldirection.1.4 This practice
5、 addresses the relationship of the on-linemedical physician to the off-line Medical Director.1.5 The authority for control of medical services at thescene of a medical emergency is addressed in this practice.1.6 The requirements for a Communication Resource arealso addressed within this practice.2.
6、Referenced Documents2.1 ASTM Standards:F 1031 Practice for Training the Emergency Medical Tech-nician (Basic)2F 1086 Guide for Structures and Responsibilities of Emer-gency Medical Services Systems Organizations23. Terminology3.1 Description of Terms Specific to This Practice3.2 communication resour
7、cean entity responsible forimplementation of direct medical control. (Also known asmedical control resource.)3.3 delegated practiceonly physicians are licensed topractice medicine; prehospital providers must act only underthe medical direction of a physician.3.4 direct medical controlwhen a physicia
8、n or authorizedcommunication resource personnel, under the direction of aphysician, provides immediate medical direction to prehospitalproviders in remote locations. (Also known as on-line medicaldirection.)3.5 emergency medical services system (EMSS)all com-ponents needed to provide comprehensive p
9、rehospital andhospital emergency care including, but not limited to; MedicalDirector, transport vehicles, trained personnel, access anddispatch, communications, and receiving medical facilities.3.6 intervener physiciansa licensed M.D. or D.O., havingnot previously established a doctor/patient relati
10、onship with theemergency patient and willing to accept responsibility for amedical emergency scene, and can provide proof of a currentMedical License.3.7 medical directionwhen a physician is identified todevelop, implement, and evaluate all medical aspects of anEMS system. (syn. medical accountabili
11、ty.)3.8 medical director off-linea physician responsible for allaspects of an EMS system dealing with provision of medicalcare. (Also known as System Medical Director.)3.9 on-line medical physiciana physician immediatelyavailable, when medically appropriate, for communication ofmedical direction to
12、non-physician prehospital providers inremote locations.3.10 prehospital providerall personnel providing emer-gency medical care in a location remote from facilities capableof providing definitive medical care.3.11 protocolsstandards for EMS practice in a variety ofsituations within the EMS system.3.
13、12 standing ordersstrictly defined written orders foractions, techniques, or drug administration when communica-tion has not been established with an on-line physician.1This practice is under the jurisdiction of ASTM Committee F30 on EmergencyMedical Services and is the direct responsibility of Subc
14、ommittee F30.03 onOrganization/Management.Current edition approved Sept. 10, 2003. Published October 2003. Originallyapproved in 1988. Last previous edition approved in 1998 as F 1149 93 (1998).2Annual Book of ASTM Standards, Vol 13.02.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C70
15、0, West Conshohocken, PA 19428-2959, United States.4. Significance and Use4.1 Implementation of this practice will ensure that the EMSsystem has the authority, commensurate with the responsibility,to ensure adequate medical direction of all prehospital provid-ers, as well as personnel and facilities
16、 that meet minimumcriteria to implement medical direction of prehospital services.4.1.1 The state will develop, recommend, and encourageuse of a plan that would assure the standards outlined in thisdocument can be implemented as appropriate at the local,regional, or state level (see Guide F 1086).4.
17、1.2 This practice is intended to describe and define re-sponsibility for medical directions during transfers. It is notintended to determine the medical or legal, or both, appropri-ateness of transfers under the Consolidated Omnibus BudgetReconciliation Act and other similar federal and/or state law
18、s.5. Medical Director5.1 PositionSystem Medical Director (Off-line MedicalDirector).5.1.1 Each EMS system shall have an identifiable MedicalDirector who, after consultation with others involved andinterested in the system, is responsible for the development,implementation, and evaluation of standard
19、s for provision ofmedical care within the system.5.1.1.1 All prehospital providers (including EMT (Emer-gency Medical Technician) basics) shall be medically account-able for their actions and are responsible to the MedicalDirector of the EMS agency (local, regional, or state) thatapproves their cont
20、inued participation.5.1.1.2 All prehospital providers, with levels of certificationabove EMT basic, shall be responsible to an identifiablephysician who directs their medical care activity.5.1.2 The Medical Director shall be appointed by, andaccountable to, the appropriate EMS agency in accordancewi
21、th Guide F 1086.5.2 Requirements of a Medical Director:5.2.1 The medical aspects (see 5.3) of an emergency medi-cal service system shall be managed by physicians who meetthe following requirements:5.2.1.1 Licensed physician, M.D. or D.O.5.2.1.2 Experience in, and current knowledge of, emergencycare
22、of patients who are acutely ill or traumatized.5.2.1.3 Knowledge of, and access to, local mass casualtyplans.5.2.1.4 Familiarity with Communication Resource opera-tions where applicable, including communication with, anddirection of, prehospital emergency units.5.2.1.5 Active involvement in the trai
23、ning of prehospitalpersonnel.5.2.1.6 Active involvement in the medical audit, review, andcritique of medical care provided by prehospital personnel.5.2.1.7 Knowledge of the administrative and legislativeprocess affecting the local, regional, and/or state prehospitalEMS system.5.2.1.8 Knowledge of la
24、ws and regulations affecting local,regional, and state EMS.5.3 Authority of a Medical Director Includes but is notLimited to:5.3.1 Establishing system-wide medical protocols (includ-ing standing orders) in consultation with appropriate special-ists.5.3.2 Recommending certification or decertification
25、 of non-physician prehospital personnel to the appropriate certifyingagencies.5.3.2.1 Every system shall have an appropriate review andappeals mechanism, when decertification is recommended, toassure due process in accordance with law and establishedlocal policies. The Director shall promptly refer
26、the case to theappeals mechanism for review, if requested.5.3.3 Requiring education to the level of approved profi-ciency for personnel within the EMS system. This includes allprehospital personnel, EMTs at all levels, prehospital emer-gency care nurses, dispatchers, educational coordinators, andphy
27、sician providers of on-line direction (see Practice F 1031).5.3.4 Suspending a provider from medical care duties fordue cause pending review and evaluation.5.3.4.1 Because the prehospital provider operates under thelicense (delegated practice) or direction of the Medical Direc-tor, the director shal
28、l have ultimate authority to allow theprehospital provider to provide medical care within the pre-hospital phase of the EMS system.5.3.4.2 Whenever a Medical Director makes a decision tosuspend a provider from medical care duties, the process shallbe prescribed by previously established criteria.5.3
29、.5 Establishing medical standards for dispatch proce-dures to assure that the appropriate EMS response unit(s) aredispatched to the medical emergency scene when requested,and the duty to evaluate the patient is fulfilled.5.3.6 Establishing under what circumstances non-transportmight occur.5.3.6.1 Al
30、l decisions by prehospital providers regardingnon-transport shall be based on defined protocol or on-linecommunications.5.3.6.2 Develop a procedure for record keeping when thereason for non-transport was the result of a patients refusal,including the appropriate forms and review process.5.3.7 Establ
31、ishing under which circumstances a patient maybe transported against his or her will; in accordance with statelaw including, procedure, appropriate forms, and review pro-cess.5.3.8 Establishing criteria for level of care and type oftransportation to be used in prehospital emergency care (that is,adv
32、anced life support versus basic life support, ground, air, orspecialty unit transportation).5.3.9 Establishing criteria for selection of patient destina-tion.5.3.10 Establishing educational and performance standardsfor Communication Resource personnel.5.3.11 Establishing operational standards for Co
33、mmunica-tion Resource.5.3.12 Conducting effective system audit and quality assur-ance.5.3.12.1 The Medical Director shall have access to allrelevant EMS records needed to accomplish this task. Thesedocuments shall be considered quality assurance documentsand shall be privileged and confidential info
34、rmation.F 1149 93 (2003)25.3.13 Insuring the availability of educational programswithin the system and that they are consistent with acceptedlocal medical practice.5.3.14 May delegate portions of his or her duties to otherqualified individuals.6. Direct Medical Control (On-Line Medical Direction)6.1
35、 The Practice of Direct Medical Control:6.1.1 On-line medical direction capabilities shall exist andbe available within the EMS system, unless impossible due todistance or geographic considerations.6.1.1.1 All prehospital providers, above the certification ofEMT basic, shall be assigned to a specifi
36、c on-line communi-cation resource by a predetermined policy.6.1.2 Specific local protocols shall exist which define thosecircumstances under which on-line medical direction is re-quired.6.1.3 On-line medical direction is the practice of medicineand all orders to the prehospital provider shall origin
37、ate from orbe under the direct supervision and responsibility of a physi-cian.6.1.4 The receiving hospital shall be notified prior to thearrival of each patient transported by the EMS system unlessdirected otherwise by local protocol.6.2 The On-Line Medical Physician:6.2.1 This physician shall be ap
38、proved to serve in thiscapacity by the system Medical Director (off-line).6.2.1.1 This physician shall have received education to thelevel of proficiency approved by the off-line Medical Directorfor proper provision of on-line medical direction, includingcommunications equipment, operation, and tech
39、niques.6.2.1.2 This physician shall be appropriately trained inprehospital protocols, familiar with the capabilities of theprehospital providers, as well as local EMS operational poli-cies and regional critical care referral protocols.6.2.2 This physician shall have demonstrated knowledgeand experti
40、se in the prehospital care of critically ill and injuredpatients.6.2.3 This physician assumes responsibility for appropriateactions of the prehospital provided to the extent that the on-linephysician is involved in patient care direction.6.2.4 The on-line physician is responsible to the systemMedica
41、l Director (off-line) regarding proper implementation ofmedical and system protocols.7. Authority for Control of Medical Services at the Sceneof Medical Emergency7.1 General:7.1.1 Control of a medical emergency scene shall be theresponsibility of the individual in attendance who is mostappropriately
42、 trained and knowledgeable in providing prehos-pital emergency stabilization and transport.7.1.2 When an advanced life support (ALS) squad, undermedical direction, is requested and dispatched to the scene ofan emergency, a doctor/patient relationship has been estab-lished between the patient and the
43、 physician providing medicaldirection.7.1.3 The prehospital provider is responsible for the man-agement of the patient and acts as the agent of medicaldirection.7.2 Patients Private Physician Present:7.2.1 When the patients private physician is present andassumes responsibility for the patients care
44、, the prehospitalprovider should defer to the orders of the private physician ifthey do not conflict with established system protocols and theprivate physician documents the orders in a manner acceptableto the EMS system.7.2.2 The Communication Resource shall be contacted forrecordkeeping purposes t
45、o notify the on-line medical physi-cian.7.2.3 When the medical orders of the private physiciandiffer from system protocol, Communication Resource shall becontacted and the private physician placed in communicationwith the on-line physician. If the private physician and theon-line physician are unabl
46、e to agree on treatment, the privatephysician must either continue to provide direct patient careand accompany the patient to the hospital, or defer allremaining care to the on-line physician.7.2.4 The prehospital providers responsibility reverts to thesystems Medical Director or on-line medical dir
47、ection any timethe private physician is no longer in attendance.7.3 Intervener Physician Present and Non-Existent On-LineMedical Direction:7.3.1 When an intervener physician has been satisfactorilyidentified as a licensed physician and has expressed his or herwillingness to assume responsibility and
48、 document his or herintervention in a manner acceptable to the local emergencymedical services system (EMSS), the prehospital providershould defer to the orders of the physician on the scene if theydo not conflict with system protocols.7.3.2 If treatment by the intervener physician at the emer-gency
49、 scene differs from that outlined in a local protocol, thephysician shall agree in advance to assume responsibility forcare, including accompanying the patient to the hospital.7.3.3 In the event of a mass casualty incident or disaster,patient care needs may require the intervener physician toremain at the scene.7.4 Intervener Physician Present and Existent On-LineMedical Direction:7.4.1 If an intervener physician is present and on-linemedical direction does exist, the on-line physician should becontacted and the on-line physician is ultimately responsible.7.4.2 The on-
