1、Designation: F 1149 93 (Reapproved 2008)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:2F 1031 Practice for Training the Emergency Medical Tech-nician (Basic)F 1086 Guide for Structures and Responsibilities of Emer-gency Medical Services Systems Organizations3. Terminology3.1 Description of Terms Specific to This Practice3.2 communication resourc
7、ean 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 physician
8、 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 pr
9、ehospital 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 relatio
10、nship 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 accountabilit
11、y.)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 n
12、on-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.1Th
13、is practice is under the jurisdiction of ASTM Committee F30 on EmergencyMedical Services and is the direct responsibility of Subcommittee F30.03 onOrganization/Management.Current edition approved Feb. 1, 2008. Published March 2008. Originallyapproved in 1988. Last previous edition approved in 2003 a
14、s F 1149 98(2003).2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.1Copyright ASTM International, 100 Barr Har
15、bor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.3.12 standing ordersstrictly defined written orders foractions, techniques, or drug administration when communica-tion has not been established with an on-line physician.4. Significance and Use4.1 Implementation of this practice
16、 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 that meet minimumcriteria to implement medical direction of prehospital services.4.1.1 The state will develo
17、p, 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).4.1.2 This practice is intended to describe and define re-sponsibility for medical directions during transfers.
18、 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 laws.5. Medical Director5.1 PositionSystem Medical Director (Off-line MedicalDirector).5.1.1 Each EMS system sha
19、ll have an identifiable MedicalDirector who, after consultation with others involved andinterested in the system, is responsible for the development,implementation, and evaluation of standards for provision ofmedical care within the system.5.1.1.1 All prehospital providers (including EMT (Emer-gency
20、 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 continued participation.5.1.1.2 All prehospital providers, with levels of certificationabove EMT basic, shall be
21、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 accordancewith Guide F 1086.5.2 Requirements of a Medical Director:5.2.1 The medical aspects (see 5.3) of an emergency me
22、di-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 of patients who are acutely ill or traumatized.5.2.1.3 Knowledge of, and access to, local mass casualtyplans.
23、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 training of prehospitalpersonnel.5.2.1.6 Active involvement in the medical audit, review, andcritique of medical
24、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 laws and regulations affecting local,regional, and state EMS.5.3 Authority of a Medical Director Includes but i
25、s 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 of non-physician prehospital personnel to the appropriate certifyingagencies.5.3.2.1 Every system shall have
26、 an appropriate review andappeals mechanism, when decertification is recommended, toassure due process in accordance with law and establishedlocal policies. The Director shall promptly refer the case to theappeals mechanism for review, if requested.5.3.3 Requiring education to the level of approved
27、profi-ciency for personnel within the EMS system. This includes allprehospital personnel, EMTs at all levels, prehospital emer-gency care nurses, dispatchers, educational coordinators, andphysician providers of on-line direction (see Practice F 1031).5.3.4 Suspending a provider from medical care dut
28、ies 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 shall have ultimate authority to allow theprehospital provider to provide medical care within the pre-hospital ph
29、ase 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.5.3.5 Establishing medical standards for dispatch proce-dures to assure that the appropriate EMS response unit(s
30、) 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 All decisions by prehospital providers regardingnon-transport shall be based on defined protocol or on-linecomm
31、unications.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 Establishing under which circumstances a patient maybe transported against his or her will; in accordance with stat
32、elaw 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,advanced life support versus basic life support, ground, air, orspecialty unit transportation).5.3.9 Establishin
33、g 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 Communica-tion Resource.5.3.12 Conducting effective system audit and quality assur-ance.F 1149 93 (2008)25.3.12
34、.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 information.5.3.13 Insuring the availability of educational programswithin the system and that t
35、hey 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 The Practice of Direct Medical Control:6.1.1 On-line medical direction capabilities shall exist andbe availa
36、ble 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 specific on-line communi-cation resource by a predetermined policy.6.1.2 Specific local protocols shall exist which
37、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 originate from orbe under the direct supervision and responsibility of a physi-cian.6.1.4 The receiving hospital sh
38、all 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 approved to serve in thiscapacity by the system Medical Director (off-line).6.2.1.1 This physician shall have r
39、eceived education to thelevel of proficiency approved by the off-line Medical Directorfor proper provision of on-line medical direction, includingcommunications equipment, operation, and techniques.6.2.1.2 This physician shall be appropriately trained inprehospital protocols, familiar with the capab
40、ilities 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 expertise in the prehospital care of critically ill and injuredpatients.6.2.3 This physician assumes responsibility
41、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 systemMedical Director (off-line) regarding proper implementation ofmedical and system protocols.7. Authority for Control
42、 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 trained and knowledgeable in providing prehos-pital emergency stabilization and transport.7.1.2 When an adva
43、nced 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 physician providing medicaldirection.7.1.3 The prehospital provider is responsible for the man-agement of th
44、e 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, the prehospitalprovider should defer to the orders of the private physician ifthey do not conflict with est
45、ablished 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 to notify the on-line medical physi-cian.7.2.3 When the medical orders of the private physiciandiffer from sys
46、tem 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 unable to agree on treatment, the privatephysician must either continue to provide direct patient careand accompan
47、y 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 direction any timethe private physician is no longer in attendance.7.3 Intervener Physician Present and Non-Exis
48、tent 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 document his or herintervention in a manner acceptable to the local emergencymedical services system (EMSS),
49、 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 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 Directio
