1、Designation: F1149 93 (Reapproved 2013)Standard Practice forQualifications, Responsibilities, and Authority of Individualsand Institutions Providing Medical Direction of EmergencyMedical Services1This standard is issued under the fixed designation F1149; the number immediately following the designat
2、ion 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 () indicates an editorial change since the last revision or reapproval.1. Scope1.1 This practice covers the qualifica
3、tions, 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) p
4、rovider 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 ad
5、dresses 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. Ref
6、erenced Documents2.1 ASTM Standards:2F1031 Practice for Training the Emergency Medical Tech-nician (Basic)F1086 Guide for Structures and Responsibilities of Emer-gency Medical Services Systems Organizations3. Terminology3.1 Description of Terms Specific to This Practice3.2 communication resourcean e
7、ntity 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 or a
8、uthorizedcommunication 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 prehos
9、pital 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 relationshi
10、p 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 accountability.)3
11、.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 non-p
12、hysician 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.3.12 st
13、anding 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 Subcommit
14、tee F30.03 onOrganization/Management.Current edition approved June 1, 2013. Published August 2013. Originallyapproved in 1988. Last previous edition approved in 2008 as F1149 98(2008).DOI: 10.1520/F1149-93R13.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Custom
15、er Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States14. Significance and Use4.1 Implementat
16、ion of this practice will ensure that the EMSsystem has the authority, commensurate with the responsibility,to ensure adequate medical direction of all prehospitalproviders, as well as personnel and facilities that meet mini-mum criteria to implement medical direction of prehospitalservices.4.1.1 Th
17、e 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 F1086).4.1.2 This practice is intended to describe and define re-sponsibility for medical directions
18、 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 or state laws, orboth.5. Medical Director5.1 PositionSystem Medical Director (Off-line MedicalDirector).5.1
19、.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 standards for provision ofmedical care within the system.5.1.1.1 All prehospital providers (inc
20、luding 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 continued participation.5.1.1.2 All prehospital providers, with levels of certificationabov
21、e 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 accordancewith Guide F1086.5.2 Requirements of a Medical Director:5.2.1 The medical aspects (see 5.
22、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 of patients who are acutely ill or traumatized.5.2.1.3 Knowledge of, and access to, loca
23、l 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 training of prehospitalpersonnel.5.2.1.6 Active involvement in the medical audit, review, an
24、dcritique of medical care provided by prehospital personnel.5.2.1.7 Knowledge of the administrative and legislativeprocess affecting the local, regional, or state prehospital EMSsystem, or combinations thereof.5.2.1.8 Knowledge of laws and regulations affecting local,regional, and state EMS.5.3 Auth
25、ority 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 of non-physician prehospital personnel to the appropriate certifyi
26、ngagencies.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 the case to theappeals mechanism for review, if requested.5.3.3 Req
27、uiring 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, andphysician providers of on-line direction (see Practice F1031).5.3.4 Su
28、spending 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 MedicalDirector, the director shall have ultimate authority to allow theprehospital provider to provide
29、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.5.3.5 Establishing medical standards for dispatch proce-dures to assure t
30、hat 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 All decisions by prehospital providers regardingnon-transport shall be b
31、ased 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 Establishing under which circumstances a patient maybe transported against h
32、is 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,advanced life support versus basic life support, ground, air, orspecialty
33、 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 Communica-tion Resource.5.3.12 Conducting effective system audit and qua
34、lity assur-ance.5.3.12.1 The Medical Director shall have access to allrelevant EMS records needed to accomplish this task. TheseF1149 93 (2013)2documents shall be considered quality assurance documentsand shall be privileged and confidential information.5.3.13 Insuring the availability of educationa
35、l 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 The Practice of Direct Medical Control:6.1.1 On-line medical direction
36、 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 specific on-line communi-cation resource by a predetermined policy.6.1.2 Speci
37、fic 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 originate from orbe under the direct supervision and responsibility of a phys
38、i-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 approved to serve in thiscapacity by the system Medical Director (off-lin
39、e).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 techniques.6.2.1.2 This physician shall be appropriately trained inprehospi
40、tal 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 expertise in the prehospital care of critically ill and injuredpatients.6.2.3
41、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 systemMedical Director (off-line) regarding proper implementation ofmedical and sys
42、tem 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 trained and knowledgeable in providing prehos-pital emergency stabiliz
43、ation 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 physician providing medicaldirection.7.1.3 The prehospital provider is
44、 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, the prehospitalprovider should defer to the orders of the private phy
45、sician 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 to notify the on-line medical physi-cian.7.2.3 When the medical orders o
46、f 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 unable to agree on treatment, the privatephysician must either continue to p
47、rovide 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 direction any timethe private physician is no longer in attendance.7.3 Int
48、ervener 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 document his or herintervention in a manner acceptable to the local em
49、ergencymedical 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 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 Prese
