Medical Direction of EMS

–James C. Collinsauthor of Good to Great: Why Some Make the Leap… and

Others Don’t

“Faith in the endgame helps you live through the months or years of buildup.”

Medical Directionof EMS

Franco Castro-Marín, MD, FACEP

Prehospital Administrative Medical DirectorScottsdale Emergency Associates | HonorHealth -

Scottsdale

Public Safety Medical DirectorCity of Scottsdale (AZ)

Disclosures

• Salaried EMS Medical Director

Medical Direction of EMS

Current Reality Future Vision

Advisory medical oversight provided on a volunteer or pseudo-volunteer, convenient

basis

Authoritative medical oversight that is

engaged, integrated, qualified, talented;

provided with necessary funding and

staff support

Medical Director Doctrine

• Commitment to High Quality Medical Care

• Welfare of Patients, Community, and Workforce

• EMS is a Practice of Medicine

• Physician/Agency “Relationship” must be strong

The Relationship

• EMS Medical Director + EMS Agency

• A mutual INVESTMENT of confidence focused on betterment of the human condition

The Relationship• Benefits to the agency

• Chance to be the best

• Better partnerships with hospitals

• Improved credibility with civic leadership and citizens

• Maintain and maximize relevance

Threats to the Relationship

• Agency not aware of or committed to Doctrine

• Frequent turnover of EMS Leadership

• Budgetary Challenges

• Zero-sum game

EMS Medical Direction

• Foundation and Philosophy

• How we fulfill our DOCTRINE

Foundations and Philosophy

• EMS is Emergency MEDICAL Services

• EMS requires committed oversight

• Culture, tone, STANDARD of how we provide medical care

• Direction ≠ advice, supervision, control

Foundations and Philosophy

• EMS is a delegated practice of medicine

• 911 response is a "referral" to EMS medical director and credentialed agency personnel

• Personnel will deliver same quality of care as designated EMS medical director

Foundations and Philosophy

• Two-way obligation - The Relationship

• Physician obligation to patient/agency

• Agency obligation to patient/physician

• A mutual INVESTMENT of confidence focused on betterment of the human condition

Apprenticeship

The Role of Apprenticeship• Seattle Medic One

• CORE VALUE: Strict, meticulous physician leadership

• Medic candidates vetted

• 3x more patient contacts than national standard

• 2x more instruction hours than national standard

• Intensive apprenticeship and mentoring by physicians

The Role of Apprenticeship

• Cardiac arrest survival rate

• Witnessed VF/VT 50% +

Achieve Greatness

• Paramedic Education

• High quality experiential learning

• High quality professional development

• Strong mentorship from Medical Director

Sets and Reps

0.68 1.63 1.16 2.62 4.680

7.5

15

22.5

30

37.5

Percent Survival of Cardiac Arrest

Annual Cases per Medic

Perc

ent

Surv

ived t

o

Dis

charg

e

Sayre MR, et al. Cardiac Arrest Survival Depends On Paramedic Experience. Acad Emerg Med. May 2006:13(5) Suppl 1: S55-S56

Experience Matters

• Every additional year of “procedure” medic experience adds 2% chance of survival

• Additional experience of “command” medic not associated with increased survival

Gold LS, et al. The Effect Of Paramedic Experience On Survival From Cardiac Arrest. Prehosp Emerg Care. 2009 Jul-Sept;13(3):341-4.

Medics + Physician= Success

Operational Medical Director

Operational Medical Director

• “on-scene supervision and interaction”

Operational Medical Director

• “no better place than… in the midst… of operations on a routine basis”

Operational Medical Director

• “on-scene supervision and experience…obligatory component”

Operational Medical Director

• “respond to as many 911 calls as possible”

Operational Medical Director

• “best form of QA…routine practice…on scene”

Operational Medical Director

• “routine response…factual assessment…of service delivery”

Operational Medical Director

• “common knowledge…MDs can and will show up…”

“Medical directors, doctors hired by the cities to supervise emergency medical care, are often aware of these delays, but many told USA TODAY in the survey and interviews that they are viewed as outsiders by firefighters. The directors can make suggestions to improve care, but the fire chiefs have the final say about how money will be spent and how resources will be deployed.

In Los Angeles, fire department commanders and a powerful firefighters union view fire suppression as the main focus of the department, with medical services ‘a very distant second,’ says medical director Marc Eckstein.

He says many obstacles, including a ‘lack of attention to emergency medical systems issues, overwhelming priority in terms of training, and budget for fire-suppression activities instead,’ stand in the way of better performance. Still, he says, ‘our department is much further along in merging the two cultures than most.’

And operating within the system's structure requires cooperation: Today, Seattle paramedics work for the fire chief, but they deliver medical care as an extension of their hospital base.

One of the fire stations is built into the ground floor of Harborview. The fact that fire department ambulances back into a station inside the hospital is more than just a matter of logistics. Cobb sees it as a sign of a healthy marriage of two systems — but a marriage that takes perhaps a certain amount of nagging to keep it on track.

"The fire department itself is like most fire departments. It's not used to dealing with medical quality issues," he says. "If you left them alone, I don't think they would push this very far. I think most fire departments don't."

Seattle's respected system could easily collapse without constant effort and close scrutiny of care.

"It's a fragile system," Cobb says. "The quality of care is overseen by a handful of people. It wouldn't take much to disrupt that."

EMS Medicine

• Official authority

• Well defined role

• Combined prospective, concurrent, retrospective methods

• EMS system has obligation to provide resources

• Compensation for time

• Materials and personnel

• Liability insurance

• Written agreements

• Physicians should:

• Maintain a presence in the field

• Maintain current knowledge and skills

• Participate in CME

• Obligations of the EMS System:

• Compensation for services

• Materials and personnel

• Liability insurance

• Knowledge of the Incident Command System

“Expert physician supervision and accountability should be considered a

cornerstone element of the EMS system, and this medical oversight function must be

anticipated as a major budget line item appropriate to the jurisdiction.”

Resources• Liability coverage

• ePCR with robust QA/QI capability

• Prehospital coordinator

• PPE

• Appropriate identification

• Radio

• Uniform

• Response vehicle

• Fireground training

• Medical Equipment

Fire Chief

Division Chief

Deputy ChiefDeputy ChiefDeputy Chief

Division Chief Division ChiefDivision Chief Division Chief

“Consultant”Medical Director

???

“face-to-face training is a best practice”-ICMA

MD

Org Chart Example

CO = FC CAG = MD

CWC = Mayor, CM, CEO

Vessel = Fire Dept Air Wing = EMS Division

Administrative Command Clinical Command

Fire Chief

Division Chief

Battalion Chief

Deputy ChiefDeputy ChiefDeputy Chief

Division Chief Division ChiefDivision Chief Division Chief

Battalion ChiefBattalion ChiefBattalion ChiefBattalion ChiefBattalion ChiefBattalion Chief

Medical Director

Citizens

Mayor

City Manager

Medical Director Duties

Defining Duties

• What is my job, exactly?

• Defined by degree of...

• Involvement

• Engagement

• Accountability

EMS System Activity

Impact onPatient Outcome

Consistent

Compliance Effective System Protocols

Most Important Duties

• Formulate system performance specifications

• Monitor compliance with specifications

• Initiate action for compliance as needed

Formulating Specs

• Establish the clinical standard of care

• Oversee and deliver medical education, training, professional development

• Manage research infrastructure

Monitor Compliance

• Implement and maintain the clinical standard of care

• Manage and measure performance quality and outcomes

Initiate Action for Compliance

• Fulfill regulatory functions

• System enhancements

Other Duties

• Advocacy for profession, providers, patients

• Provide public education

• Occupational health (?)

Performance Qualityand Outcomes

Why Quality Matters

• Changes in healthcare financing

• Increasing scrutiny and accountability

• EMS will need to report quality accurately

• “Prove it…”

Quality Improvement

• Prospective

• Concurrent

• Retrospective

Quality Improvement• Prospective

• Concurrent

•Retrospective

Quality Improvement

• Prospective

• Concurrent• Retrospective

Added Value

• Not just for the EMS agency

• Mayor and City Council

• Risk Management

• Law Enforcement

• Corrections

Added Value• City Leadership

• Homeland security, public health emergencies

• Liaison between City and medical community

• Evaluation of budgetary requests

• Help with grant funding

• Contract evaluation

Added Value

• Risk Management

Added Value

• Law Enforcement

Added Value

• Medical resource to all city employees

Added Value

• Medical research beneficial to citizens, employees, and visitors

Added Value

• Improved customer service and public satisfaction

• Not just lip service

• Clinical sophistication

• Reliability, credibility

• Performance accountability

• Economic efficiency

• Positive outcomes

REQUIR

ED

EMS Field Bill• EMS under HHS

• Establishes Office of EMS and Trauma

• National strategy based on excellence, quality, innovation, preparedness

• Improve medical oversight

• Evidence-based practice

More Lives Saved?

More Lives Saved?

Medical Direction of EMS

Current Reality Future Vision

Advisory medical oversight provided on a volunteer or pseudo-volunteer, convenient

basis

Authoritative medical oversight that is

engaged, integrated, qualified, talented;

provided with necessary funding and

staff support

fcmarin@shc.org