Medical Direction of EMS
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Transcript of 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