ASTM F1149-93(2013)

NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
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Designation:F1149 −93 (Reapproved 2013)
Standard Practice for
Qualifications, Responsibilities, and Authority of Individuals
and Institutions Providing Medical Direction of Emergency
Medical Services
This standard is issued under the fixed designation F1149; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope 3.2 communication resource—an entity responsible for
implementation of direct medical control. (Also known as
1.1 This practice covers the qualifications, responsibilities,
medical control resource.)
and authority of individuals and institutions providing medical
3.3 delegated practice—only physicians are licensed to
direction of emergency medical services.
practice medicine; prehospital providers must act only under
1.2 This practice addresses the qualifications, authority, and
the medical direction of a physician.
responsibility of a Medical Director (off-line) and the relation-
3.4 direct medical control—when a physician or authorized
ship of the EMS (Emergency Medical Services) provider to
communication resource personnel, under the direction of a
this individual.
physician, provides immediate medical direction to prehospital
1.3 This practice also addresses components of on-line
providers in remote locations. (Also known as on-line medical
medical direction (direct medical control) including the quali-
direction.)
fications and responsibilities of on-line medical physicians and
3.5 emergency medical services system (EMSS)— all com-
the relationship of the prehospital provider to on-line medical
ponents needed to provide comprehensive prehospital and
direction.
hospital emergency care including, but not limited to; Medical
1.4 This practice addresses the relationship of the on-line
Director, transport vehicles, trained personnel, access and
medical physician to the off-line Medical Director.
dispatch, communications, and receiving medical facilities.
1.5 The authority for control of medical services at the
3.6 intervener physicians—a licensed M.D. or D.O., having
scene of a medical emergency is addressed in this practice.
notpreviouslyestablishedadoctor/patientrelationshipwiththe
emergency patient and willing to accept responsibility for a
1.6 The requirements for a Communication Resource are
also addressed within this practice. medical emergency scene, and can provide proof of a current
Medical License.
2. Referenced Documents
3.7 medical direction—when a physician is identified to
develop, implement, and evaluate all medical aspects of an
2.1 ASTM Standards:
F1031 Practice for Training the Emergency Medical Tech- EMS system. (syn. medical accountability.)
nician (Basic)
3.8 medical director off-line—a physician responsible for all
F1086 Guide for Structures and Responsibilities of Emer-
aspects of an EMS system dealing with provision of medical
gency Medical Services Systems Organizations
care. (Also known as System Medical Director.)
3.9 on-line medical physician—a physician immediately
3. Terminology
available, when medically appropriate, for communication of
3.1 Description of Terms Specific to This Practice
medical direction to non-physician prehospital providers in
remote locations.
3.10 prehospital provider—all personnel providing emer-
This practice is under the jurisdiction ofASTM Committee F30 on Emergency
gency medical care in a location remote from facilities capable
Medical Services and is the direct responsibility of Subcommittee F30.03 on
Organization/Management. of providing definitive medical care.
Current edition approved June 1, 2013. Published August 2013. Originally
3.11 protocols—standards for EMS practice in a variety of
approved in 1988. Last previous edition approved in 2008 as F1149 – 98(2008).
situations within the EMS system.
DOI: 10.1520/F1149-93R13.
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
3.12 standing orders—strictly defined written orders for
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
actions, techniques, or drug administration when communica-
Standards volume information, refer to the standard’s Document Summary page on
the ASTM website. tion has not been established with an on-line physician.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
F1149−93 (2013)
4. Significance and Use 5.3 Authority of a Medical Director Includes but is not
Limited to:
4.1 ImplementationofthispracticewillensurethattheEMS
5.3.1 Establishing system-wide medical protocols (includ-
system has the authority, commensurate with the responsibility,
ing standing orders) in consultation with appropriate special-
to ensure adequate medical direction of all prehospital
ists.
providers, as well as personnel and facilities that meet mini-
5.3.2 Recommending certification or decertification of non-
mum criteria to implement medical direction of prehospital
physician prehospital personnel to the appropriate certifying
services.
agencies.
4.1.1 The state will develop, recommend, and encourage
5.3.2.1 Every system shall have an appropriate review and
use of a plan that would assure the standards outlined in this
appeals mechanism, when decertification is recommended, to
document can be implemented as appropriate at the local,
assure due process in accordance with law and established
regional, or state level (see Guide F1086).
local policies. The Director shall promptly refer the case to the
4.1.2 This practice is intended to describe and define re-
appeals mechanism for review, if requested.
sponsibility for medical directions during transfers. It is not
5.3.3 Requiring education to the level of approved profi-
intended to determine the medical or legal, or both, appropri-
ciency for personnel within the EMS system. This includes all
ateness of transfers under the Consolidated Omnibus Budget
prehospital personnel, EMTs at all levels, prehospital emer-
Reconciliation Act and other similar federal or state laws, or
gency care nurses, dispatchers, educational coordinators, and
both.
physician providers of on-line direction (see Practice F1031).
5. Medical Director 5.3.4 Suspending a provider from medical care duties for
due cause pending review and evaluation.
5.1 Position—System Medical Director (Off-line Medical
5.3.4.1 Because the prehospital provider operates under the
Director).
license (delegated practice) or direction of the Medical
5.1.1 Each EMS system shall have an identifiable Medical
Director, the director shall have ultimate authority to allow the
Director who, after consultation with others involved and
prehospital provider to provide medical care within the pre-
interested in the system, is responsible for the development,
hospital phase of the EMS system.
implementation, and evaluation of standards for provision of
5.3.4.2 Whenever a Medical Director makes a decision to
medical care within the system.
suspend a provider from medical care duties, the process shall
5.1.1.1 All prehospital providers (including EMT (Emer-
be prescribed by previously established criteria.
gency Medical Technician) basics) shall be medically account-
5.3.5 Establishing medical standards for dispatch proce-
able for their actions and are responsible to the Medical
dures to assure that the appropriate EMS response unit(s) are
Director of the EMS agency (local, regional, or state) that
dispatched to the medical emergency scene when requested,
approves their continued participation.
and the duty to evaluate the patient is fulfilled.
5.1.1.2 All prehospital providers, with levels of certification
5.3.6 Establishing under what circumstances non-transport
above EMT basic, shall be responsible to an identifiable
might occur.
physician who directs their medical care activity.
5.3.6.1 All decisions by prehospital providers regarding
5.1.2 The Medical Director shall be appointed by, and
non-transport shall be based on defined protocol or on-line
accountable to, the appropriate EMS agency in accordance
communications.
with Guide F1086.
5.3.6.2 Develop a procedure for record keeping when the
5.2 Requirements of a Medical Director:
reason for non-transport was the result of a patient’s refusal,
5.2.1 The medical aspects (see 5.3) of an emergency medi-
including the appropriate forms and review process.
cal service system shall be managed by physicians who meet
5.3.7 Establishing under which circumstances a patient may
the following requirements:
be transported against his or her will; in accordance with state
5.2.1.1 Licensed physician, M.D. or D.O.
law including, procedure, appropriate forms, and review pro-
5.2.1.2 Experiencein,andcurrentknowledgeof,emergency
cess.
care of patients who are acutely ill or traumatized.
5.3.8 Establishing criteria for level of care and type of
5.2.1.3 Knowledge of, and access to, local mass casualty
transportation to be used in prehospital emergency care (that is,
plans.
advanced life support versus basic life support, ground, air, or
5.2.1.4 Familiarity with Communication Resource opera-
specialty unit transportation).
tions where applicable, including communication with, and
5.3.9 Establishing criteria for selection of patient destina-
direction of, prehospital emergency units.
tion.
5.2.1.5 Active involvement in the training of prehospital
5.3.10 Establishing educational and performance standards
personnel.
for Communication Resource personnel.
5.2.1.6 Activeinvolvementinthemedicalaudit,review,and
5.3.11 Establishing operational standards for Communica-
critique of medical care provided by prehospital personnel.
tion Resource.
5.2.1.7 Knowledge of the administrative and legislative
5.3.12 Conducting effective system audit and quality assur-
process affecting the local, regional, or state prehospital EMS
system, or combinations thereof. ance.
5.2.1.8 Knowledge of laws and regulations affecting local, 5.3.12.1 The Medical Director shall have access to all
regional, and state EMS. relevant EMS records needed to accomplish this task. These
F1149−93 (2013)
documents shall be considered quality assurance documents an emergency, a doctor/patient relationship has been estab-
and shall be privileged and confidential information. lished between the patient and the physician providing medical
direction.
5.3.13 Insuring the availability of educational programs
within the system and that they are consistent with accepted
7.1.3 The prehospital provider is responsible for the man-
local medical practice.
agement of the patient and acts as the agent of medical
5.3.14 May delegate portions of his or her duties to other direction.
qualified individuals.
7.2 Patient’s Private Physician Present:
7.2.1 When the patient’s private physician is present and
6. Direct Medical Control (On-Line Medical Direction)
assumes responsibility for the patient’s care, the prehospital
6.1 The Practice of Direct Medical Control:
provider should defer to the orders of the private physician if
6.1.1 On-line medical direction capabilities shall exist and
they do not conflict with established system protocols and the
be available within the EMS system, unless impossible due to
private physician documents the orders in a manner acceptable
distance or geographic considerations.
to the EMS system.
6.1.1.1 All prehospital providers, above the certification of
7.2.2 The Communication Resource shall be contacted for
EMT basic, shall be assigned to a specific on-line communi-
recordkeeping purposes to notify the on-line medical physi-
cation resource by a predetermined policy.
cian.
6.1.2 Specific local protocols shall exist which define those
7.2.3 When the medical orders of the private physician
circumstances under which on-line medical direction is re-
differ from system protocol, Communication Resource shall be
quired.
contacted and the private physician placed in communication
6.1.3 On-line medical direction is the practice of medicine
with the on-line physician. If the private physician and the
andallorderstotheprehospitalprovidershalloriginatefromor
on-line physician are unable to agree on treatment, the private
be under the direct supervision and responsibility of a physi-
physician must either continue to provide direct patient care
cian.
and accompany the patient to the hospital, or defer all
6.1.4 The receiving hospital shall be notified prior to the
remaining care to the on-line physician.
arrival of each patient transported by the EMS system unless
7.2.4 The prehospital provider’s responsibility reverts to the
directed otherwise by local protocol.
systemsMedicalDirectororon-linemedicaldirectionanytime
6.2 The On-Line Medical Physician: the private physician is no longer in attendance.
6.2.1 This physician shall be approved to serve in this
7.3 Intervener Physician Present and Non-Existent On-Line
capacity by the system Medical Director (off-line).
Medical Direction:
6.2.1.1 This physician shall have received education to the
7.3.1 When an intervener physician has been satisfactorily
level of proficiency approved by the off-line Medical Director
identified as a licensed physician and has expressed his or her
for proper provision of on-line medical direction, including
willingness to assume responsibility and document his or her
communications equipment, operation, and techniques.
intervention in a manner acceptable to the local emergency
6.2.1.2 This physician shall be appropriately trained in
medical services system (EMSS), the prehospital provider
prehospital protocols, familiar with the capabilities of the
should defer to the orders of the physician on the scene if they
prehospital providers, as well as local EMS operational poli-
do not conflict with system protocols.
cies and regional critical care referral protocols.
7.3.2 If treatment by the intervener physician at the emer-
6.2.2 This physician shall have demonstrated knowledge
gency scene differs from that outlined in a local protocol, the
and expertise in the prehospital care of critically ill and injured
physician shall agree in advance to assume responsibility for
patients.
care, including accompanying the patient to the hospital.
6.2.3 This physician assumes responsibility for appropriate
7.3.3 In the event of a mass casualty incident or disaster,
actions of the prehospital provided to the extent that the on-line
patient care needs may require the intervener physician to
physician is involved in patient care direction.
remain at the scene.
6.2.4 The on-line physician is responsible to the system
Medical Director (off-line) regarding
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