ASTM F1149-93(2003)

NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
Designation: F 1149 – 93 (Reapproved 2003)
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 F 1149; 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 (e) indicates an editorial change since the last revision or reapproval.
1. Scope 3.3 delegated practice—only physicians are licensed to
practice medicine; prehospital providers must act only under
1.1 This practice covers the qualifications, responsibilities,
the medical direction of a physician.
and authority of individuals and institutions providing medical
3.4 direct medical control—when a physician or authorized
direction of emergency medical services.
communication resource personnel, under the direction of a
1.2 This practice addresses the qualifications, authority, and
physician, provides immediate medical direction to prehospital
responsibility of a Medical Director (off-line) and the relation-
providers in remote locations. (Also known as on-line medical
ship of the EMS (Emergency Medical Services) provider to
direction.)
this individual.
3.5 emergency medical services system (EMSS)—all com-
1.3 This practice also addresses components of on-line
ponents needed to provide comprehensive prehospital and
medical direction (direct medical control) including the quali-
hospital emergency care including, but not limited to; Medical
fications and responsibilities of on-line medical physicians and
Director, transport vehicles, trained personnel, access and
the relationship of the prehospital provider to on-line medical
dispatch, communications, and receiving medical facilities.
direction.
3.6 intervener physicians—a licensed M.D. or D.O., having
1.4 This practice addresses the relationship of the on-line
notpreviouslyestablishedadoctor/patientrelationshipwiththe
medical physician to the off-line Medical Director.
emergency patient and willing to accept responsibility for a
1.5 The authority for control of medical services at the
medical emergency scene, and can provide proof of a current
scene of a medical emergency is addressed in this practice.
Medical License.
1.6 The requirements for a Communication Resource are
3.7 medical direction—when a physician is identified to
also addressed within this practice.
develop, implement, and evaluate all medical aspects of an
2. Referenced Documents EMS system. (syn. medical accountability.)
3.8 medical director off-line—aphysicianresponsibleforall
2.1 ASTM Standards:
aspects of an EMS system dealing with provision of medical
F 1031 Practice for Training the Emergency Medical Tech-
care. (Also known as System Medical Director.)
nician (Basic)
3.9 on-line medical physician—a physician immediately
F 1086 Guide for Structures and Responsibilities of Emer-
available, when medically appropriate, for communication of
gency Medical Services Systems Organizations
medical direction to non-physician prehospital providers in
3. Terminology
remote locations.
3.10 prehospital provider—all personnel providing emer-
3.1 Description of Terms Specific to This Practice
gency medical care in a location remote from facilities capable
3.2 communication resource—an entity responsible for
of providing definitive medical care.
implementation of direct medical control. (Also known as
3.11 protocols—standards for EMS practice in a variety of
medical control resource.)
situations within the EMS system.
3.12 standing orders—strictly defined written orders for
This practice is under the jurisdiction ofASTM Committee F30 on Emergency
actions, techniques, or drug administration when communica-
Medical Services and is the direct responsibility of Subcommittee F30.03 on
tion has not been established with an on-line physician.
Organization/Management.
Current edition approved Sept. 10, 2003. Published October 2003. Originally
approved in 1988. Last previous edition approved in 1998 as F 1149 – 93 (1998).
Annual Book of ASTM Standards, Vol 13.02.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
F 1149 – 93 (2003)
4. Significance and Use 5.3.1 Establishing system-wide medical protocols (includ-
ing standing orders) in consultation with appropriate special-
4.1 ImplementationofthispracticewillensurethattheEMS
ists.
systemhastheauthority,commensuratewiththeresponsibility,
5.3.2 Recommending certification or decertification of non-
to ensure adequate medical direction of all prehospital provid-
physician prehospital personnel to the appropriate certifying
ers, as well as personnel and facilities that meet minimum
agencies.
criteria to implement medical direction of prehospital services.
5.3.2.1 Every system shall have an appropriate review and
4.1.1 The state will develop, recommend, and encourage
appeals mechanism, when decertification is recommended, to
use of a plan that would assure the standards outlined in this
assure due process in accordance with law and established
document can be implemented as appropriate at the local,
local policies. The Director shall promptly refer the case to the
regional, or state level (see Guide F 1086).
appeals mechanism for review, if requested.
4.1.2 This practice is intended to describe and define re-
5.3.3 Requiring education to the level of approved profi-
sponsibility for medical directions during transfers. It is not
ciency for personnel within the EMS system. This includes all
intended to determine the medical or legal, or both, appropri-
prehospital personnel, EMTs at all levels, prehospital emer-
ateness of transfers under the Consolidated Omnibus Budget
gency care nurses, dispatchers, educational coordinators, and
Reconciliation Act and other similar federal and/or state laws.
physician providers of on-line direction (see Practice F 1031).
5.3.4 Suspending a provider from medical care duties for
5. Medical Director
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 Direc-
5.1.1 Each EMS system shall have an identifiable Medical
tor, 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 F 1086.
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
critique of medical care provided by prehospital personnel. 5.3.11 Establishing operational standards for Communica-
tion Resource.
5.2.1.7 Knowledge of the administrative and legislative
process affecting the local, regional, and/or state prehospital 5.3.12 Conducting effective system audit and quality assur-
EMS system. 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
5.3 Authority of a Medical Director Includes but is not documents shall be considered quality assurance documents
Limited to: and shall be privileged and confidential information.
F 1149 – 93 (2003)
5.3.13 Insuring the availability of educational programs 7.1.3 The prehospital provider is responsible for the man-
within the system and that they are consistent with accepted agement of the patient and acts as the agent of medical
local medical practice. direction.
7.2 Patient’s Private Physician Present:
5.3.14 May delegate portions of his or her duties to other
qualified individuals. 7.2.1 When the patient’s private physician is present and
assumes responsibility for the patient’s care, the prehospital
6. Direct Medical Control (On-Line Medical Direction) provider should defer to the orders of the private physician if
they do not conflict with established system protocols and the
6.1 The Practice of Direct Medical Control:
private physician documents the orders in a manner acceptable
6.1.1 On-line medical direction capabilities shall exist and
to the EMS system.
be available within the EMS system, unless impossible due to
7.2.2 The Communication Resource shall be contacted for
distance or geographic considerations.
recordkeeping purposes to notify the on-line medical physi-
6.1.1.1 All prehospital providers, above the certification of
cian.
EMT basic, shall be assigned to a specific on-line communi-
7.2.3 When the medical orders of the private physician
cation resource by a predetermined policy.
differ from system protocol, Communication Resource shall be
6.1.2 Specific local protocols shall exist which define those
contacted and the private physician placed in communication
circumstances under which on-line medical direction is re-
with the on-line physician. If the private physician and the
quired.
on-line physician are unable to agree on treatment, the private
6.1.3 On-line medical direction is the practice of medicine
physician must either continue to provide direct patient care
andallorderstotheprehospitalprovidershalloriginatefromor
and accompany the patient to the hospital, or defer all
be under the direct supervision and responsibility of a physi-
remaining care to the on-line physician.
cian.
7.2.4 The prehospital provider’s responsibility reverts to the
6.1.4 The receiving hospital shall be notified prior to the
systemsMedicalDirectororon-linemedicaldirectionanytime
arrival of each patient transported by the EMS system unless
the private physician is no longer in attendance.
directed otherwise by local protocol.
7.3 Intervener Physician Present and Non-Existent On-Line
6.2 The On-Line Medical Physician:
Medical Direction:
6.2.1 This physician shall be approved to serve in this
7.3.1 When an intervener physician has been satisfactorily
capacity by the system Medical Director (off-line).
identified as a licensed physician and has expressed his or her
6.2.1.1 This physician shall have received education to the
willingness to assume responsibility and document his or her
level of proficiency approved by the off-line Medical Director
intervention in a manner acceptable to the local emergency
for proper provision of on-line medical direction, including
medical services system (EMSS), the prehospital provider
communications equipment, operation, and techniques.
should defer to the orders of the physician on the scene if they
6.2.1.2 This physician shall be appropriately trained in
do not conflict with system protocols.
prehospital protocols, familiar with the capabilities of the
7.3.2 If treatment by the intervener physician at the emer-
prehospital providers, as well as local EMS operational poli-
gency scene differs from that outlined in a local protocol, the
cies and regional critical care referral protocols.
physician shall agree in advance to assume responsibility for
6.2.2 This physician shall have demonstrated knowledge
care, including accompanying the patient to the hospital.
and expertise in the prehospital care of critically ill and injured
7.3.3 In the event of a mass casualty incident or disaster,
patients.
patient care needs may require the intervener physician to
6.2.3 This physician assumes responsibility for appropriate
remain at the scene.
actionsoftheprehospitalprovidedtotheextentthattheon-line
7.4 Intervener Physician Present and Existent On-Line
physician is involved in patient care direction.
Medical Direction:
6.2.4 The on-line physician is responsible to the system
7.4.1 If an intervener physician is present and on-line
Medical Director (off-line) regarding proper implementation of
medical direction does exist, the on-line physician should be
medical and system protocols.
contacted and the on-line physician is ultimately responsible.
7.4.2 The on-line physician has the option of managing the
7. Authority for
...