Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 12 - Bureau of Emergency Medical Services › Subpart 31 - Emergency Medical Services › Chapter 10 - Critical Care Paramedic › Appendix 15-12-31-10-1 - MEDICAL DIRECTION: STANDARD PRACTICE FOR QUALIFICATIONS, RESPONSIBILITIES, AND AUTHORITY

Current through June 25, 2024
Medical Direction (pre-hospital Emergency Medical
					 Services)
All aspects of the organization and provision of emergency
					 medical services (EMS), including both basic and advanced life support, require
					 the active involvement and participation of physicians. These aspects should
					 incorporate design of the EMS system prior to its implementation; continual
					 revisions of the system; and operation of the system from initial access, to
					 pre-hospital contact with the patient, through stabilization in the emergency
					 department. All pre-hospital medical care may be considered to have been
					 provided by one or more agents of the physician who controls the pre-hospital
					 system, for this physician has assumed responsibility for such care.
Implementation of this standard practice will insure that
					 the EMS system has the authority, commensurate with the responsibility, to
					 insure adequate medical direction of all pre-hospital providers, as well as
					 personnel and facilities that meet minimum criteria to implement medical
					 direction of pre-hospital services.
OFF-LINE (PROSPECTIVE AND RETROSPECTIVE) MEDICAL
					 DIRECTION
Off-line medical direction includes the administrative
					 promulgation and enforcement of accepted standards for out-of-hospital care.
					 Off-line medical direction can be accomplished through both prospective and
					 retrospective methods. Prospective methods include, but are not limited to,
					 training, testing, and credentialing of providers, protocol development,
					 operational policy and procedures development, and legislative activities.
					 Off-line medical direction shall ensure the qualifications of out-of-hospital
					 personnel involved in patient care and dispatch are maintained on an ongoing
					 basis through education, testing, and credentialing as the local/state
					 authorities have determined. Retrospective activities include, but are not
					 limited to medical audit and review of care, (process improvement), direction
					 of remedial education, and limitation of patient care functions if needed.
					 Committees functioning under the medical director with representation from
					 appropriate medical and provider personnel can perform various aspects of
					 prospective and retrospective medical direction.
Each EMS agency providing pre-hospital care shall be
					 licensed by the Mississippi State Department of Health, BEMS, and shall have an
					 identifiable off-line Medical Director who after consultation with others
					 involved and interested in the agency is responsible for the development,
					 implementation and evaluation of standards for provision for medical care
					 within the agency.
All pre-hospital providers (including EMT-Bs) shall be
					 medically accountable for their actions and are responsible to the off-line
					 Medical Director of the licensed EMS agency that approves their continued
					 participation. All pre-hospital providers, with levels of certification EMT-B
					 or above, shall be responsible to an identifiable physician who directs their
					 medical care activity. The off-line Medical Director shall be appointed by, and
					 accountable to, the appropriate licensed EMS agency.
The licensee's off-line medical director shall ensure that
					 there is a capability and method to provide on-line medical control to EMS
					 personnel on board any permitted unit at all times. If patient specific orders
					 are written, there shall be a formal procedure to use them. In addition to
					 on-line medical control capabilities, the licensee shall have a written plan,
					 procedure, and resources in place for off-line medical control. This may be
					 accomplished by use of comprehensive written, guidelines, procedures, or
					 protocols.
Qualifications of a Medical Director
To optimize off-line medical direction of all
					 out-of-hospital emergency medical services, these services should be managed by
					 physicians who have demonstrated the following:
1. Mississippi licensed physician, M.D. or D.O.
2. Familiarity with the design and operation of
					 out-of-hospital EMS systems.
3. Experience or training in the out-of-hospital emergency
					 care of the acutely ill or injured patient.
4. Experience or training in medical direction of
					 out-of-hospital emergency units.
5. Active participation or reasonable associated experience
					 in the ED management of the acutely ill or injured patient.
6. Experience or training in the instruction of
					 out-of-hospital personnel.
7. Active involvement in the training of pre-hospital
					 personnel.
8. Experience or training in the EMS performance
					 improvement process.
9. Active involvement in the medical audit, review and
					 critique of medical care provided by pre-hospital personnel.
10. Knowledge of EMS laws and regulations.
11. Knowledge of EMS dispatch and communications.
12. Knowledge of local mass casualty and disaster plans
					 including preparation for responding to terrorism and weapons of mass
					 destruction.
13. By July 1, 2017, board certification in emergency
					 medicine by the American Board of Emergency Medicine or the American Board of
					 Osteopathic Emergency Medicine. Substitutions may be approved by the State
					 Medical Director.
14. Completion of an EMS Medical Directors training course.
					 (Effective January, 2013)
15. Familiarity with base station operations where
					 applicable, including communication with, and direction of, pre-hospital
					 emergency units.
16. Knowledgeable of the administrative and legislative
					 process affecting the local, regional and/or state pre-hospital EMS
					 system.
17. Knowledgeable of laws and regulations affecting local,
					 regional, and state EMS.
18. Approved by the State EMS Medical Director
Authority of an off-line Medical Director includes,
					 but is not limited to:
Unless otherwise defined or limited by state or regional
					 requirements, the medical director shall have authority over all clinical and
					 patient care aspects of the EMS system including, but not limited to, the
					 following:
1. Recommend certification, recertification, and
					 decertification of non-physician out-of-hospital personnel to the appropriate
					 certifying agency.
2. Establish, implement, revise, and authorize the use of
					 system-wide protocols, policies, and procedures for all patient care activities
					 from dispatch through triage, treatment, transport, and/or
					 non-transport.
3. Establish criteria for determining patient destination
					 in a non-discriminatory manner in compliance with state guidelines as
					 appropriate.
4. Ensure the competency of personnel who provide on-line
					 medical direction to out-of-hospital personnel including, but not limited to,
					 physicians, EMTs, Advanced EMTs, Paramedics and nurses.
5. Establish the procedures or protocols under which
					 non-transport of patients may occur.
6. Require education and testing to the level of
					 proficiency approved for the following personnel within the EMS system:
a. EMTs
b. Advanced EMTs
c. Paramedics
d. Critical Care Paramedics
e. Nurses involved in out-of-hospital care
f. Dispatchers
g. Educational coordinators
h. On-line physicians
i. Off-line physicians
7. Implement and supervise an effective process improvement
					 program. The medical director shall have access to all relevant records needed
					 to accomplish this task.
8. Remove a provider from medical care duties for due
					 cause, using an appropriate review and appeals mechanism.
9. Set or approve hiring standards for personnel involved
					 in patient care.
10. Set or approve standards for equipment used in patient
					 care.
11. Establishing system-wide medical and trauma protocols
					 in consultation with appropriate specialists.
12. Recommending certification or decertification of
					 non-physician pre-hospital personnel to the appropriate certifying agencies.
					 Every licensed agency shall have an appropriate review and appeals mechanism,
					 when decertification is recommended, to assure due process in accordance with
					 law and established local policies. The Director shall promptly refer the case
					 to the appeals mechanism for review, if requested.
13. Requiring education to the level of approved
					 proficiency for personnel within the EMS system. This includes all pre-hospital
					 personnel, EMTs at all levels, pre-hospital emergency care nurses, dispatchers,
					 educational coordinators, and physician providers of on-line direction.
14. Suspending a provider from medical care duties for due
					 cause pending review and evaluation. Because the pre-hospital provider operates
					 under the license (delegated practice) or direction of the Medical Director,
					 the Director shall have ultimate authority to allow the pre-hospital provider
					 to provide medical care within the pre-hospital phase of the EMS system.
15. Establishing medical standards for dispatch procedures
					 to assure that the appropriate EMS response unit(s) is dispatched to the
					 medical emergency scene when requested, and the duty to evaluate the patient is
					 fulfilled.
16. Establishing under which circumstances a patient may be
					 transported against his will; in accordance with, state law including,
					 procedures, appropriate forms, and review process.
17. Establishing criteria for level of care and type of
					 transportation to be used in pre-hospital emergency care (i.e., advanced life
					 support vs. basic life support, ground air, or specialty unit
					 transportation).
18. Establishing criteria for selection of patient
					 destination.
19. Establishing educational and performance standards for
					 communication resource personnel.
20. Establishing operational standards for communication
					 resource.
21. Conducting effective system audit and quality
					 assurance. The Medical Director shall have access to all relevant EMS records
					 needed to accomplish this task. These documents shall be considered quality
					 assurance documents and shall be privileged and confidential
					 information.
22. Insuring the availability of educational programs
					 within the system and that they are consistent with accepted local medical
					 practice.
23. May delegate portions of his/her duties to other
					 qualified individuals.
24. The owner, manager, or medical director of each
					 publicly or privately owned ambulance service shall inform the State Department
					 of Health, Bureau of EMS of the termination of service in a licensed county or
					 defined service area no less than 30 days prior to ceasing operations. This
					 communication should also be sent by the owner, manager or medical director of
					 each publicly or privately owned ambulance service to related parties and local
					 governmental entities such as, but not limited to, emergencies management
					 agency, local healthcare facilities, and the public via mass media.
25. Medical direction with concurrent and retrospective
					 oversight supervision;
26. Standardized protocols;
27. Actively engaged in a continuous quality assurance,
					 quality control, performance review, and when necessary, supplemental training.
Medical Direction (Online, Direct Medical
					 Control)
On-line medical direction is the medical direction provided
					 directly to out-of-hospital providers by the medical director or designee, as
					 defined in the BEMS approved medical control plan, generally in an emergency
					 situation, either on-scene or by direct voice communication. The mechanism for
					 this contact may be radio, telephone, or other means as technology develops,
					 but must include person-to-person communication of patient status, and orders
					 to be carried out. Ultimate authority and responsibility for concurrent medical
					 direction rests with the off-line medical director.
The practice of on-line medical direction shall exist and
					 be available within the EMS system, unless impossible due to distance or
					 geographic considerations. All credentialed pre-hospital providers shall be
					 assigned to a specific on-line communication resource by a predetermined policy
					 and this shall be included in the application for ALS licensure.
When EMS personnel are transporting patients to locations
					 outside of their geographic medical control area, they may utilize recognized
					 communication resources outside of their own area.
Specific local protocols shall exist which define those
					 circumstances under which on-line medical direction is required.
On-line medical direction is the practice of medicine and
					 all orders to which the pre-hospital provider shall originate from/or be under
					 the direct supervision and responsibility of a physician.
The receiving hospital shall be notified prior to the
					 arrival of each patient transported by the EMS system unless directed otherwise
					 by local protocol.
Requirements of a Medical Director
1. This physician shall be approved to serve in this
					 capacity by system (Off-Line) Medical Director.
2. This physician shall have received education to the
					 level of proficiency approved by the off-line Medical Director for proper
					 provision of on-line medical direction, including communications equipment,
					 operation, and techniques. (January 2013) All Mississippi On-Line Medical
					 Directors are encouraged to complete the Medical Director's course as
					 prescribed by the Mississippi State Department of Health, Bureau of Emergency
					 Medical Services and the Medical Direction, Training and Quality Assurance
					 Committee.
3. This physician shall be appropriately trained in
					 pre-hospital protocols, familiar with the capabilities of the pre-hospital
					 providers, as well as local EMS operational policies and regional critical care
					 referral protocols.
4. This physician shall have demonstrated knowledge and
					 expertise in the pre-hospital care of critically ill and injured
					 patients.
5. This physician assumes responsibility for appropriate
					 actions of the pre-hospital provider to the extent that the on-line physician
					 is involved in patient care direction.
6. The on-line physician is responsible to the system
					 Medical Director (off-line) regarding proper implementation of medical and
					 system protocols.
7. The licensee's off-line medical director shall ensure
					 that there is a capability and method to provide on-line medical control to air
					 medical personnel on board any of its air ambulance aircraft at all times. If
					 patient specific orders are written, there shall be a formal procedure to use
					 them. In addition to on-line medical control capabilities, the licensee shall
					 have a written plan, procedure, and resources in place for off-line medical
					 control. This may be accomplished by use of comprehensive written, guidelines,
					 procedures, or protocols.
8. There must be - at all times - Medical direction with
					 concurrent and retrospective oversight supervision; Standard Protocols;
					 Continuing quality assurance, quality control, performance review, and when
					 necessary, supplemental training.
Authority for Control of Medical Services at the
					 Scene of Medical Emergency.
Authority for patient management in a medical emergency
					 shall be the responsibility of the individual in attendance who is most
					 appropriately trained and knowledgeable in providing pre-hospital emergency
					 stabilization and transport.
When an advanced life support (ALS) squad, under medical
					 direction, is requested and dispatched to the scene of an emergency, a
					 doctor/patient relationship has been established between the patient and the
					 physician providing medical direction.
The pre-hospital provider is responsible for the management
					 of the patient and acts as the agent of medical direction.
Authority for Scene Management.
Authority for the management of the scene of a medical
					 emergency shall be vested in appropriate public safety agencies. The scene of a
					 medical emergency shall be managed in a manner designed to minimize the risk of
					 death or health impairment to the patient and to other persons who may be
					 exposed to the risks as a result of the emergency condition, and priority shall
					 be placed upon the interests of those persons exposed to the more serious risks
					 to life and health. Public safety personnel shall ordinarily consult emergency
					 medical services personnel or other authoritative medical professionals at the
					 scene in the determination of relevant risks.
Patient's Private Physician Present
The EMT should defer to the orders of the private
					 physician. The base station should be contacted for record keeping purposes if
					 on-line medical direction exists. The ALS squad's responsibility reverts back
					 to medical direction or on-line medical direction at any time when the
					 physician is no longer in attendance.
Intervener Physician Present and Non-Existent On-Line
					 Medical Direction
When the intervener physician has satisfactorily identified
					 himself as a licensed physician and has expressed his willingness to assume
					 responsibility and document his intervention in a manner acceptable to the
					 local emergency medical services system (EMSS); the pre-hospital provider
					 should defer to the orders of the physician on the scene if they do not
					 conflict with system protocol.
If treatment by the intervener physicians at the emergency
					 scene differs from that outlined in a local protocol, the physician shall agree
					 in advance to assume responsibility for care, including accompanying the
					 patient to the hospital. In the event of a mass casualty incident or disaster,
					 patient needs may require the intervener physician to remain at the
					 scene.
Intervener Physician Present and Existent On-Line
					 Medical Direction
If an intervener physician is present and on-line medical
					 direction does exist, the on-line physician should be contacted and the on-line
					 physician is ultimately responsible.
The on-line physician has the option of managing the case
					 entirely, working with the intervener physician, or allowing him to assume
					 responsibility.
If there is any disagreement between the intervener
					 physician and the on-line physician, the pre-hospital provider should take
					 orders from the on-line physician and place the intervener physician in contact
					 with on-line physician.
In the event the intervener physician assumes
					 responsibility, all orders to the pre-hospital provider shall be repeated to
					 the communication resource for purposes of record-keeping.
The intervener physician should document his intervention
					 in a manner acceptable to the local EMS system.
The decision of the intervener physician to accompany the
					 patient to the hospital should be make in consultation with the on-line
					 physician. Nothing in this section implies that the pre-hospital provider CAN
					 be required to deviate from system protocols.
Communication Resource
A communication resource is an entity responsible for
					 implementation of direct (on-line) medical control. This entity/facility shall
					 be designated to participate in the EMS system according to a plan developed by
					 the licensed ALS provider and approved by the system (off-line) medical
					 director and the State Department of Health, BEMS.
The communication resource shall assure adequate staffing
					 for the communication equipment at all times by health care personnel who have
					 achieved a minimal level of competence and skill and are approved by the system
					 medical director.
The communication resource shall assure that all requests
					 for medical guidance assistance or advice by pre-hospital personnel will be
					 promptly accommodated with an attitude of utmost participation, responsibility,
					 and cooperation.
The communication resource shall provide assurance that
					 they will cooperate with the EMS system in collecting and analyzing data
					 necessary to evaluate the pre-hospital care program as long as patient
					 confidentiality is not violated.
1. The communication resource will consider the
					 pre-hospital provider to be the agent of the on-line physician when they are in
					 communication, regardless of any other employee/employer relationship.
2. The communication resource shall assure that the on-line
					 physicians will issue transportation instructions and hospital assignments
					 based on system protocols and objective analysis of patient's needs and
					 facility capability and proximity.
3. No effort will be made to obtain institutional or
					 commercial advantages through use of such transportation instructions and
					 hospital assignments.
4. When the communication resource is acting as an agent
					 for another hospital, the information regarding patient treatment and expected
					 time of arrival will be relayed to the receiving hospital in an accurate and
					 timely fashion.
5. Communication resource shall participate in regular case
					 conferences involving the on-line physicians and pre-hospital personnel for
					 purposes of problem identification and provide continuing education to correct
					 any identified problems.
6. If the communication resource is located within a
					 hospital facility, the hospital shall meet the requirements listed herein and
					 the equipment used for on-line medical direction shall be located within the
					 emergency department.
Educational Responsibilities
Because the on-line and off-line medical directors allow
					 the use of their medical licenses, specific educational requirements should be
					 established. This is not only to insure the best available care, but also to
					 minimize liability. All personnel brought into the system must meet minimum
					 criteria established by state law for each level; however, the law should in no
					 way preclude a medical director from enforcing standards beyond this
					 minimum.
Personnel may come to the system untrained (in which case
					 the medical director will design and implement the educational program directly
					 or through the use of ancillary instructors), or they may have previous
					 training and/or experience. Although the Department of Transportation has
					 defined curricula for training, the curricula are not standardized nationally,
					 and often are not standardized within a state or county. Certification or
					 licensure in one locale does not automatically empower an individual to
					 function as an EMT within another system. The medical director must evaluate
					 applicants trained outside the system in order to determine their level of
					 competence. Such evaluation may be made in the form of written examinations,
					 but should also include practical skills and a field internship with competent
					 peers and time spent with the medical director.
The educational responsibilities of the medical director do
					 not end with initial training; skills maintenance must be considered. To insure
					 the knowledge does not stagnate, programs should cover all aspects of the
					 initial training curriculum on a cyclical basis. Continuing education should
					 comprise multiple formats, including lectures, discussions, and case
					 presentations, as well as practical situations that allow the EMT to be
					 evaluated in action. The continuing education curriculum should also include
					 topics suggested by audits, and should be utilized to introduce new equipment
					 or skills.
Paramedics are allowed to administer any pharmaceutical
					 that is approved in these Rules and Regulations; through any route that falls
					 within the skill set taught consistent with the National Standard Curriculum;
					 and approved by off line medical director.
Review and Audit
Personnel may be trained to the highest standards and many
					 protocols may be written, but if critical review is not performed, the level of
					 patient care will deteriorate. Review is intended to determine inadequacies of
					 the training program and inconsistencies in the protocols. The data base
					 required includes pre-hospital care data, emergency department and inpatient
					 (summary) data, and autopsy findings as appropriate. The cooperation of system
					 administrators, hospital
administrators, and local or state medical societies must
					 be elicited. On occasion, the state legislature may be required to provide
					 access to vital information.
The medical director or a designated person should audit
					 pre-hospital run records, either randomly or inclusively. The data must be
					 specifically evaluated for accuracy of charting and assessment; appropriateness
					 of treatment; patterns of error, morbidity, and mortality; and need for
					 protocol revision.
It cannot be assumed that all pre-hospital care will be
					 supervised by on-line physicians. When proper or improper care is revealed by
					 the audit process, prompt and appropriate praise or censorship should be
					 provided by the medical director after consultation with the system
					 administrator.
Individual Case Review.
Compliance with system rules and regulations is most
					 commonly addressed by state and regional EMS offices. Audit by individual case
					 review requires a more detailed plan. Each of the components defined in detail
					 by the individual EMS system must be agreed on prior to the institution of any
					 case review procedures. Case review may involve medical audit, including
					 reviews of morbidity and mortality data (outcome-oriented review), and system
					 audit, including compliance with rules and regulations as well as adherence to
					 protocols and standing orders (process-oriented review). The personnel to be
					 involved in a given case review process should include the off-line medical
					 director; emergency department and critical care nurses; and EMS, technical and
					 other support personnel who were involved in the specific cases.
The following must be written and agreed to in
					 advance:
Procedural guidelines of how the individuals will interact
					 during meetings.
Because considerations of medical malpractice may be
					 present when issues concerning appropriateness of care and compliance with
					 guidelines are raised, legal advice for procedural guidelines must be obtained
					 prior to the institution of any medical audit program in order that medical
					 malpractice litigation will neither result from nor become the subject of the
					 meeting.
Confidentiality of case review in terms of local open
					 meeting laws and public access to medical records and their
					 distribution.
Format for recording the meeting and its outcome.
Access to overall system performance records, both current
					 and historical, to allow comparison.
Overall outcome data (morbidity and mortality) and
					 individual, unit-specific, and system-wide performance can be measured by the
					 following means:
The severity of presentation of patients must be known, and
					 a scale for that measurement must be agreed on, included in all EMT education,
					 and periodically checked for reliability.
Appropriate treatment on scene and in transit should be
					 recorded and subsequently evaluated for its effect on overall patient
					 outcome.
At the emergency department, the severity of cases
					 presenting (according to a severity scoring technique) and treatment needed
					 should be recorded in detail.
An emergency department diagnosis and outcome in terms of
					 admission to a general medical bed, critical care unit, or morgue must be
					 known. The length of stay in the hospital, cost of stay, discharge status, and
					 pathologic diagnosis should be made available.
Specialty Care Transport (SCT) Services
Specialty Care Transport (SCT) Services provide
					 interfacility transportation of a critically injured or ill beneficiary by a
					 ground ambulance vehicle including the provision of medically necessary
					 supplies and services, at a level of service beyond the scope of the
					 EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing
					 care that must be furnished by one or more health professionals in an
					 appropriate specialty area, for example, emergency or critical care nursing,
					 emergency medicine, respiratory care, cardiovascular care, or a paramedic with
					 additional training.
The off-line medical director for SCT agencies shall have
					 access to consult with medical specialists for patient(s) whose illness and
					 care needs are outside his/her area of practice. The medical director must have
					 education experience in those areas of medicine that are commensurate with the
					 mission statement of the medical transport service or utilize specialty
					 physicians as consultants when appropriate.
Miss. Code
					 Ann.§
											41-59-5