Minnesota Medical Director Course 2019 This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H54RH00023, The Rural Flexibility Program, total grant amount for Minnesota $754,133. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Introduction • Welcome • Description of the EMS Director and role • Granting authorities to act and accept responsibility for the delivery of EMS patient care • EMTs and EMTP required by MN law to have a Medical Director overseeing their work • Presentation designed to: • Introduce the basic framework • Obligations and responsibilities of EMS medical direction

Upon completion, you will have a greater understanding of the issues, but also an enhanced sense of confidence in your ability to provide medical oversight Objectives

• At the conclusion of this presentation you will be able to: • Overview of State and regional roles • Identify the Role and Responsibility of a Minnesota EMS Provider Medical Director. • Identify level of EMS Providers • Discuss the Scope of Authority. • Identify ways to protect yourself as a medical director. • Outline types of contractual relationships and compensation. • Locate my regional and state medical director resources Emergency Medical Service Regulatory Board (EMSRB) • Priorities: • Values: • Compliance inspections • Collaboration • Investigations • Inclusivity • Accountability • Efficiency • Grand Funds for Regional Programs • Consistency • Licensing • Fairness • Registration/Certification • Communication • Efficiency • Fairness • Competency • Consistency • Customer Service Mission: To protect the public’s health and safety through regulation and support of the EMS system Regional EMS Programs

• Purpose of the 8 EMS Regions • Systematic and cost- effective EMS delivery • Identifying and addressing local, regional and EMS system needs • Public Education and exchange • Ensuring consistent quality of training standards Roles and Purpose Overview of Medical Direction • Education and training • Credentialing EMS personnel for practice • The development and maintenance of treatment protocols • Participating in quality assurance • Serving as a liaison between EMS and other parts of the medical community • Providing leadership in system issues that impact patient care • Patient advocacy • Economic stewardship in new program development

Ultimately, the Medical Director is a patient advocate who is willing to dedicate time to your community and EMS team. Legal Requirements of an EMS Medical Director • What is required to be a Medical Director? • Minnesota licensed physician • Medical Director Statutory Requirements • Medical Control • Authorization • Written agreement • Oversight

https://www.revisor.mn.gov/?id=144E.265 Know this, appreciate this Legal Requirements of an EMS Medical Director

• Medical Director’s Are: • Educators • Evaluators • Innovators • Collaborators • Motivators Scope of Authority

• Organization Types: • BLS- • ALS- • MRU- Medical Response Unit- Organized service by a local political subdivision • (First Responders) Police, Sheriff, State Patrol, Fire • Specialized Life Support • Helicopter • Fixed Wing Plane • Level of EMS Providers in Minnesota • EMR-Emergency Medical Responder • EMT- Emergency Medical Technical • CEMT- Community EMT • EMTP- • CP- Community Paramedic Scope of Authority

• Scope of Responsibility of Medical Director • Ensuring EMT and Paramedic practical skills competency • Signed off with Medical Director’s ORGINAL signature • Providers Certification

• Scope of Authority and Responsibility • Establish SOP’s for Pre-Hospital care • Triage, treatment and transportation protocols Scope of Authority

• Communications • Medical direction is usually distinguished between online and offline roles. The offline Medical Director is considered the EMS Provider Medical Director. Online medical direction is contemporaneous direction of EMS personnel by a physician either by phone, radio or in person. Scope of Authority

• Communication Protocols • Define method and timing of communications with on-line medical control • Who , What to say, and When to call

• Alternate Plan in communication failure: • Phone • Text • Radio (Ham) Communications Another way the Medical Director communicates with their crew is via Telemedicine. This gives the ER physician or Medical Director the ability to see directly into the back of the truck, giving the everyone full accessibility to ask questions and to see the patient. Scope of Authority

• Transfer of Patients • Transferring Physician responsible for the legal process: (EMTALA) • Prescribing life support equipment • Medical treatment • Possible change in patient condition

• Medical Director is responsible : • Qualified Personnel are required to transport • EMT – RN - Paramedic • Proper Medical Equipment • Staff handoff at departure & arrival Scope of Authority

• Transport Protocols • Address patient transport situations • Air transport – Trauma – STEMI – Stroke- Sepsis • Psychiatric/Detox – Special Needs • Based On • Trauma/Stroke/STEMI/Sepsis protocols • Patient Needs • Facility location and designation • Staffing and vehicles • Patient condition and stability • Weather • Nearest appropriate facility if unstable. Scope of Authority

• Disaster Medicine/ Mass Casualty • EMS Surge Operation and Crisis Care 2016 • EMS & MDH joint strategy • Key point is put plans together in advance • Describes operations in various Scenarios • Conventional • Crisis • Contingency • The severity of the crisis, leads to greater risk potential • Plan in Advance with Local, Regional, and State resources. Scope of Authority

• Event Medicine- EMSRB Website VARIABLE POINTS • Event classification matrix – add up scores2 (0 - 2) for each of 6 1 categories: 0

Weather >90° F (heat index) 80-90° F (heat index) Climate-controlled (outdoor events) <0° F (wind chill) 0-40° F (wind chill) environment No climate controlled shelter Minimal climate controlled shelter

Peak Attendance >15,000 1,00-15,000 <1,000 Ethanol Consumption Significant Limited None Crowd Age Older Mixed Younger Crowd Intent Animated/Rowdy Intermediate Calm Transport Time to Hospital >30 minutes 20-29 minutes <20 minutes

• Higher Risk: total score >=5, or scores of 2 in two different categories. • ALS onsite medical aid station, ALS onsite ambulance and roaming teams are recommended. An onsite physician should be considered, • Intermediate event: Total score 3 or 4, or a score of 2 in any category • BLS onsite medical aid station and onsite ALS ambulance recommended. Staffing levels, number of aid stations and consideration of mobile teams should be based on event characteristics • Lower risk event: Total score <3 and no single category with a score of 2. • BLS onsite care with consideration of onsite BLS ambulance based on event characteristics. Scope of Authority • BLS Variance • Medical Director for BLS Service may request variance to allow administration of certain medications: • Sublingual nitroglycerin • Epinephrine pen injector • Beta agonist (nebs and metered dose inhalation) • Glucagon • No variance required for non prescription medicines, (aspirin, Benadryl) but Medical Director gives order.

• Naloxone: does not require a variance, but does require Medical Director approval/education/protocol

• Medical Director is responsible for annual education • This can be delegated to staff and ideally should be done collaboratively • It is a high yield time to connect with staff Scope of Authority

• BLS Specific Procedures • Medical Director may also allow personnel with appropriate education to: • Initiate/maintain IV infusion • Use Supraglottic Airway • CPAP • Other reasonable interventions Agreements, Compensation, Insurance • How can I protect myself? • Employee • Hired or appointed position within the EMS Provider • Contractor • Request for Proposal (RFP) or invitation to bid where they will contract out for medical director services • Legally binding agreement • Memorandum of Understanding (MOU) • Define the clarity of the relationship between two parties • Establish the expectations of how the parties will pursue a positive cooperative effort • List of terms Agreements, Compensation, Insurance • How can I protect myself? • Insurance Coverage (Liability Coverage) • Must have a clear understanding of who, what and when their activities are covered by agency’s policies • Medical Malpractice • Act of commission or omission by a health-care provider when their care deviates from accepted practice standards • Professional liability policy must include medical malpractice coverage Agreements, Compensation, Insurance • How can I protect myself? • Errors and Omission Coverage • Defense costs and damage awards that may be associated with professional liability claims • Cover risk associated with any non-patient care activities • General liability • Commercial general liability policy – utilizing equipment • Indemnification • EMS agency will agree to assume the financial responsibility associated with defending the claim or lawsuit • Responsible for monetary awards if any individual prevails in a lawsuit related to performance of duties by the medical director Agreements, Compensation, Insurance Medical directors should seek independent consultation with an attorney or other medical directors familiar with liability issues for additional guidance related to requirements for adequate coverage. Agreements, Compensation, Insurance • Compensation and Benefits • EMS Provider has an obligation to support the medical director • Resources vary depending on locale • Continuing Education • Maintain specific certifications • Clearly stated in the job description, contract, MOU or MOA. • IRS Requirements • Individually responsible for all Federal and State taxes Agreements, Compensation, Insurance • Dissolution • Termination of the service agreement • Timing of the intent to terminate • Return of property, compensation is adjusted or reconciled and liability protection is addressed Workforce Oversight and Supervision • Communication • Relationship with EMS Provider • Board of Director • Service Director • EMT’s and • How to build relationships Time Requirements and Activities • Time Requirements -At LEAST one monthly activity • Daily (Crew Chief to review) • Call monitoring • Online medical direction • Weekly (Crew Chief to review) • Chart review and other QA activities • Monthly (Medical Director) • Education and training • Run reviews • Annual (Mandated by the State- Medical Director or his/her designee) • Skills review • As needed • Hospital/medical staff coordination • Remediation/complaints Conflicts of Interest

• Potential conflicts of interest: • Conflict between two separate EMS agencies whom both employ the same medical director • Financial conflicts • Personal relationships • EMS agency and hospital • Nepotism situations or concerns Areas of Caution

• Working with EMS • Withdrawing EMS Provider supervision • Maintaining • Operational Issues professionalism Summary

• What’s next? • Should not feel isolated and without support of peers and other dedicated resources • Networking opportunities and education opportunities • Take advantage of regional contacts • Always contact the Emergency Medical Services Regulatory Board (EMSRB) or the Minnesota Ambulance Association (MAA) for additional resources