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EMS Medical Oversight in Alberta A New Model Hal B. Canham MD, CCFP (EM), FCFP Provincial EMS Medical Director Alberta Health and Wellness November 2008 Objective To inform and update attendees on the future model of medical oversight of EMS in Alberta. Brooks, Alberta The ‘true’ Gas City History of Medical Direction 1950s and 60s Cities Centrally coordinated-Hospital/fire hall based Rural Funeral home hearses or local fire dep‟t Early Ambulance Services Pre- 1966 Little legislation and regulation. Providers had little formal training. Physician involvement minimal at best. 1966 NAS-NRC Report “Accidental Death and Disability: The Neglected Disease of Modern Society” Prehospital and ED care: “woefully inadequate” Medical interest in emergency and ambulance services non-existent. 1966 NAS-NRC Report “No longer can responsibility be assigned to the least experienced member of the medical staff, or solely to specialists, who, by the nature of their training and experience, cannot render adequate care without the support of other staff members.’ History of Medical Direction 1967: Belfast, Ireland. 1st Physician responder mobile program. 1969: OOH Cardiac arrests Ohio Seattle Dade County, Florida History of Medical Direction 1969-1973: ACS AHA AAOS ASA Valuable but uncoordinated input into EMS. Most initiatives were still at the local level. History of Medical Direction 1973: The Emergency Medical Services System Act Federal encouragement, guidelines and funding. Goal of encouraging the development of comprehensive regional EMS systems. The Emergency Medical Services System Act Fifteen essential EMS components: 1. Manpower 2. Training 3. Communication 4. Transportation Medical oversight not 5. Facilities recognized! 6. Critical care units 7. Public safety agencies 8. Consumer participation 9. Access to care 10. Patient transfer 11. Coordinated patient record keeping 12. Public information and education 13. Review and evaluation 14. Disaster plan 15. Mutual aid History of Medical Direction 1973-1978 EMS “Growth, Scrutiny and Belief” Some states required physician involvement Others did not even reference medical oversight. History of Medical Direction 1970‟s: Evolution of Emergency Medicine. Extension of Emergency Medicine to field. 1979 Emergency Medicine formally recognized as a specialty. 1985 NAEMSP established. History of Medical Direction Alberta’s perspective 1972: Alberta Medical Association “Medical Aspects of Transport Accidents”, which recommended: Ambulance Act Training standards Improved ambulance care Proper funding Ambulance services be a part of health care system. History of Medical Direction Alberta’s perspective 1973: 1st paramedic service established in Calgary 1974: Alberta Hospitals Association recommended ambulance services be upgraded on a high priority. 1976: High River, Medicine Hat, Grande Prairie and Brooks all had paramedics. History of Medical Direction Alberta’s perspective 1976: “Recommendations for Development of the Provincial Ambulance Service for Alberta” AMA Special Committee Dr. W. Donald, Dr. E. King, Dr. W. Mackenzie, Mr. W. Tudge Province wide 24 hour ground ambulance system with air evacuation support. …planned organized and coordinated at a provincial level. Minimum standards for ambulances Training programs Enactment of legislation for vehicles Province wide telecommunications Provincial emergency ambulance number No medical oversight History of Medical Direction Alberta’s perspective 1980 Provincial government set up team to develop “province wide ambulance program” Formed Ambulance Service Advisory Committee “Draft-Ground Ambulance Study – Ambulance Program and Standards” Eight areas examined. History of Medical Direction Alberta’s perspective Placement of ambulance services Ambulance service regulation Public education programs Rescue and ambulance standards Hours of work Ambulance entrances to hospitals Ambulance personnel training and licensing Insurance No medical oversight. History of Medical Direction Alberta’s perspective 1982 Bill 205 “Ambulance Service Act” was introduced Mr. Russell, Minister of Health: “no improvements in ambulance service” 1983 Public Ambulance Act introduced in legislature. No second reading. 1984 Health Disciplines Act ALS and BLS defined. References prospective and retrospective medical control. 1985 amended to include EMT-A and EMT-P History of Medical Direction Alberta’s perspective 1985 AAOA encouraged the government to reconsider the ambulance industry. Mr. Russell (MOH): “ambulances were municipal responsibility” gov‟t would not impose standards nor provide funding. 1986 Alberta Association Emergency Medical Services Physicians (AAEMSP) formed Medical directors and advisors Physician educators Interested 3rd party physicians History of Medical Direction Alberta’s perspective 1987 “New Dimensions in Emergency Health Services: an Alberta Solution” Stan Schumacher: Ministers Policy Advisory Committee on Hospitals and Medical Care 41 recommendations covering legislation, jurisdiction, standards, personnel and training, communications, revenues and costs, interhospital and interprovincial transfers and air ambulance. Recommendation 1: That an Emergency Health Services Act be established, covering all aspects of ambulance services. Recommendation 14: That a provincial system of emergency medical protocols be established and maintained with the assistance of medical advisors. Medical Direction and Control of Emergency Medical Services AAEMSP 1992 Organization of Medical Direction of EMS in Alberta: Local Medical Directors (exist already): about 130 physicians in two tertiary care urban settings, five secondary care urban settings and 100 rural communities. Regional Medical Directors (proposed by AAEMSP) in each of the regions identified by the PACTS initiative. Provincial Medical Director (proposed by AAEMSP). A prehospital physician financed by Alberta Health. The EMS Patient Care Tripod Consensus 1992 APPA, AAOA, AAEMSP OPERATOR AAOA EMT PHYSICIAN APPA AAEMSP “Best hope for Alberta‟s prehospital emergency patient” AAOA APPA AAEMSP Consensus Statement regarding proposed Ambulance Legislation May, 1992 Poor consultation process. Copies of final draft not available for review. Medical direction overlooked Moved away from Schumacher report AAOA APPA AAEMSP Consensus Statement regarding proposed Ambulance Legislation May, 1992 Consensus Opinion: BLS minimum standard. Medical direction and control must be addressed. AAOA, APPA and AAEMSP be consulted on final draft prior to proclamation. Provincial Medical Director sought and appointed. Medical director /advisor must have “interest, experience and expertise” in EMS and EM. AAOA APPA AAEMSP Consensus Statement regarding proposed Ambulance Legislation May, 1992 “This proposed legislation will hopefully require ambulance services to engage physicians to act as medical directors and hospital boards to engage physicians as medical advisors.” Ambulance Services Act Following two further years of consultation the ASA was proclaimed on March 1, 1994. Medical oversight not directly addressed. Toward a Model of Governance and Funding of Ground Ambulance Services in Alberta Ground Ambulance Services Task Force Judy Gordon 1996 Recommendations: “..the Provincial Government recognize ambulance services as a core health service Baseline funding should be provided by the Provincial Government to support Basic Life Support Toward a Model of Governance and Funding of Ground Ambulance Services in Alberta Ground Ambulance Services Task Force Judy Gordon 1996 Recommendations: “The 110 ambulance agencies/companies in the province have numerous arrangements for provision of medical direction to their attendants. The level of involvement of medical directors varies considerably, as does their influence on the provision of prehospital and interfacility care” Recommendation: “…each Regional Ambulance Service Committee should appoint a Regional Medical Director. Patient Focused Emergency Medical Services MLA Review:" The Cenaiko Report” 2001 Recommendations: Ambulance Service is Health Care Medical Direction “We recommend establishing clear professional roles (with remuneration recommendations) for a Provincial Medical Director and regional medical directors, standardizing regional medical protocols, …” 2004 EMS Governance and Funding Transition Part 1 EMS Transition to Health Two decades of ambulance reviews (Schumacher, Gordon, Cenaiko) all recommending EMS is „health‟. 2004 EMS Governance and Funding transition (Part 1): decision made to bring EMS governance and funding under auspices of Health. 2005: „Politics‟ intervened and transition halted other than Palliser and Peace. Current Medical Oversight of EMS in Alberta 2004 Provincial Medical Advisor to EHS was contracted. Two Regional Medical Directors in discovery projects (Palliser and Peace) Status quo elsewhere. Current Medical Oversight of EMS in Alberta Presently 60+ medical directors in province providing oversight to ambulance services (municipally funded, private, health-based). Huge discrepancies in levels of engagement by these physicians. Many smaller services have “rubber stamp” medical directors. Current Medical Oversight of EMS in Alberta 2005-08 Some regional initiatives maintained Protocol projects initiated. No coordination. Minimal communication. Legislative initiatives. PEMDAC 2007-08 Provincial EMS Medical Directors Advisory Committee (PEMDAC) Dr. Hal B. Canham (AH&W- Chair) Dr. Andrew Anton (Medical Director – Calgary EMS and Fire Rescue Services) Dr. Michael Betzner (Medical Director – STARS – Calgary) Dr. Cledwyn Lewis (Medical Director – Peace Country Health Region) Dr. Kevin Martin (Medical Director – Lethbridge Fire Department) Dr. Gordon Neil (Medical Director – David Thompson Health Region) Dr. Christopher Nichol (Medical Director – Camrose EMS) Dr. Peter Palma (Medical Director – Fort McMurray Fire Department) Dr. Robert Bernier (Medical Director, Associated Ambulance) Dr. Sunil Sookram (Medical Director – Edmonton EMS and Fire Rescue Services) Dr. Terry Sosnowski (Department of Emergency Medicine – University of Alberta) Dr. Richard Birkill (Medical Director – Alberta Central Air Ambulance – Lac La Biche) Provincial EMS Medical Directors Advisory Committee (PEMDAC) Mandate: To provide recommendations on a provincial framework for medical direction of EMS in Alberta. Provincial EMS Medical Directors Advisory Committee (PEMDAC) Recommendations: Institute a governance structure for medical oversight of EMS. Establish an Alberta EMS Medical Advisory Committee. Establish qualifications for physicians providing medical oversight of EMS. Establish roles and responsibilities for physicians providing medical oversight of EMS systems and have this form a basis for job descriptions in this area. Establish appropriate remuneration guidelines for medical directors. Provincial EMS Medical Directors Advisory Committee (PEMDAC) All recommendations with exception of remuneration guidelines were accepted by the Minister and form the basis of where we are at today and where we will be going tomorrow. 2008 EMS Governance and Funding Transition Part 2… but this is not the only ‘transition’… EMS in Alberta 2008… A time of tremendous change! ACP: HDA to HPA AHW: ASA to EHSA EMS: G & F Transition 9 RHAs to one Alberta Health Services Board EMS Medical Direction in Alberta Health Disciplines Act, EMT regulations In Alberta all EMS practitioners are required to have a medical director. “Physician extenders”. Practicing under MDs medical license. Health Disciplines Act, EMT regulations An Emergency Medical Technologist- Paramedic who has received Registration Committee approval under subsection (4) may, under medical control and with an ongoing medical audit, provide the following health services: Health Disciplines Act, EMT regulations “medical audit” means an assessment by the medical director of the health services provided by a registered member and the protocols under which a medical member operates; “medical control” means orders within the registered members scope of practice that define patient management and are issued by the medical director or a person designated by the medical director But….. Health Discipline Act will soon be replaced by the Health Professions Act (HPA) Health Professions Act A college: (a) must carry out its activities and govern its regulated members in a manner that protects and serves the public interest, (b) must provide direction to and regulate the practice of the regulated profession by its regulated members, (c) must establish, maintain and enforce standards for registration and of continuing competence and standards of practice of the regulated profession, (d) must establish, maintain and enforce a code of ethics, (e) carry on the activities of the college and perform other duties and functions by the exercise of the powers conferred by this Act, and (f) may approve programs of study and education courses for the purposes of registration requirements Health Professions Act EMS practitioners will now be recognized as truly independent health professionals. No longer “practicing under a physicians medical license”. Medical Oversight within the Health Professions Act “14 (2) Subject to subsection (7), a regulated member registered on any register may, in the practice of paramedic, perform the following restricted activities under medical oversight and in accordance with the standards of practice:” Health Professions Act 14 (1) (a) “medical audit” means an assessment by a medical director of the restricted activities that a regulated member provides; (b) “medical oversight” means protocols governing the provision of restricted activities by regulated members approved by a medical director and includes guidelines, oral or written orders and medical audit. (c) “medical director” means a member in good standing of the College of Physicians and Surgeons of Alberta who is engaged to provide medical oversight to regulated members; Health Professions Act In short: The EMS medical director will provide medical oversight to the system rather than the individual practitioner. Ambulance Services Act (ASA) Current regulations accompanying the Ambulance Services Act provide considerable technical detail as to operators‟ duties as licensed ambulance services providers. Defining standards for vehicles, personnel, equipment, etc for licensed ambulances in the province. Minimal clinical standards. No direct reference to medical direction. Medical direction is indirectly addressed in the requirements for qualified practitioners. AAOA APPA AAEMSP Consensus Statement regarding proposed Ambulance Legislation May, 1992 “This proposed legislation will hopefully require ambulance services to engage physicians to act as medical directors ...” Emergency Health Services Act (EHSA) Proposed regulations to accompany the Emergency Health Services Act include: Air Ambulance Regulation Ground Ambulance Regulation Dispatch Regulation Medical Direction Regulation First Response Regulation Information and Reporting Requirements Regulation Rates Regulation EHSA Medical Direction Reg The Minister may appoint a Provincial Medical Director to provide oversight of and ensure consistent emergency health service policies, practices and standards. Medical accountability structure to be established which will include standards for medical directors. Emergency Health Services Act (EHSA) Medical Direction Standard Minimal requirements for medical directors. Responsibilities of a medical director. Provincial Other EMS medical directors EMS Transition to Health 3 key deliverables by April 1, 2009: Seamless transition of governance and funding Consolidation of EMS Dispatch Province-wide Medical Oversight Framework EMS Transition to Health System vs. Operational Governance System Governance („what‟) Includes legislative and regulatory approaches. “the provincial government’s responsibility to provide all Albertans with access to quality ground and air ambulance services.” Operational Governance („how‟) Accountable to the Minister of Health, includes how business, clinical and technical policies, processes and tools are directed and managed in meeting the provincial public policy objectives. “refers to the health system’s responsibility for the provision of ground EMS in their jurisdictions.” EMS Transition to Health Provincial Medical Oversight Structure: Provincial EMS Medical Director 9 (or less) Area Offices of Medical Oversight with Area/Regional Medical Directors. Associate Medical Directors as required. EMS Transition to Health Goal: Improved standards for medical oversight. Province-wide consistency. Replace „rubber stamp‟ medical directors. Resolve rural vs. urban inconsistencies. Provincial Office of EMS Medical Oversight (POEMO) Goals: Provincially standardized clinical protocols; Consistent and standardized clinical quality management; Stronger alignment and integration between clinical practice and operational practices; Continuous improvement through provincially coordinated research in the area of emergency medical services; Leadership and support to the province‟s EMS Medical Directors; and Support to a committee of qualified physicians providing provincial advisory service in emergency medical services. Provincial Office of EMS Medical Oversight (POEMO) The key responsibility of the POEMO is consistent high quality EMS medical oversight throughout the province. In a shared-leadership role with the provincial operations lead, ensures that clinical EMS standards are proven (evidence based), implemented, and monitored consistently. Quality Management / Area Office of Medical Oversight Clinical protocols and audit Standards and measures QM monitoring and reporting Education and development Continuum innovations Continuum relationships Research Alberta EMS Medical Advisory Committee (AEMAC) Purpose: To provide advice on all medical issues in the delivery of EMS care in Alberta. Alberta EMS Medical Advisory Committee (AEMAC) Membership Provincial EMS Medical Director (Chair) Representatives of each of the Regional Medical Director‟s Offices Air Ambulance Medical Director Alberta Health Services EMS Senior Leader Two appointed EMS administrative leads Alberta EMS Medical Advisory Committee (AEMAC) Roles and Responsibility of Committee: To advocate for quality EMS care within Alberta (“advocacy” meaning that patient care concerns should be the primary focus in defining EMS overall, particularly as a coordinated, province- wide system) To advise the Minister of Health, Executive Director Emergency Health Services and Alberta Health Services on EMS issues. To establish provincial consensus on EMS clinical standards, protocols and policy. To promote assurance of consistent delivery of EMS clinical care on a province-wide basis To establish and review medical protocols, procedures and medical policy from a provincial perspective. Alberta EMS Medical Advisory Committee (AEMAC) Roles and Responsibility of Committee: To promote and advocate for EMS innovations and the full integration of EMS in the health continuum. To promote and advocate for evidence based standard of care. To review and provide advice on new clinical procedures/ directives/treatments and equipment being contemplated / implemented by EMS throughout the province. To advise the Alberta College of Paramedics as pertains to the delivery of clinical care by EMS practitioners. To act in an advisory capacity to the AHS on the structure of EMS medical oversight. EMS Medical Direction The Future : Present MD qualifications Licensed to practice medicine in the province of Alberta by the College of Physicians and Surgeons. EMS Medical Direction New Essential qualifications: License to practice medicine by the College of Physicians and Surgeons of Alberta Participation in a National Association of EMS Physicians (NAEMSP) or equivalent EMS Medical Directors Course Active participation in the management of the acutely ill or injured patient in an Emergency Department setting in Alberta. EMS Medical Direction New Preferred Qualifications: Familiarity with the design and operation of EMS. Knowledge of the prehospital emergency care of the acutely ill or injured patient. Experience or training in medical direction of prehospital emergency units. Experience or training in the instruction of prehospital personnel. Experience or training in the EMS quality improvement process. EMS Medical Direction New Preferred Qualifications: Knowledge of EMS laws and regulations. Knowledge of EMS dispatch and communications. Knowledge of local mass casualty and disaster plans. CCFP (EM), FRCP in Emergency Medicine or American Board of Emergency Medicine (ABEM) certification. Fellowship in EMS Membership in CAEP and NAEMSP EMS Medical Direction The Medical Director is the official authority over patient care. Must have a well defined position with respect to other components of EMS. Shared-leadership in EMS Shared Leadership Necessity “The community of EMS: - Involves a team approach with the medical director as team leader, working with operational leaders (cooperative leadership)” National Highway Traffic Safety Administration (NHTSA, 2001), Medical Direction Curriculum “Successful systems [EMS] balance the two powers of administration and medical control.” Zalar, C,.M. (1995), Overcoming Adversarial Administrative and Medical Relationships “Rubber Stamp” Medical Directors “The role played by many medical directors is that of a figurehead who simply meets the regulatory agency‟s requirement and subsequently exists in signature only.” (Fitch, 1993, p. 245) In absence of physician direction, the EMS Manager (administrator) sets the system‟s clinical path for care. May not have the necessary focus on clinical outcomes Figure 2. Sliding Scale Model of Shared Leadership in EMS High Quality Patient Care AKA: “GOOD” Care Shared Leadership Admin. Clinical Leader Leader Figure 3. Sliding Scale: Greater Clinical Influence High Quality Patient Care AKA: “GOOD” Care Shared Leadership Admin. Issues largely Clinical affecting Leader clinical outcomes Leader Scale slides right. Both roles share with emphasis on clinical leadership Figure 4. Sliding Scale: Greater Administrative Influence High Quality Patient Care AKA: “GOOD” Care Shared Leadership Admin. Issues largely Clinical affecting Leader admin./operations Leader Scale slides left. Both roles share with emphasis on administrative leadership EMS Medical Direction Past Lack of standards, direction and consistency for medical oversight of EMS. Resulted in a collage of medical oversight and inconsistencies across the province. Many areas of excellence in EMS medical oversight but equally as many areas of “rubber stamp” MDs. EMS Medical Direction Present Provincial Medical Director in place. POEMO being defined and resourced. Provincial protocol project initiated. AHS has produced job descriptions and contracts for Regional/Area Medical Directors. Hiring's are imminent. Status quo for most services. EMS Medical Direction Future QM/AOMO will define requirements to staff their offices in consultation with AHS centrally. Once staffed these office‟s will work with the POEMO to define QM processes, standards and measures, education and development, research initiatives, etc. Early involvement of AEMAC. EMS Medical Direction Future „Failsafe‟ Medical Oversight: Contracts from AHS for medical directors will clearly stipulate standards and requirements. EHSA will define standards for medical oversight. HPA will mandate medical oversight of practitioners. Summary A time of transition in EMS HDA HPA ASA EHSA RHA AHS Local EMS (Municipalities) Provincial EMS (Health) A time of opportunity in EMS Truly integrated in health. Thank You… Questions ??
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