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EMS Medical Direction

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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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