1. TEXAS MEDICAL COMMAND/DIRECTIONS What does this mean to you?

2. WHO ARE THESE MEDICAL DIRECTORS?

3. Medical Director

4. PURPOSE OF THIS CHAPTER  Educate Medical Command Physicians on the Texas EMS system  Educate Medical Command Physicians on Texas EMS Laws and Rules  Educate on the required role for Texas Medical Command Physicians/Authority

5. WHICH TEXAS LAW OR RULE DOES NOT INVOLVE MEDICAL DIRECTOR? A. Texas Administrative Code Chapter 157 B. Texas Administrative Code Chapter 197 C. Texas Health and Safety Code Chapter 773 D. Texas Administrative Code Chapter 123

6. SO WHAT DO I NEED TO KNOW AS A TEXAS EMS MEDICAL DIRECTOR? Chapter 197 Chapter 157 Chapter 773

7. TEST YOUR CURRENT KNOWLEDGE OF THE TEXAS EMS SYSTEM AND REQUIREMENTS?

8. WHICH TEXAS LAW OR RULE DOES NOT INVOLVE MEDICAL DIRECTOR? A. Texas Administrative Code Chapter 157 B. Texas Administrative Code Chapter 197 C. Texas Health and Safety Code Chapter 773 D. Texas Administrative Code Chapter 123

9. HOW MANY EMS PROVIDERS CAN A MEDICAL DIRECTOR PROVIDE OVERSIGHT FOR WITHOUT GETTING A WAVIER? A. 4 B. 8 C. 20 D. 50

10. UP TO HOW MANY EMS PROVIDERS CAN A MEDICAL DIRECTOR PROVIDE OVERSIGHT FOR WITHOUT GETTING A WAVIER? A. 4 B. 8 C. 20 D. 50

11. PHYSICIANS WHO FAIL TO SUPERVISE EMS PERSONNEL MAY BE SUBJECT TO DISCIPLINARY ACTION PURSUANT TO THE MEDICAL PRACTICE ACT A. TRUE B. FALSE

12. PHYSICIANS WHO FAIL TO SUPERVISE EMS PERSONNEL MAY BE SUBJECT TO DISCIPLINARY ACTION PURSUANT TO THE MEDICAL PRACTICE ACT A. TRUE B. FALSE

13. CAN A MEDICAL DIRECTOR BE EMPLOYED BY AN EMS PROVIDER THAT HAS BEEN EXCLUDED BY MEDICARE, MEDICAID OR CHIP? A.YES B.NO

14. CAN A MEDICAL DIRECTOR BE EMPLOYED BY AN EMS PROVIDER THAT HAS BEEN EXCLUDED BY MEDICARE, MEDICAID OR CHIP? A.YES B.NO

15. HEALTH AND SAFETY CODE Title 9 Safety Subtitle B. Emergencies Chapter 773 Emergency Medical Services Subchapter A Texas Administrative Code Title 25 Health Services Part 1 Department of State Health Services Chapter 157 Emergency Medical Care

16. AND Texas Administrative Code Title 22 Examining Boards Part 9 Texas Medical Board Chapter 197 Emergency Medical service Rule § 197.1,3,5 and 6 Medical Director

17. Texas Administrative Code Title 22: Examining Boards Part 9: Texas Medical Board Chapter 197: Emergency Medical Service Rule § 197.3 Off-Line Medical Director

18. 197.1 PURPOSE  Purpose is to  Facilitate the most appropriate utilization of the skills of physicians who delegate health care tasks to qualified EMS personnel  Take into account the skill, training, and experience of both physicians and EMS personnel  Addresses the relationship between EMS personnel and On-line and Off-line Medical Direction

19. 197.1 DOES NOT………  This does not restrict a physician from delegating tasks not involving the exercise of independent medical judgment to trained individuals by a licensed physician who accepts responsibility  Nothing prohibits a physician from instructing a technician or other employee to perform delegated tasks if the physician retains supervision  Does not relieve the supervising physician of the responsibility for the care and treatment of his or her patients

20.  Physicians who fail to supervise EMS personnel may be subject to disciplinary action pursuant to the Medical Practice Act

21. 197.1 PURPOSE  A medical director shall not be held responsible for noncompliance with this chapter if the EMS administration fails to provide the necessary administrative support to permit compliance with the provisions of this chapter

22. 197.2 DEFINITIONS  Delegated practice is permission given by a physician licensed by the board, either in person or by treatment protocols, to a specific prehospital provider to provide medical care **Medical Director should clarify when EMS personnel can practice under their delegation – on duty and off duty.  Medical director is responsible for all aspects of the operation of an EMS system concerning provision of medical care

23. I HAVE A RESPONSE BAG IN MY CAR.… I AM OBLIGATED TO STOP AND HELP IN EMERGENCIES.

24. WHO CAN BE A MEDICAL DIRECTOR?

25. OFF-LINE? OR ON-LINE?

26. CHAPTER 197 RULE§ 197.3  Medical director shall be:  Licensed to practice in Texas  Familiar with EMS operations  Experienced in pre-hospital emergency care and management of ill and injured patients  Actively involved in:  Training and continuing education of EMS personnel under direct supervision  Medical audits of EMS Personnel  Administrative and legislative environments affecting EMS organizations

27. CHAPTER 197, RULE§ 197.3  Knowledgeable of local multi-casualty plans  Familiar with EMS dispatch and communications  Knowledgeable about EMS Laws and Regulations

28. MY MEDICAL DIRECTOR IS A NEPHROLOGIST!

29. MY MEDICAL DIRECTOR SIGNS MY PROTOCOLS!

30. OFF-LINE MEDICAL DIRECTOR SHALL  Approve level of care being rendered by EMS personnel before permitted to provide such care to the public  Establish and monitor compliance of EMS personnel performance  Establish and monitor compliance with training guidelines which meet or exceed the minimum standards set forth in the Texas Department of State Health Services EMS certification regulations

31. I AM A TEXAS CERTIFIED PARAMEDIC AND YOU CAN’T KEEP ME FROM PROVIDING CARE.

32. OFF-LINE MEDICAL DIRECTOR SHALL  Develop, implement, and revise protocols and/or standing delegation orders, if appropriate, governing prehospital care and medical aspects of patient triage, transport, transfer, dispatch, extrication, rescue, and radio-telephone-telemetry communication by the EMS  Direct an effective system audit and quality assurance program

33. OFF-LINE MEDICAL DIRECTOR SHALL  Determine standards and objectives for all medically related aspects of operation of the EMS including the inspection, evaluation, and approval of the system's performance specifications

34. OFF-LINE MEDICAL DIRECTOR SHALL  Function as the primary liaison between the EMS administration and the local medical community  Develop a letter or agreement or contract between the medical director(s) and the EMS administration outlining the specific responsibilities and authority of each  Take or recommend appropriate remedial or corrective measures for EMS personnel, in conjunction with local EMS administration

35. DEVELOP A LETTER OR AGREEMENT OR CONTRACT BETWEEN THE MEDICAL DIRECTOR(S) AND THE EMS ADMINISTRATION OUTLINING THE SPECIFIC RESPONSIBILITIES AND AUTHORITY OF EACH

36. SUSPENSION FROM CARE  Suspend a certified EMS individual from medical care duties for due cause pending review and evaluation

37. I AM A TEXAS CERTIFIED PARAMEDIC AND YOU CAN’T KEEP ME FROM PROVIDING CARE.

38. PATIENT TRANSPORT  Establish the circumstances under which a patient might not be transported  Establish criteria for selection of a patient's destination  Establish the circumstances under which a patient may be transported against his or her will in accordance with state law, including approval of appropriate procedures, forms, and a review process

39. COMPLAINTS  Develop and implement a comprehensive mechanism for management of patient care incidents, including patient complaints, allegations of substandard care, and deviations from established protocols and patient care standards

40. YOU CAN’T DO THAT…….  Only approve care or activity that was provided at the time the medical director was employed, contracted or volunteering as a medical director

41. IDENTIFY YOURSELF  Notify the board at time of licensure registration under §166.1 of this title (relating to Physician Registration) of the physician's position as medical director and the names of all EMS providers for whom that physician holds the position of off-line medical director

42. NEW REQUIREMENTS  Complete the following educational requirements;  Within (2) two years before or after initial notification to the board of medical directors position,  12 hours of formal CME as defined in 166.2 in the area of EMS medical director  Board certification in Emergency Medical Services by the American Board of Medical Specialties or a Certificate of Added Qualification in EMS by the American Osteopathic Association Bureau of Osteopathic Specialists; or  a DSHS approved EMS medical director course

43. AND  Every two years after meeting the requirements of subparagraph (A) of this paragraph, one hour of formal CME in the area of EMS medical direction.

44. OFF-LINE NO-NOS  A physician may not hold the position of off-line medical director  For more than 20 EMS providers unless obtain waiver  For any EMS provider if excluded from Medicare, Medicaid or CHIP programs.

45. BUT WAIT……  The board may grant a waiver to allow a physician to serve as an off-line medical director for more than 20 EMS providers, if the physician provides evidence that  The Department of State Health Services has reviewed the waiver request and has determined that the waiver in the best interest of the public;  The physician is in compliance with this chapter, by submitting documentation of protocols and standing orders upon request; and  Appropriate safeguards exist for patient care and adequate supervision of all EMS personnel under the physician's supervision

46. TEST YOU KNOWLEDGE ON THIS CHAPTER? Medical Director should clarify when EMS personnel can practice under their delegation only when on duty? YES or NO

47. TEST YOU KNOWLEDGE ON THIS CHAPTER? NO Medical Director should clarify when EMS personnel can practice under their delegation – on duty and off duty.

48. WHICH STATEMENT IS NOT TRUE? Medical Director needs to be knowledgeable with which the following? 1) Knowledgeable of local multi-casualty plans 2) Familiar with EMS dispatch and communications 3) Knowledgeable about EMS Laws and Regulations 4) Establish and monitor compliance of EMS personnel performance

49. ALL THE ABOVE

50. 197.4 ON-LINE MEDICAL DIRECTOR  The medical director shall assign the prehospital provider to a specific on-line communication  Protocols shall define when on-line medical direction is required  A physician providing or delegating on-line medical direction shall be appropriately trained on the protocols

51. MY MEDICS CALL THE RECEIVING HOSPITAL FOR ORDERS….

52. 197.4 ON-LINE MEDICAL DIRECTOR  A physician providing or delegating on-line medical direction shall have personal expertise in the emergency care of ill and injured patients  A physician providing on-line medical direction assumes responsibility for the appropriateness of care provided

53. DOES THAT PHYSICIAN KNOW YOUR PROTOCOLS? DOES HIS INSURANCE COVER DELEGATED PRACTICE?

54. WHAT ABOUT INTERFACILITY TRANSPORTS?

55. 197.5 AUTHORITY FOR CONTROL OF MEDICAL SERVICES AT THE SCENE OF A MEDICAL EMERGENCY  Control at the scene shall be the responsibility of the individual in attendance who is most appropriately trained and knowledgeable in providing pre-hospital emergency stabilization and transport  The pre-hospital provider on the scene is responsible for the management of the patient and acts as the agent of the physician providing medical direction

56. WHICH PHYSICIAN IS THAT?

57.  If the patient's personal physician is present and assumes responsibility for the patient's care, the pre- hospital provider should defer to the orders of said physician  The physician providing on-line medical direction shall be notified of the participation of the patient's personal physician  If a physician is on scene and has expressed their willingness to assume responsibility for the patient, the medical director should be contacted  Once the medical director is contacted, the medical director is responsible for the patient unless they allow the intervener physician to assume responsibility

58. PERSONAL PHYSICIAN ON-SCENE  If personal physicians orders conflict with protocols, the two physicians need to talk  If the two physicians cannot agree, the personal physician must either  Continue to provide direct patient care and accompany the patient to the hospital  Defer all remaining care to the on-line medical director

59. TWO DOCTORS AGREEING?  If the physician on scene is authorized to assume responsibility, all orders to the pre-hospital provider shall also be repeated to medical control for recordkeeping purposes  The on scene physician must document his or her intervention in a manner acceptable to the local EMS  The decision of the on scene physician not to accompany the patient to the hospital shall be made with the approval of the on-line physician

60. Nothing in this section implies that the pre- hospital provider can be required to deviate from standard protocols

61. 197.6 AUTHORITY FOR CONDUCT RESEARCH AND/OR EDUCATIONAL STUDIES  The medical director has the authority to design research projects and educational studies  Such studies should be approved by:  EMS administrative officials; and  Independent review panel if the project/study may have a differential impact on patient care.  The results of the study should be made available through publications to the EMS community

62. TEST YOU KNOWLEDGE?  If the patient's personal physician is present and assumes responsibility for the patient's care, the pre- hospital provider should defer to the orders of said physician? YES or NO

63. TEST YOU KNOWLEDGE?  If the patient's personal physician is present and assumes responsibility for the patient's care, the pre- hospital provider should defer to the orders of said physician? YES or NO

64. Every two years after meeting the requirements for initial medical command/ authority there is a required _______ hour(s) of formal CME in the area of EMS medical direction? 1……2……3…….4……5.

65. Every two years after meeting the requirements for initial medical command/ authority there is a required _______ hour(s) of formal CME in the area of EMS medical direction? 1……2……3…….4……5.

66. CHAPTER 773 HIGHLIGHTS  Medical supervision means direction given to EMS personnel by a licensed physician under subtitle B, Occupation Code, and the rules adopted under that subtitle by Texas State Board of Medical Examiners. EMS LAW

67. DO YOU NEED A MEDICAL DIRECTOR  Sec 773.007 Supervision of emergency pre- hospital care  The provision of advance life support MUST be under medical supervision and a licensed physician’s control  The provision of basic life support MAY be under medical supervision and a licensed physician’s control

68. SECTION 773.0571  An EMS Provider must employ a medical director

69. SEC 773.016 DUTIES OF EMS PERSONNEL  If a person's personal physician is not present or does not assume responsibility for the care of the person while the person is receiving emergency pre-hospital care, the emergency medical services system's medical director or online physician  Shall be responsible for directing the emergency medical services personnel who are providing emergency pre-hospital care to the person; and  May order the termination of cardiopulmonary resuscitation only if, based on the medical director's or online physician's professional medical judgment, the medical director or online physician determines that resuscitation should be discontinued.

70. MEDICAL INFORMATION  An emergency medical services operator who holds a certificate under Section 773.144 is not liable for damages that arise from the provision of medical information according to the protocol adopted under Section 773.145 if the information is provided in good faith. This subsection does not apply to an act or omission of the operator that constitutes gross negligence, recklessness, or intentional misconduct. This subsection does not affect any liability imposed on a public agency for the conduct of the emergency medical services operator under Section 101.062, Civil Practice and Remedies Code.  Section 101.062, Civil Practice and Remedies Code, governs the liability of a public agency the employees or volunteers of which provide medical information under this subchapter.

71. ONLY LEGISLATION CAN ADD TO OR CHANGE CHAPTER 773  Chapter 773 is the law and cannot be waived by DSHS.  When making changes to Rules you have to be able to refer to the stature with Chapter 773 before adoption by DSHS.  If DSHS does not have authority in Chapter 773 then DSHS cannot gain authority by writing it in rule.  Once you open up Chapter 773 to add or change language you always run the risk of other changes to the current law being attached

72. TEXAS ADMINISTRATIVE CODE Title 25: Health Services Part 1: Department of State Health Services Chapter 157: Emergency Medical Care

73. MAIN CHAPTER 157 EMS RULES THAT MEDICAL DIRECTOR NEEDS TO KNOW  157.01 Purpose  157.02 Definitions  157.03 EMS Provider Licenses and application for EMS Personnel  157.11 Requirements for EMS Providers  157.12 Rotor-wing Operations  157.13 Fixed-wing Operations  157.16 Emergency Suspension, probation, revocation, denial of a Provider License  157.25 Out of Hospital (DNR)  157.32 EMS Education Program  157.33 Certification  157.34 Re-Certification  157.36 Denial and Disciplinary Action (Personnel)  157.37 Certification with Criminal Backgrounds

74. TEXAS OCCUPATIONS CODE  CHAPTER 157. AUTHORITY OF PHYSICIAN TO DELEGATE CERTAIN MEDICAL ACTS  Sec. 157.001. GENERAL AUTHORITY OF PHYSICIAN TO DELEGATE

75. SECTION 157.001  A physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate if, in the opinion of the delegating physician:

76. SECTION 157.001  The Act:  Can be properly and safely performed by the person to whom the medical act is delegated  Is performed in its customary manner; and  Is not in violation of any other statute; and  the delegating physician remains responsible for medical acts of the person performing the delegated medical acts.

77. SEC. 157.003. EMERGENCY CARE  The authority to delegate medical acts to a properly qualified person as provided by this subchapter applies to emergency care provided by emergency medical personnel certified by the Texas Department of Health.

78. FINAL CHECK OF KNOWLEDGE?

79. THE EMS SYSTEM IN TEXAS IS OPERATED AS A DELEGATED PRACTICE OF THE MEDICAL DIRECTOR AUTHORITY? TRUE or FALSE

80. THE EMS SYSTEM IN TEXAS IS OPERATED AS A DELEGATED PRACTICE OF THE MEDICAL DIRECTOR AUTHORITY? TRUE or FALSE

81. CONCLUSION  TAC Title 25, Part 1, Chapter 157 is specific to EMS Act, Providers and Personnel  TAC Title 22, Part 9, Chapter 197 is specific to EMS Medical Direction  Health & Safety Code Chapter 773 is specific to Emergency Medical Services  Medical Directors must be familiar with all (3) documents

82. QUALITY ASSURANCE

83.  How  How will you ensure your doing what you think  Who  Who will assure this  Goal should be to identify issues and areas to improve.

84. QA DEVELOPMENT  How will you measure  Does it cover all aspects  What will be your KPIs  Are they data driven  Where are areas of opportunity

85. EVIDENCE BASED CLINICAL  Benzodiazepines in Seizures  Glucose in Hypoglycemia  STEMI  ASA  12 lead  Direct to PCI  CHF  NTG  CPAP  Trauma centers for geriatric trauma

86. WHAT MATTERS?  Cardiac Arrest  STEMI  Acute Stroke  Sepsis/SIRS  Response Times

87. CURRENT DATA MINING  High Risk Procedures  Airway  Hot Transports  Safety  No Transports  Perceptions

88. QUALITY IMPROVEMENT  Transport Review  Emergency Call to Dispatch  On Scene to Electrocardiogram  Recognition to Activation  Transport Mode

89. IT ALL STARTS HERE

90. OUTCOME DATA?

92. SHARING OUTCOME DATA

93. TEXAS STATE HEALTH AND SAFETY CODE 241.153. SUBSECTION C ALLOWS HOSPITALS TO SHARE INFORMATION WITH EMS SERVICES FOR THE PURPOSES OF QUALITY IMPROVEMENT, MEDICAL AUDIT, AND COMPETENCY ASSURANCE WITHOUT WRITTEN AUTHORIZATION FROM THE PATIENT.

95. 100% PROX RCA LESION ASPIRATION, BALLOON, AND STENT X 1 After The information contained in this email is privileged and confidential. It is for the sole use of the above named recipient. If the reader is neither the recipient nor the employee/agent responsible for delivering it to the recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this email in error, please immediately notify the person listed above and return the original message to the sender by mail at the address above. Before

96. SIMILAR FEEDBACK  Acute Stroke  Trauma  Sepsis Alert  Interesting Cases  Monthly Grand Rounds

97. TAC 157.11(M) (2) (A-G)  Standard of patient care and MD protocols  Pharmaceutical Storage  Readiness Inspections  Preventative Maintenance  Policies and Procedures  Complaint Management  Patient care reporting and documentation

99. ADDITIONAL RESOURCES DSHS GETAC TMB TCEP

100. TEXAS COLLEGE OF EMERGENCY PHYSICIANS www.texacep.org

101. NATIONAL ASSOCIATION OF EMS PHYSICIANS www.naemsp.org

102. AMERICAN COLLEGE OF EMERGENCY PHYSICIANS (ACEP) www.acep.org