Major Topic # 4: Medical Oversight

The Medical Director
The practice of critical care medicine is different from the practice of emergency medicine. Likewise, emergency medicine is different from EMS, and IFT is different from the portion of EMS providing prehospital care. Each is a distinct specialty with focused knowledge, skills, and abilities. Trying to find one medical director to wear all of these hats may not be easy, and it could take several physicians working together to provide the experience and expertise required for comprehensive IFT service.

Physicians in medical specialty usually practice within hospital walls (e.g., neonatology, thoracic surgery) and may not be familiar with the operational aspects of the IFT process. Specialists are more likely to require additional training to function efficiently in the out-of-hospital environment, and for them to function in medical direction capacity. It may be easier for physicians/medical directors who are familiar with EMS and/or IFT (e.g., EMS Medical Directors) to assume leadership of IFT programs. EMS physicians in general are familiar with what is involved in caring for patients in out-of-hospital settings.

The ideal IFT Medical Direction might be a cross-trained physician or through a collaborative working relationship between two (or more) physicians. If one physician is designated as medical director for an IFT program, that physician should function as medical director for the IFT program using other specialists as resources, rather than having several physicians serving as multiple medical directors. There should be assurance that the Medical Direction arrangement is consistent with applicable State laws and regulations.

Guidance for medical directors can also be found from multiple sources, including:

Air Medical Physician Association
Medical Direction and Medical Control of Air Medical Services (2002)
http://www.ampa.org/component/option,com_docman/task,cat_view/gid,23/Itemid,42/

American College of Emergency Physicians
Interfacility Transportation of the Critical Care Patient and Its Medical Direction (1999)
http://www.acep.org/webportal/PracticeResources/PolicyStatements/

National Association of EMS Physicians
Medical Direction of Interfacility
Transports (2000)
Medical Direction for Air Medical Transport Programs (2002)
Physician Medical Direction in EMS (1997)
(table of contents:)
http://www.naemsp.org/Position%20Papers/Contents.html

Commission on Accreditation of Medical Transport Systems
Best Practices: A Collection of Outstanding Programs and Policies from Accredited Transport Services
http://www.camts.org

Medical oversight in IFT may take multiple forms:

Off-Line Medical Direction
Off-line medical direction includes those activities performed by the medical director that do not occur during actual transport. These duties are usually performed before transport (e.g., training, education, development of protocols) and after transport (e.g., chart review, case review, continuing or remedial education, quality improvement). The medical director is ultimately responsible for the care provided by the IFT service and should be involved in all aspects of IFT that have a direct, potential impact on patient care.

Role of Standardized IFT and Destination Protocols
Written orders from the transferring facility may suffice for the stable patient during most transfers, but on-line medical direction should be available at all times, in case unforeseen situations arise during transport. Off-line protocols can be developed as a basis for care during transport, but complexity of care for many patients seems to suggest that they may be of limited usefulness. A standard order sheet shared system-wide that can be individualized by the transferring physician may be more useful. Advance development of this form in conjunction with referring and/or accepting physicians may further facilitate the IFT process.

Unlike prehospital EMS, which may dictate that a patient be taken to the closest or most appropriate facility, IFT is a physician order to transport a patient from one specific location to another. Therefore, destination protocols are of very limited utility unless they address the event of a rapid deterioration of patient condition requiring transport to the nearest appropriate facility.

Consultation with Specialty Care
The medical director is ultimately responsible for the care provided by the IFT service. Therefore, it behooves the medical director to have access to specialists and consultants who are available for real-time (on-line medical direction) problem solving, and for protocol development, case review and post-transport consultation. It may be in the patient’s best interest, and extremely helpful to both crew and medical director, to seek the opinions of those with extensive experience and expertise in medical specialties. One possible model includes a single medical director who receives input and assistance from other medical specialists (i.e., neonates, pediatrics, intra-aortic balloon pump, etc.) in drafting protocols, education, and case review for IFT.

On-Line Medical Direction
On-line medical direction includes those activities performed by the medical director that occur real time, during actual transport. On-line medical direction should be available at all times, in case unforeseen situations arise during transport.

Medical oversight and interfacility transfers: which medical director is liable for what part of interfacility transfer
Medical oversight is variable and depends on State and local regulations. As per the Emergency Medical Treatment and Labor Act (EMTALA), the referring physician is responsible for the patient being transferred from one facility to another, until the patient arrives at the receiving facility. On-line medical direction may be provided by the referring physician, the accepting physician, the transferring agency medical director, the medical director’s proxy for specialty care issues, or some combination of the above. This often is determined by the State and local regulations, and may differ between jurisdictions. For example, in some jurisdictions, if the transport vehicle is owned by the receiving facility that liability begins when the crew assumes care of the patient.

While on-line medical direction may be provided by the referring physician, the accepting physician, the transporting agency medical director, the medical director’s proxy for specialty care issues, it is essential that the roles of each are determined prior to transport and while the IFT system is developed. It may require a contract, a memorandum of understanding, or other legal documents between the agencies or jurisdictions. Whatever the case, it needs to be clearly defined in advance of transfer and not decided while transport takes place.

To anticipate possible situations where there may be confusion or difference of opinion regarding the bounds of responsibility and liability, IFT services should develop and adopt protocols for how crew members and the medical director will handle such situations. This protocol should include provisions to assure medical director responsibility is resolved prior to patient transport. Advance knowledge of this protocol by all stakeholders may be helpful in proactively addressing potential situations concerning medical oversight.