Prehospital emergency medical care by EMS providers can be defined as physician-directed medical care in the prehospital setting with or without ambulance transport. A wealth of details clarifies this definition within specific jurisdictions and for particular circumstances. The care provided by prehospital providers as a part of the EMS system is a practice of medicine with standards of care established by the training and experience of practitioners and system leaders. Therefore, a key component of the EMS system is physician oversight and medical direction. A well-developed and well-designed EMS system usually incorporates four opportunities for physician input:
Operational policies and guidelines
Patient care protocols
In an excellent EMS system, all four opportunities are coordinated by EMS physicians collaborating with EMS professionals to produce excellent and efficient care for patients while improving all aspects of the system and the providers working within it. System design, at a national and state level, provides guidance regarding curriculum, scope of practice, regulatory & licensing structure, and other overall aspects of the EMS system. Medical direction, provided at the time of care (online) and all other activities of the medical director (off-line), is discussed in Chapter 4. This chapter focuses on the development of protocols, policies, procedures, and guidelines and defining important concepts relative to these activities.
Define the terms guidelines, policies, procedures, protocols.
Define the terms scope of practice and standard of care.
Discuss how the above concepts relate to the medical care provided in the field.
Describe the processes involved in development of guidelines, policies, procedures, and protocols.
In order to fully appreciate the importance of clear and definitive documents defining prehospital medical operations, it is essential to know the purpose of the different document types and understand how they serve to define the parameters by which prehospital care is delivered. If the medical director confuses these components, and their purpose, there is potential for inappropriate development of these documents that could lead to operational, regulatory, legal, and medical complications.
KEY TERMS AND DEFINITIONS
Guidelines: provide broad parameters for management of a particular problem. They should be the result of expert consensus, based on evidence, and typically apply at a national or international level. An example would be recommending early 12-lead ECG acquisition for EMS patients with possible cardiac ischemia as a method to triage STEMI patients to the best treatment option.
Scope of practice: is the range of care expected and allowed for a particular type of care provider, such as an EMT or paramedic, but the term applies to all types of providers. It typically is described in laws, regulations, and protocols and includes allowed procedures, medications, and requirements for each type of provider in a system. Scope-of-practice documents define the bounds of practice expectation and procedural limits for providers. An example would be describing the level of provider and training required to acquire and interpret a 12-lead ECG. In many cases performing and intervention outside a provider’s scope of practice could have legal implications, even if they were given an order by a physician to performing an intervention.
Standard of care: is the minimum acceptable quality of practice expected of a provider of similar level or type facing a particular situation. The standard of care for any particular instance is usually derived from review of medical literature, position papers from expert panels, and by examining local practices. It is typically limited by the scope of practice and defined during legal proceedings through review of these materials and the expert opinion of providers with the same or similar training as the provider being evaluated, and should be applied to the same or similar clinical circumstances. Acceptable practice is performed above the standard of care; practice below the standard of care is negligent practice. While some aspects of the standard-of-care apply without regard to geography, variability in EMS scope of practice, guidelines and protocols may create local and regional variations in the standard of care. An example would be the expectation that trained and equipped providers would obtain a 12-lead ECG early in the care of a 48-year-old patient with acute onset of atraumatic chest pain. Breaches in the standard of care can be ground for the allegations of malpractice in cases where harm and causality can be established.
Policies: set forth the general operational parameters for a system or service. They encompass all aspects of operation (eg, human resources, equipment maintenance, and response for patient care, etc). They may reflect these elements of a national organization, a state agency, or an individual ambulance agency. Examples would be the ACEP Policy on Leadership in Emergency Medical Services,1 or an ambulance agency policy that sets out a clinical goal to provide the best possible patient care.
Protocols: specify care, often including the chronological order of care, for a specific situation or patient complaint. They are often service or system specific. They implement guidelines and policies. An example would be a protocol that sets forth the steps expected by the EMS system in the care of a 48-year-old patient with chest pain.
Procedures: are delineated methods to perform tasks or implement policies and protocols. They are typically detailed, ordered, and specific to the service, piece of equipment, or task. An example would be the exact steps necessary to acquire a 12-lead ECG using the particular brand and model of monitor available at a particular ambulance service.
Physician directed: means that properly committed, knowledgeable, and collaborative physicians provide oversight for the EMS system. EMS is a developing subspecialty, and board-certified EMS physicians will eventually become the logical choice to serve in this role, supported by consultation with other medical specialties as indicated. Currently, many physicians with varied training and backgrounds provide EMS system oversight. This physician oversight may take many forms, and does not require that a physician be present at every EMS incident, communicate with EMS providers during every patient transport, review every document, or teach every EMS course, although these circumstances may be indicated at times. Instead, what we mean is that physician oversight is reflected throughout the EMS system wherever patient care is involved. This oversight may, for example, take the form of EMS provider scope of practice and curriculum guidance, direct and indirect education, research, efforts to seek and secure system funding, provider standards and supervision, development and interpretation of guidelines, policies, protocols and procedures, and other measures that implement physician judgment throughout the EMS system. The degree and mechanism of physician direction will vary from system to system, as designated by the laws, regulations, and other guidance of the jurisdiction.
Ambulance: refers to any vehicle or conveyance used to transport patients or personnel and equipment used to treat patients, including all associated equipment, supplies, and medications. These vehicles may or may not be dedicated to sole use as ambulances, may or may not be motorized, and may be designed for a variety of travel environments (ie, air, on and off road, water, snow, mud, wilderness, urban structures, etc). Ambulances and their associated equipment may be specified by, inspected by, and their operation and use controlled by the EMS system. The degree and mechanism of ambulance control and regulation will vary from system to system, as designated by the laws, regulations, and other guidance of the jurisdiction.
Transport: means the potential that a patient or patients may be best served by physical relocation from their current location to another for medical care, safety, or other associated purpose. This may include evaluation and care to determine if such transport is indicated, the actual movement of patients within or between entities or facilities, and any associated vehicles, mechanisms, and personnel. It also includes search for and rescue of patients from entrapment or other hazardous circumstances, evacuation of persons during a time of hazard, care at gatherings and mass events, and transportation to, from, or between temporary, emergency, or alternate health care entities.
Patient: any person to whom the EMS system owes, or may owe, a duty of care. Patients may include those who have gathered at a mass event and are potentially in need of medical care, persons living in or located in a particular area or circumstance (such as a flood zone or epidemic area), persons in routine or emergency need of medical evaluation, care, and/or transportation, and any other person within the jurisdiction of the EMS system who may be affected by the design, operation, regulation, or other aspects of the EMS system and its personnel and equipment.
Care: is that medical evaluation and treatment provided to a patient by an EMS provider. It may include physical relocation to a place of greater safety, remote evaluation of patient circumstances or risk, efforts to identify a patient, obtaining a medical history from the patient or others, hands-on physical examination, testing (including laboratory testing, imaging, and other evaluation), and treatment with medications, devices, equipment, and transport. Care includes ensuring the safety of patients, providers, and others through the use of accepted means to immobilize, restrain, protect, splint, isolate, and otherwise provide measures that protect patients, providers, and others from harm.
GUIDELINES, POLICIES, PROCEDURES, AND PROTOCOLS AS TOOLS FOR DEFINING EMS SYSTEM STRUCTURE
Organization of EMS systems is, ideally, logical and transparent. When asked, “Why do we do it that way?” it is helpful to have both evidence and structure supporting the answer. Proper development of (or reference to) relevant guidelines when defining scope of practice, creating protocols, and drafting policies and procedures provides the foundation for good quality EMS practice. The tools then available to system leaders (protocols, procedures, etc) are used to ensure that best practices are provided throughout the system. Of course, a thorough quality improvement system is necessary to close the loop.
Guidelines paint, in broad strokes, current best practice information (or the lack thereof—such as the lack of a single recommended outcome measure for cardiac arrest studies2). They are a means to promulgate current best practice information throughout the EMS system. They should be developed using an objective, transparent, and commonly accepted approach to evaluating the evidence, and should answer important clinical questions. However, guidelines require interpretation and review before application during patient care.
The development of guidelines probably does not occur at a local level. As a statement of expert consensus after review of the best available evidence, guidelines are typically beyond the scope of a local EMS system. However, to be applied locally they need to be examined and interpreted to ensure that their local use matches needs, operational capabilities, and realities, and can be measured through a quality assurance process to assess both positive and negative influences on the local EMS system. A number of national professional organizations maintain guidelines (sometimes referred to as positions) relevant to EMS systems (eg, National Association of EMS Physicians, American College of Emergency Physicians, American Heart Association, American College of Surgeons). A process should be described for the evaluation of the evidence used in development of these guidelines, including scoring of the evidence considered3 and conflict of interest management during involvement of the experts involved in the guideline development process.4