We will now look at EMS systems, examining both EMS in general and the Maine EMS system in particular
The on-line medical control officer must have a broad understanding of the structure and function of EMS. By the end of this session, you will be able to identify several components of EMS systems (it’s more than just an expensive truck), differentiate between basic and advanced life support services, describe protocols in general, define the scope of practice for EMS providers, and describe the structure of Maine EMS.
The emergency medical services systems are unique clinical entities. We will focus specifically on emergency response, which is also called primary response or 911 response, as opposed to interfacility transfers or scheduled transports. Through an organized structure, patients access in home assessments, care and, usually, transport to a hospital. This care is provided by personnel with a wide range of training, from first responders to flight paramedics and nurses. Through a state’s licensing structure, these formally trained and licensed individuals function to extend to emergency department clinician’s practice to the preshospital realm. This is not delegated practice, as the EMS providers are individually licensed. Therefore, EMS provider’s do not “work under a doctor’s license.” Generally, each provider needs endorsement by a physician (his or her medical director) who attests to that person’s ability to practice. Most states require a service level medical director at the advanced life support level and many require it at the basic life support level. Maine is one of a handful of states in the US that do not require medical directors at the service level. Instead, Maine uses a combination of regional medical directors, statewide EMS protocols, and regional and statewide quality assurance programs to perform the functions of service level medical directors. Also note that in the following discussion, the term “EMT” is used to describe all level of practice from first responder to paramedic.
There are 16 recognized components of EMS systems. These components must all exist and interact to assure that patients receive the highest quality care.
EMS services are licensed to practice at a specific level, as are EMS providers. Typically, EMS services are divided into Basic Life Support (BLS) and Advanced Life Support (ALS). Basic life support units are staffed by EMT-Basics, which is a specific level of training. All ambulances will carry oxygen, splinting and immobilization equipment, and bandaging supplies. BLS ambulances will typically carry automatic external defibrillators (AEDs). Some EMTs will be trained in advanced airway skills as well. In Maine, the EMT-Intermediate level of certification (EMT-I) is considered an ALS level of certification since the EMT-I may, under the direction of a paramedic or via on-line medical control, establish IV’s, intubate, apply a cardiac monitor / defibrillator, and administer a limited number of medications. Nonetheless, where the MEMS protocols direct BLS providers to call “ALS if available,” Maine EMT-I’s are also expected to request paramedic level response if available.
Advanced Life Support ambulances in Maine will be staffed by EMT-Intermediates, Critical Care Technicians or Paramedics. Skills may include IV access, oral and parenteral medication administration, intubation, intraosseous access, and other skills. For Paramedics, these procedures are mostly performed on standing orders; that is, they do not require contact with medical control.
Protocols are what guide the EMS provider in his or her care. The protocols are both symptom based and presumptive diagnosis based. They are written documents that spell out a series of treatments for specific symptom sets. They define what interventions may be done, when they must be done, and when contact with medical control is necessary before an intervention may be performed. Some protocols will also address non-clinical conditions such as mass casualty incidents.
Protocols are divided into standing orders, those skills which the EMT may do without consultation with medical control, and orders requiring on-line medical control. In Maine, the vast majority of paramedic orders are standing orders. There are a few situations, however, where the protocols require providers to contact on-line medical control. These situations involve cases where the intervention is either consider potentially dangerous if performed in the wrong clinical setting or where the treatment is controversial.
Protocols are written to describe the majority of clinical situations the EMT will encounter. However, “patients don’t read the textbooks,” so patients may fall outside of the protocols. In cases where patients clearly fall within multiple protocols such as a patient with respiratory distress, CHF and COPD, who is wheezing and has rales, the EMT may treat using both protocols. However, if a patient clearly falls outside of all of the protocols, medical control may authorize other treatments. These treatments, however, must not fall outside of the EMT’s scope of practice.
The concept of scope of practice is simple, but its application may be somewhat confusing. Loosely speaking, scope of practice is the set of skills, procedures, and interventions a provider may perform. It is defined by the EMT’s licensure, education, and medical director authorization. In the case of Maine, the scope of the licensure and the medical director authorization are essentially identical since there are few service level medical directors and providers practice under the statewide protocols. There are some regional administrative variations to the protocols (such as hospital destinations), but, aside from pilot projects, clinical care is guided by the same protocols statewide.
Consider scope of practice to be three intersecting circles; licensure, education, and medical director authorization
The limits of state licensure are defined by the rules and regulations of the state EMS office. The state EMS Medical Director or medical direction board is the authorizing physician or physicians for this practice. Regardless of education or service level medical director authorization, except in very extreme circumstances, the EMT may never perform a skill outside of the limits of his state licensure.
Unless they have adequate education on the subject, the EMT cannot perform a skill or intervention. For example, although his state license and medical director may authorize an EMT to perform 12-lead EKGs, unless he has been educated about cardiology and the skill of 12-lead acquisition and interpretation, the skill falls outside of his scope of practice.
Finally, when applicable, the service level medical director must also authorize the EMT to perform certain skills. While the service medical director may want his or her EMTs to perform certain skills such as rapid sequence intubation, and may even train the providers to do so, if the state does not allow RSI, then it falls outside of the EMT’s scope of practice. The Institute of Medicine, in its report “EMS at the Crossroads,” recommended that states move towards state wide protocols, so the future role of the service level medical director in protocol development may change.
The EMT’s scope of practice, then, is potentially very limited compared to the EMTs education, state license, and protocol. It is only where those three limiting factors intersect that the EMT may practice.
Next we will discuss specifics of Maine EMS. As mentioned, Maine is relatively unique both in the administrative system structure and in not requiring service level medical direction. Because of a historical lack of trained and qualified service level medical directors, Maine has developed a system of regional and state level medical direction. The day to day functions of medical direction are carried out by the regional medical director or, in some cases, a service level medical director if one exists. Medical direction at the state level is focused on all EMS in the state as an integrated system rather than on the function or operations of any individual service. This regionalization of oversight has resulted in statewide protocols, a model that is being adopted in many other states, and a regional and statewide QI process, which we will describe in more detail shortly.
Maine EMS falls under the Department of Public Safety. The Board of EMS has the oversight responsibility for Maine EMS. Jay Bradshaw is the Maine EMS Director, essentially responsible for state level operational oversight, and Steve Diaz, MD, is the Maine EMS Medical Director, essentially responsible for state level medical oversight. These roles will be further clarified shortly. These two individuals, along with the regional EMS offices, perform the oversight and medical direction work that the Board of EMS oversees.
There are several members of the Board of EMS, each of whom serves a specific role in assuring that the views of all the major stakeholders in EMS in Maine are represented.
At the state level, there as a Maine EMS office of EMS, which is part of the Department of Public safety. The staff in the office is responsible for training and education, licensing, data, preparedness, and emergency medical dispatch.
There are a number of ways to contact the Maine EMS office.
The regional offices are independent, not for profit corporations who contract for services with Maine EMS. The regional coordinator and regional medical director oversee the operations and report to the regional board of directors. The primary functions of the regional offices include medical oversight, total quality management, and both primary and continuing education.
The medical oversight of Maine EMS is carried out via the State Medical Director and the Medical Directions and Practice Board. This is the ultimate authority for medical issues, particularly for protocol development. In addition, the State Medical Director serves as the medical authority on the State EMS Board. The Medical Directions and Practice Board is composed of the state medical director, the 6 regional medical directors, and a representative from the Maine Chapter of the American College of Emergency Physicians. Although the decisions that come out of the MDPB are ultimately made by this group of physicians, the meetings are open and contributions by others are welcome.
The Medical Directions and Practice Board is responsible for medical practice in Maine EMS. It is responsible for the EMS protocols, the medical devices to be used, and establishes quality assurance benchmarks. The board works closely with other committees to assure that quality care is being delivered by EMS providers in Maine.
There are two major functions of QI in the state. The first is to maintain the statewide database. All EMS data are entered into the statewide database and is utilized for research and other projects. Interested individuals can access that data with permission (and paperwork) from the office of EMS. The state focuses on “big picture” issues such as psychiatric transfers, airway management, and 12 lead EKG utilization. From a call by call quality of care perspective; however, QI is handled at the regional level. All EMS services leave a patient care report at the hospital and some submit an additional copy to the regional EMS office. In many hospitals, there is an individual at each hospital responsible for run review for the EMS services that deliver patients to that emergency department. However, in some regions this review is conducted by the regional office staff. Issues in patient care may be recognized through this mechanism, through allied healthcare worker and clinician identification, through peer review and reporting, or via a service medical director. When an issue is identified, depending on the specifics it may be managed at the service level. If this does not produce a satisfactory result or if the issue is of a more serious nature, it may be forwarded to the regional office for review. If a deficit in knowledge or ability is identified, the regional office may choose to issue a remediation agreement which were formerly called consent agreements, require reeducation, or require skills demonstration or testing. Violations of Maine EMS Law or Rules, and individuals who fail to comply with the regional QI requirements may be referred to Maine EMS for further investigation.
There are several committees at the state level responsible for effective functioning of EMS. These include: quality assurance, HART (cardiac), education, exam, data, Emergency Medical Dispatch, Emergency Medical Services for Children, investigations, operations (regional coordinators and state staff), and others as needed.
This map shows the 6 EMS regions in Maine, The following slides will give you the contact information of each of the regions
There are many types of local EMS services in Maine. Transporting ambulance services include ground ambulances, fixed wing ambulance services, and rotor wing or helicopter ambulance services. LifeFlight of Maine, the helicopter EMS service in Maine, has a statewide response area. There are also a number of first responder agencies that rapidly respond to emergencies with trained providers but rely on other services to transport the patient. Finally, there are an unknown number of unregulated industrial and private first response agencies that provide a bridge between the the lay public and EMS providers at select locations such as ski areas, summer camps, colleges, and industrial settings.
This map shows the distribution of all licensed EMS services in Maine. Note in particular the low service density in the northern 2/3rds of the state, which is mostly inhabited by wildlife, loggers, and smugglers bringing in Cuban cigars from Canada.
Generally speaking, there are two large categories of EMS services in Maine, Basic Life Support and Advanced Life Support. However, there are nuances to these licensure levels that are important for the On-Line Medical Control officer to understand. The licensure levels reflect the licensure level of the providers as well as the requirements for equipment and medications.
Just as providers are licensed by the state to practice at a certain level, so too are EMS services. The level of licensure reflects the minimum level at which a service will always provide emergency response. Recognizing that some services will,on occasion, have additional capacity through advanced-level personnel and equipment, MEMS also allows the issuance of “permit”. For example while a service licensed at the paramedic level must always equip and staff a paramedic for all emergency calls, a service with an EMT license and permit to paramedic will have a minimum of an EMT licensed provider on all calls, but may provide a higher level of care when a paramedic and paramedic-level equipment is available.
Of the levels of practice, some are grandfathered and some represent a training program only and not a true level of certification. Actual levels of practice are First responder, EMT, EMT-Intermediate, and EMT-Paramedic. Licensed Ambulance Attendants are a grandfathered level and practice as first responders. EMT-Critical Care is also a grandfathered license level which adds ACLS medications not included in the EMT-I scope of practice. Paramedic Interfacility Transfer, or PIFT, is a training program and EMS service level that, through additional training and mandatory physician medical oversight, enhances paramedics’ ability to perform interfacility transfers for stable patients.
Agencies designated as basic life support agencies are staffed by licensed first responders, ambulance attendants, and emergency medical technicians. Ambulances are not stocked with most medications, IV equipment, or advanced medical supplies. Many, however, are equipped with Automatic External Defibrillators and epinephrine auto-injectors.
Advanced life support services are staffed by EMT-Intermediates, EMT-Critical Care, or EMT-Paramedics. The ambulances are stocked with a full complement of medications, IV supplies, intubation and other airway management supplies, and, when appropriate based on staffing, manual monitor/defibrillator/external pacemakers. The PIFT paramedic level adds critical care transport training and equipment, as well as mandatory service level medical direction.
This map shows the distribution of ALS EMS services in Maine by part or full time paramedic staffing. Note that many EMS agencies cannot assure full time paramedic staffing.
The Maine EMS Office coordinates a number of federal grants and projects. One such project was the Rural Access to Emergency Devices grant, which provides free AEDs to rural areas, makes discounted AEDs available throughout the state, and promoted CPR and AED training. This project ended in August 2006, when federal funding was eliminated.
Maine also has a trauma program once supported via federal funding that oversees and coordinates the system of established trauma centers and trauma triage and protocols for EMS providers in the state. This plan designates 3 trauma centers, Central Maine Medical Center, Eastern Maine Medical Center, and Maine Medical Center. The state EMS trauma protocols direct EMS providers as to an appropriate destination hospital based on physiological criteria. Federal funding for this project ended July 31, 2006, however, the work continues with generous in-kind support and volunteer committee members.
Maine EMS receives $115,000 per year from the federal Department of Health & Human Services, Maternal and Child Heath Bureau to conduct an EMS for Children project. Past projects include the development of a Youth Suicide Prevention Gatekeeper Training program to teach EMS providers and teachers how to identify children at risk of suicide and help guide them to counseling resources. EMSC is currently involved in a multi-year project to establish an infrastructure for pediatric care. As this foundation is being developed, there are ongoing projects for playground safety, child passenger seat use, and health and safety fairs for K-8 children. Other projects include EMS for Special Healthcare Need patients, standardizing data collection using the National EMS Information System data dictionary, and collecting data on the availability of pediatric equipment, training, and medical control.
Maine has a single set of protocols for the entire state with local variances based only on administrative differences regarding hospital destination and quality improvement requirements.
Maine is a pioneering state in the development of statewide protocols. All EMS providers and services practice the same type of care under these protocols regardless of where in the state a provider works. However, there are pilot projects that are run in various regions that, if successful, may be expanded to the statewide protocols. For example, CPAP is in trial in several regions, while Mid Coast EMS is evaluating a new stroke protocol. The new PIFT curriculum was beta-tested in two regions prior to statewide adoption, and the use of the EZ-IO drill, after a limited trial, is now used throughout the state.
In summary, it is important to remember that EMS care is not the same as emergency department care. Furthermore, EMS agencies function at different levels based on licensure, equipment, and staffing, and some individual agencies may function at different levels at different times of the day. Maine EMS, both at a regional and state level, oversees, monitors, and supports EMS in agencies and providers in Maine. The statewide protocols, which are the guidelines for the bulk of care delivered in Maine, are key documents with which every on-line medical control provider must be familiar.
Maine EMS On-Line
Module 1: EMS systems