MCA Roles & Responsibilities Robin Shivley Section Manager

1. MCA Roles & Responsibilities Robin ShivleySection Manager

2. Medical Control Authority • A Medical Control Authority is an organization designated by the department for the purpose of supervising and coordinating an emergency medical services system, as prescribed, adopted, and enforced through department-approved protocols for a particular geographic region.

3. Medical Control Authority Requirements • MDCH designates Medical Control Authorities for a particular region (currently 65 MCAs) • A Medical Control Authority is a hospital or group of hospitals that operates a service that treats patients 24 hours a day, 7 days a week

4. Medical Control Requirements • MCAs are responsible for: • The supervision and coordination of the EMS system. EMS system means a comprehensive and integrated arrangement of the personnel, facilities, equipment, services, communications, medical control, and organizations necessary to provide emergency medical services and trauma care within a particular geographic area.

5. Medical Control Requirements • MCAs are responsible for: • adopting an organizational structure of their choice, but must have an advisory body • appointing a medical director • who is board certified in emergency medicine, or • who practices emergency medicine and is current in both ACLS and ATLS

6. Medical Control Requirements • Medical Director, appointed by the MCA, is an agent of the Medical Control Authority and is responsible for Medical Control for the EMS System. • It is the Medical Director’s responsibility to ensure the provision of medical control.

7. Medical Control Requirements • MCAs are responsible for: • establishing written protocols for the practice of life support agencies and EMS personnel. • circulating draft protocols to all significantly affected persons for review, and • submitting to MDCH for approval • ensuring physicians, hospital staff, and providers are educated on protocols • adhere to protocols

8. Medical Control Requirements • Each participating and nonparticipating hospital within a medical control authority region shall follow all standards, policies, procedures, and protocols established by the MCA as approved by the Department.

9. Medical Control Requirements • Protocols adopted by the MCA and approved by the department have the force and effect of law. • Licensed life support agencies and individuals are accountable to the MCA in the provision of emergency medical services as defined in protocols.

10. Medical Control Requirements • Appoint a Professional Standards Review Organization, for the purpose of improving the quality of medical care • Collect data as necessary to assess the quality and needs of emergency medical services throughout its medical control authority region.

11. Quality Improvement • MCA must develop and implement protocols that ensure a quality improvement program is in place and provides data protection

12. Quality Improvement • The purpose of the MCA Quality Improvement program is to: • Assess the quality and need of EMS through the collection of system appropriate data. • Provide the services in the MCA area with a review process in which current protocols and their use can be monitored and upgraded.

13. Quality Improvement • The purpose of the MCA Quality Improvement program is to: • Provide a means of reviewing the standards of care in individual EMS services and the MCA as a whole. • Provide a means of documenting the need and/or desire for changes to the current protocols as written.

14. Declaratory Ruling & Clarifying Document

15. Licensure of Ambulance Operations • September 17, 2007 letter related to licensure of ambulance operations for the purpose of interfacility transfers only. • Clarification: • Ambulance Operations are licensed based upon a geographic service area • Ambulance Operations must have 1 vehicle 24/7 to respond to an emergency within their geographic service area.

16. Licensure of Ambulance Operations • A municipality/village/township/county determines who will provide EMS for their area. • Cannot license an ambulance operation for the purpose of interfacility transfer only. • An ambulance operation that chooses to conduct interfacility transfers can only do so if the transfer begins or ends within their approved MCA.

17. Licensure of Ambulance Operations • Medical Director, appointed by the MCA, is an agent of the Medical Control Authority and is responsible for Medical Control for the EMS System. • It is the Medical Director’s responsibility to ensure the provision of medical control.

18. Declaratory Ruling • Ruling is limited to the specific facts presented and the statute upon which it is based. • Ruling is binding on the MDCH and the applicant unless it is altered or set aside by any court. • MDCH may not retroactively change this ruling, by may prospectively do so in its discretion. • Ruling is subject to judicial review in the same manner as an agency final decision or order in a contested case.

19. Declaratory Ruling • Specific question asked: • “May a Medical Control Authority (MCA) adopt a protocol that allows its life support agencies to perform inter-facility transfers which both begin and end outside of the MCA’s jurisdiction?”

20. Declaratory Ruling • Response by MDCH: • “Medical Control authorities can establish written protocols for the practice of life support agencies within their geographic region. If a MCA were to adopt a protocol detailing how its life support agencies might perform inter-facility transfers which both begin and end outside of the MCA’s region, however, then that protocol might well infringe on the protocols developed by the other MCA where the inter-facility transfer may entirely occur.

21. Declaratory Ruling • Consequently, it is my ruling that under Part 209 of the Public Health Code, a medical control authority may adopt a protocol or protocols that allow its life support agencies to perform inter-facility transfers which both begin and end outside of the MCA’s jurisdiction, as long as those protocols are coordinated with and consistent with the protocols imposed by the MCA in the geographic region(s) where the transfer begins or ends, and have been approved by MDCH.” • Signed by: Janet Olszewski, Director

22. Declaratory Ruling • Implementation of the Declaratory Ruling by MDCH/EMS and Trauma Systems Section • Section 20921 (1) (a) • Section 20921 (1) (b) • Administrative Rule 325.22103 • AG Op No. 7072 • Declaratory Ruling

23. Declaratory Ruling • “An ambulance operation may perform patient transports between health care facilities in a MCA outside its licensed service area if the MCAs have coordinated protocols that allow for such transfers. At a minimum, these protocols must state that: (1) medical oversight and quality review will remain with the ambulance operation’s original MCA; and (2) that the agency will provide the appropriate level of life support and personnel for the patient transfer. The ambulance operation providing this service must also continue to provide adequate emergency services in their existing service area and will cooperate with the MCA’s quality review process.”

24. Declaratory Ruling • “If a MCA has not adopted a protocol to allow its life support agencies to perform inter-facility transfers that begin and end outside of the MCA, then the life support agency cannot conduct such transfers. Similarly, if a MCA adopts a protocol that prohibits a life support agency that is licensed outside its geographic service area from performing inter-facility transfers that begin and end within that MCA, then such a life support agency must not conduct such transfers. This means that a life support agency cannot conduct transfers that both begin and end outside of its MCA without having an established protocol in place.”

25. Declaratory Ruling • “Finally, as every life support agency must operate under the direction of a MCA, each response and/or transport must be performed under the medical direction and oversight of the MCA in which the vehicle is licensed. The Department does not envision any instance where a life support agency will respond to an emergency or non-emergency patient when not under the medical direction and oversight of a MCA.”

26. Declaratory Ruling • To assist with the implementation of the declaratory ruling: • The Department will develop a template for MCAs wishing to develop a protocol that allows for inter-facility transfers that both begin and end outside of its geographic area.

27. EMS Information System

28. Data Submission • Data submitted by the life support agencies shall be reviewed by the MCA professional standards review organization for the purpose of improving the quality of medical care. • A medical control authority shall submit data to the department as prescribed in protocol.

29. Data Submission • In most cases, the life support agency will submit data directly into the state repository (Image Trend) and not directly to the MCA. • The MCA will have the ability to pull their life support agency information from the state repository.

30. Data Submission • If a life support agency is found to not be submitting data, the MCA would contact the agency to determine why data has not been submitted. • The MCA may contact the Department for assistance if needed.

31. Data Submission • Began May 15, 2009 with collection beginning April 1, 2009 • Along with data submission, some challenges have been identified: • June 5, 2009 letter

32. Challenges/Issues Being Addressed • What are the required data elements? How did we go from 166 to 287 required data elements? • Data Task Force identified a total of 287 required data elements. • 287 data elements allow MCAs to conduct quality review • Of 287 elements, 166 are reportable data elements • Approved by the EMSCC.

33. Challenges/Issues Being Addressed • Clarify how MCAs will utilize ImageTrend (state repository) for quality improvement process. • Agencies utilizing ImageTrend as software system will submit all data elements. • Agencies using a 3rd party vendor, will submit the required data elements of 287. • Required data elements include: medical history, narrative reports, vital signs, assessments, interventions, medications, procedures, etc. • MCA will use ImageTrend for their QI process

34. Challenges/Issues Being Addressed • Clarify how confidentiality/privacy will be maintained by MCA. • John Cook, Attorney, legal opinion. • Each MCA will develop and submit a protocol, for approval by MDCH, on how data will be used, maintained, and remain confidential • EMS/Trauma Systems Section is very committed to ensuring data confidentiality, we have removed access by MCAs to their life support agency data. This is for limited time until we can ensure data confidentiality. • Eliminating first and last name from required list of data elements. Department will not require these two elements. If a MCA believes it is necessary to require these elements, they can do so through local protocol.

35. Challenges/Issues Being Addressed • Intent to review data protocols submitted by MCAs. • Intent to work with ImageTrend to turn off the patient firs and last name data elements, but ensure we don’t loose the QI information so the MCAs have the ability to conduct their QI process. • Continue to work with Prehospital Data Task Force and again review required data elements to determine if additional changes should be made.

36. State Model Protocols

37. State Model Protocols • MCAs are responsible for: • establishing written protocols for the practice of life support agencies and EMS personnel. • circulating draft protocols to all significantly affected persons for review, and • submitting to MDCH for approval • ensuring physicians, hospital staff, and providers are educated on protocols • adhere to protocols

38. State Model Protocols • Protocols adopted by the MCA and approved by the department have the force and effect of law. • Licensed life support agencies and individuals are accountable to the MCA in the provision of emergency medical services as defined in protocols.

39. State Model Protocols • Each participating and nonparticipating hospital within a medical control authority region shall follow all standards, policies, procedures, and protocols established by the MCA as approved by the Department. • Each MCA shall submit to the Department current protocols for department review and approval. Department approval shall be on a 3-year cycle as defined by the Department.

40. State Model Protocols • Started the process of updating State Model Protocols by developing the following: • MFR Adult and Pediatric Treatment Protocols • EMT & Specialist Adult and Pediatric Treatment Protocols • Paramedic Adult and Pediatric Treatment Protocols • Based upon comments received, we will be putting the MFR, Basic and Sepcialist back into the narrative document. We will not put these procedures into the algo.

41. State Model Protocols • Finalized – adult Treatment – als • Adult cardiac – als • Pediatric cardiac – als Protocols are in narrative and algo format. Also, provide choices within these protocols.

42. In addition to cardiac and treatment protocols, we will be updating: • Medical Procedures • System Protocols • CBRENE Protocols • Procedures are being updated – not final. • Pediatric treatment protocols are being updated with the inclusion of algo. These also are not quite finished.

43. State Model Protocol • MCI protocol has been updated, but a lot of discussion has occurred about adding SALT into these protocols as this is a national movement. • System procedures – at this time we are updating 2: termination of resuscitation and dead on scene. • Also developing drug sheets for all drugs. • Deviation form has been completed.

44. Mass Casualty Incident Procedure and Protocol • Includes language related to the Medical Coordination Center • MCC acts as an extension/agent of the MCA • Language related to MCC Immunity from Liability

45. Mass Casualty Incident Procedure and Protocol • Includes triage tag • Start Triage Criteria • Jump Start Triage Criteria • Mi-Start Triage Criteria

46. State Model Protocols • Intend to develop an education tool with the protocols and a protocol exam that can be utilized by the MCA • MCAs that choose to not adopt or exceed state model protocols will need to submit an addendum (form developed) along with the protocol which will be reviewed by the QA Task Force

47. Protocol Submission Timeline • November 1, 2009 – MCAs will need to have submitted new protocols that at a minimum meet state model. If Deviate, they will submit the protocol, along with the form and justification for deviation, to the state. • MCAs will submit updated protocols at least every 3 years.

48. Additional Protocol Information • EMSC conference: States were asked to develop a Congenital Adrenal Hyperplasia (CAH) protocol. This disease affects 1 in about 15,000 children. Very easy to treat, life saving if early, and drug is very inexpensive. This will be discussed with QA task force. • An EMS Evidence Based Guideline for Development of Protocols has been drafted. Dr. Wright, Medical Director for Maryland and Director for NRC program utilized this guideline to develop a pediatric seizure management protocol (this will be released very soon). My intent is to obtain a copy of this and share with QA and MCAs.