6 CCR 1015-3-2-5 - EMS Agency Medical Directors

5.1 EMS agency medical directors are responsible for the medical direction of EMS providers in the prehospital setting. Their duties shall include:
5.1.1 Be actively involved in the provision of emergency medical services in the community served by the EMS service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director but does require such involvement during the time that he or she acts as a medical director. Active involvement in the community could include, by way of example and not limitation, those inherent, reasonable, and appropriate responsibilities of a medical director to interact with patients, the public served by the EMS service agency, the hospital community, the public safety agencies, and the medical community and should include other aspects of liaison, oversight, and communication normally expected in the supervision of EMS providers.
5.1.2 Be actively involved on a regular basis with the EMS service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director but does require such involvement during the time that he or she acts as a medical director. Involvement could include, by way of example and not limitation, involvement in continuing education, audits, and protocol development. Passive or negligible involvement with the EMS service agency and supervised EMS providers does not meet this requirement.
5.1.3 Notify the Department on an annual basis and upon any change of medical direction of the EMS service agencies for which medical direction is being provided in a manner and form as determined by the Department.
5.1.4 Establish a medical continuous quality improvement (CQI) program for each EMS service agency being supervised. The medical CQI program shall assure the continuing competency of the performance of that agency's EMS providers. This medical CQI program shall include, but not be limited to: appropriate protocols and standing orders and provision for medical care audits, observation, critiques, continuing medical education, and direct supervisory communications.
5.1.5 Submit to the Department an affidavit that attests to the development and use of a medical CQI program for all EMS service agencies supervised by the medical director. As set forth in Section 4.4 , the Department may review the records of a medical director to determine compliance with the CQI requirements in these rules.
5.1.6 Provide monitoring and supervision of the medical field performance of EMS providers. This includes ensuring that EMS providers have adequate clinical knowledge of, and are competent in performing, medical acts within the EMS provider's scope of practice authorized by the medical director. These duties and operations may be delegated to other physicians or other qualified health care professionals designated by the medical director. However, the medical director shall retain ultimate authority and responsibility for the monitoring and supervision, for establishing protocols and standing orders, and for the competency of the performance of authorized medical acts.
5.1.7 Ensure that all protocols issued by the medical director are appropriate for the certification or license and skill level of each EMS provider to whom the performance of medical acts is authorized and compliant with accepted standards of medical practice. Ensure that a system is in place for timely access to communication of direct verbal orders.
5.1.8 Be familiar with the training, knowledge, and competence of EMS providers under his or her supervision and ensure that EMS providers are appropriately trained and demonstrate ongoing competency in all medical acts authorized in accordance with Section 15.1 and, as applicable, Appendices A-G.
5.1.9 Be aware that certain medical acts authorized in accordance with Section 15.1 and, as applicable, Appendices A-G (and as identified by the Department) may not be included in the National EMS Education Standards and ensure that appropriate additional training is provided to supervised EMS providers.
5.1.10 Ensure that any data and/or documentation required by the rules are submitted to the Department.
5.1.11 Notify the Department within fourteen business days excluding state holidays prior to his or her cessation of duties as medical director.
5.1.12 Notify the Department within fourteen business days excluding state holidays of his or her termination of the supervision of an EMS provider for reasons that may constitute good cause for disciplinary sanctions pursuant to the Rules Pertaining to EMS and EMR Education, EMS Certification or Licensure, and EMR Registration 6 CCR 1015-3, Chapter One. Such notification shall be in writing and shall include a statement of the actions or omissions resulting in termination of supervision and copies of all pertinent records.
5.1.13 Physicians acting as medical directors for EMS education programs recognized by the Department that require clinical and field internship performance by students shall be permitted to delegate authority to a student-in-training during their performance of program-required medical acts and only while under the control of the education program.
5.1.14 Physicians acting as medical directors responsible for the supervision and authorization of a P-CC shall have training and experience in the medical acts for which they are providing supervision and authorization. Additional duties related to medical directors responsible for the supervision and authorization of a P-CC are set forth in Section 17 of these rules.
5.2 EMS agency medical directors shall be trained in Advanced Cardiac Life Support.

Notes

6 CCR 1015-3-2-5
37 CR 12, June 25, 2014, effective 5/21/2014 37 CR 12, June 25, 2014, effective 7/15/2014 37 CR 22, November 25, 2014, effective 12/15/2014 38 CR 24, December 25, 2015, effective 1/14/2016 40 CR 10, May 25, 2017, effective 7/1/2017 40 CR 20, October 25, 2017, effective 1/1/2018 40 CR 21, November 10, 2017, effective 1/1/2018 41 CR 23, December 10, 2018, effective 1/14/2019 43 CR 22, November 25, 2020, effective 1/1/2021 44 CR 23, December 10, 2021, effective 12/30/2021 45 CR 10, May 25, 2022, effective 6/14/2022

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