Paramedicine is often dependent on physician medical directors and their associated programs for direction and oversight. A positive relationship between paramedics and their oversight physicians promotes safety and quality care while a strained or ineffective one may threaten these goals. The objective of this study was to explore and understand the professional relationship between paramedics and physician medical oversight as viewed by front-line paramedics.

All active front-line paramedics from four municipal paramedic services involving three medical oversight groups in Ontario were invited to complete an online survey.

Five hundred and four paramedics were invited to participate in the study, with 242 completing the survey (48% response rate); 66% male, 76% primary care paramedics with an average of 13 (SD=9) years of experience. Paramedics had neutral or positive perceptions regarding their autonomy, opportunities to interact with their medical director, and medical director understanding of the prehospital setting. Paramedics perceived medical directives as rigid and ambiguous. A significant amount of respondents reported a perception of having provided suboptimal patient care due to fear of legal or disciplinary consequences. Issues of a lack of support for critical thinking and a lack of trust between paramedics and medical oversight groups were often raised.

Paramedic perceptions of physician medical oversight were mixed. Concerning areas identified were perceptions of ambiguous written directives and concerns related to the level of trust and support for critical thinking. These perceptions may have implications for the system of care and should be explored further.

The pressures facing emergency medical services (EMS) in Wisconsin and their effects on the delivery of prehospital emergency medical care were not known by the Wisconsin EMS Board. In an effort to assess these pressures and the needs of the emergency medical services in the State as perceived by the services, the Board undertook a survey of the EMS providers in Wisconsin.

A survey instrument was developed and approved by the EMS Board and distributed to all of the licensed emergency medical services in Wisconsin.

Of the 453 survey instruments distributed, 323 (71.3%) were completed and returned. Intermediate- and paramedic-level services were more likely to respond than were the basic services, but 235 (72.8%) of the respondents identified their service levels as basic. In addition to providing information about the service characteristics, each responding service also rated the importance of their perceived needs. Lack of medical direction was perceived as the greatest need by all levels of service. However, the second greatest area of need for basic and intermediate services related to difficulty in recruiting new staff. For paramedic services, the second greastest need was associated with dispatching. When comparing services by rural versus urban, difficulty in recruiting new staff and collecting ambulance fees were seen as second and third to lack of a medical director by rural services, whereas urban services noted local training to be in the top three. In the assessment of educational needs, patient-care issues dominated. A review of written comments also demonstrated a difference between rural and urban services, but both noted Medicare and Medicaid reimbursement issues more commonly than any other problem.

In the restructuring of health care, it will be important to consider the various needs of prehospital providers and recognize that such needs may be unique to the providers' location and level of service.

A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to-correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times.

Paramedic trip sheets were reviewed before and after the institution of the QI feedback hop in this interrupted time series design.

The New Castle County, Delaware, Paramedic Program.

All New Castle County paramedics participated in the study.

In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documetation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year.

Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (X2 = 3.04, p <.1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (X2 = 1.40, p <.25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (X2 = 44.24, p <.001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (X2 = 320.5, p <.001).

The use of QI feedback had little effect on psychomotor skills such as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior.

Many states in the United States ‘have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders.

1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders.

Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico.

As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting.

There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders.

The concept of the necessity of a good quality assurance (QA) plan for emergency medical services (EMS) is well-accepted; guidelines as how best to achieve this and how current systems operate have not been defined. The purpose of this study was to survey EMS systems to discover current methods used to perform medical control and QA and to examine whether the existence of an emergency medicine residency affected these components.

A survey was mailed in 1989 to the major teaching hospitals associated with all of the emergency medicine residency programs (n = 79) and all other hospitals with greater than 350 beds within the 50 largest United States metropolitan areas (n = 172). If no response was received, a second request was sent in 1990. The survey consisted of questions concerning four general EMS-QA categories: 1) general information; 2) prospective; 3) immediate; and 4) retrospective medical control.

Completed surveys were received from 78.5% of residency and 50% of non-residency programs. The majority had an emergency medicine physician as medical director (80.1% vs 61.5%, p = .03). While both residency and non-residency hospitals participated in initial public and prehospital personnel education, academic programs were more likely to be involved in continuing medical education (98.2% vs 82.3%, p = .009). On-line (direct) supervision was more likely to be provided by residency institutions (96.4% vs 81.0%, p = .017) which was provided by a physician in 88.3%. Trip sheet review was utilized by 62.0% of non-residency and 75.5% of residency programs responding, and utilized the paramedic coordinator (44.5% vs 46.1%) or medical director (35.7% vs 34.5 %) primarily.

This survey characterizes some of the current methods utilized nationwide in EMS-QA programs. Further research is needed to determine the effectiveness of these various methods, and to develop a model program.