7.27.3 NMAC

This rule was filed as 7 NMAC 27.3.

TITLE 7 HEALTH

CHAPTER 27 EMERGENCY MEDICAL SERVICES

PART 3 MEDICAL DIRECTION FOR EMERGENCY MEDICAL SERVICES

7.27.3.1 ISSUING AGENCY: New Mexico Department of Health, Public Health Division.

[3/16/95, 1/1/97, 4/1/98; Recompiled 10/31/01]

7.27.3.2 SCOPE: These regulations are applicable to all emergency medical services (EMS), EMS medical directors, EMS administrators, EMS providers certified/licensed to provide pre-hospital health care in the state of New Mexico, and the medical direction committee.

[3/16/95, 1/1/97; Recompiled 10/31/01]

7.27.3.3 STATUTORY AUTHORITY: These regulations are promulgated pursuant to the following statutory authorities:

A. the Department of Health Act, Section 9-7-6.E NMSA 1978, which authorizes the secretary of the department of health to “...make and adopt such reasonable and procedural rules and regulations as may be necessary to carry out the duties of the department and its divisions”, and

B. the Emergency Medical Services Act (as amended by Laws of 1993, Chapter 161), Section 24-10B-4.D NMSA 1978, which authorizes the department of health to adopt “regulations for medical direction of a provider or emergency medical system upon the recommendation of the medical direction committee...” The medical direction committee is established pursuant to Section 24-10B-7C NMSA 1978 of the EMS Act.

[3/16/95, 1/1/97; Recompiled 10/31/01]

7.27.3.4 DURATION: Permanent.

[3/16/95, 1/1/97; Recompiled 10/31/01]

7.27.3.5 EFFECTIVE DATE: January 1, 1997, unless a later date is cited at the end of a section or paragraph.

[3/16/95, 1/1/97; Recompiled 10/31/01]

[Compiler’s note: The words or paragraph, above, are no longer applicable. Later dates are now cited only at the end of sections, in the history notes appearing in brackets.]

7.27.3.6 OBJECTIVE: The purpose of these regulations are three fold:

A. they establish the administrative functions for the medical direction committee of the department; and

B. they provide guidelines that outline the elements of medical direction necessary for all components of an EMS system in New Mexico pursuant to Section 24-10B-4D(1) NMSA 1978 of the EMS Act.

C. they establish the legal basis for use of “jumpkits” by EMT providers that are physically separate from ambulance/rescue vehicles.

[3/16/95, 1/1/97, 4/1/98; Recompiled 10/31/01]

7.27.3.7 DEFINITIONS:

A. “Academy” means the emergency medical services training program administered through the department of emergency medicine at the university of New Mexico school of medicine.

B. “Advanced directive” means a written instruction, such as living will or durable power of attorney for health care, recognizable under state law and relating to the provision of health care when a person is incapacitated.

C. “Advanced life support (ALS)” means advanced pre-hospital and inter-facility care and treatment, including basic and intermediate life support, as prescribed by regulation, which may be performed only by a person licensed as a paramedic by the bureau and operating under medical control.

D. “Basic life support (BLS)” means pre-hospital and inter-facility care and treatment, as prescribed by regulation, which can be performed by all licensed emergency medical technicians.

E. “Board-certified” means a physician who has obtained emergency medicine certification by a recognized board of medicine.

F. “Bureau” means the injury prevention and emergency medical services bureau of the public health division of the department.

G. “Commission” means the New Mexico emergency medical services licensing commission appointed by the secretary.

H. “Committee” means the medical direction committee of the bureau.

I. “Consulting pharmacist” means a pharmacist whose services are engaged on a routine part-time basis by an EMS service:

(1) to assist in drawing up correct procedures, rules and regulations for the distribution of dangerous drugs;

(2) to assume the overall responsibility for the system of control and distribution of drugs;

(3) to see that a designated person has the responsibility for day-to-day operation of the EMS service’s dangerous drug supplies; and

(4) to visit the EMS service on a regularly scheduled basis in the course of his/her duties.

J. “Controlled substance” means any drug, substance or immediate precursor enumerated in Schedules I through V of the Controlled Substance Act, Section 30-31-1, et seq. NMSA 1978.

K. “Dangerous drug” means a drug that is determined by law to be unsafe for self-medication and that is enumerated in the New Mexico Drug, Device and Cosmetic Act, Section 26-1-1, et seq. NMSA 1978.

L. “Department” means the New Mexico department of health.

M. “EMS medical director” means a physician who is responsible for all aspects of patient care for an EMS system or EMS provider service, including providing for or ensuring the medical control of EMS providers; the development, implementation, evaluation of medical protocols; and oversight of quality assurance activities.

N. “Emergency medical dispatcher” means a person who is trained and certified pursuant to Subsection G of Section 24-10B-4 NMSA 1978 to receive calls for emergency medical assistance, provide pre-arrival medical instructions, dispatch emergency medical assistance and coordinate its response.

O. “Emergency medical service (EMS)” means the services rendered by licensed emergency medical technicians, certified emergency medical services first responders or emergency medical dispatchers in response to a person’s need for immediate medical care to prevent loss of life or aggravation of physical or psychological illness or injury.

P. “Emergency medical technician (EMT)” means a health care provider who has been certified or licensed to practice by the bureau.

Q. “Intermediate life support (ILS)” means certain advanced pre-hospital and inter-facility care and treatment, including basic life support, as prescribed by regulation, which may be performed only by a person licensed by the bureau and operating under medical control.

R. “Jumpkits” means portable carrying devices that contain emergency medical equipment and/or approved quantities of dangerous drugs and controlled substances that are in the possession of a licensed emergency provider and whose contents are authorized by the service’s EMS medical director.

S. “Medical control” means supervision provided by or under the direction of physicians to providers by written protocol or direct communications.

T. “Medical direction” means guidance or supervision provided by a physician to a provider or emergency medical services system and which includes authority over and responsibility for emergency medical dispatch, direct patient care and transport of patients, arrangements for medical control and all other aspects of patient care delivered by a provider.

U. “New Mexico board of pharmacy” means the authorized board established by the New Mexico Pharmacy Act to regulate pharmaceutical practices in the state of New Mexico.

V. “Physician” means a doctor of medicine or doctor of osteopathy who is licensed or otherwise authorized to practice medicine or osteopathic medicine in New Mexico.

W. “Protocols” means predetermined, written medical care plans and includes standing orders.

X. “Provider” means a person or entity delivering emergency medical services in New Mexico.

Y. “Secretary” means the secretary of the department.

Z. “Scope of practice” means a listing of skills, techniques and medications allowed for use by each level of life support in New Mexico.

AA. “Special Skills” means a set of procedures or therapies that are beyond the usual scope of practice of a given level of life support and that have been approved by the medical direction committee for use by a specified provider.

BB. “Standing Orders” means strictly defined written orders for actions, techniques or drug administration, signed by a physician, to be utilized when an on-line medical control physician is not available.

[3/16/95, 1/1/97, 4/1/98; Recompiled 10/31/01]

7.27.3.8 MEDICAL DIRECTION ADMINISTRATION:

A. Duties: The duties of the medical direction committee shall be:

(1) reviewing the medical appropriateness of all regulations proposed by the bureau;

(2) reviewing and approving the applications of providers for special skills authorizations, as outlined in 7 NMAC 27.2 [now 7.27.2 NMAC] “Certification and Licensing of EMS Personnel”, or such other regulations as may be adopted by the department;

(3) assisting in the development of regulations pertaining to medical direction;

(4) updating at least annually a list of skills, techniques, and medications approved for each level of life support that will be approved by the secretary and issued by the bureau. These skills, techniques and medications shall be called the “scope of practice” and will be attached as an Appendix to 7 NMAC 27.3 [now 7.27.3 NMAC] “Certification and Licensing of EMS Personnel”, or such other regulations as may be adopted by the department; and,

(5) as needed, develop guidelines and appendices to regulations governing medical direction issues as prescribed by law;

(6) collecting data from the EMS community in order to oversee the actual medical impact of the approved scope of practice for each level and for actions undertaken or contemplated.

B. Organization: Members of the medical direction committee are appointed by the secretary as provided by law.

(1) Membership shall be nine individuals including:

(a) the state EMS medical director who shall serve as chair;

(b) one physician representative experienced in pre-hospital care selected from a list proposed by the New Mexico chapter of the American college of emergency physicians;

(d) one physician from each of the EMS geographic regions (may be the regional medical director or other physician within the region); and,

(e) one emergency medical technician from each level of life support.

(f) There shall be no designated term of service for these members who shall serve at the pleasure of the secretary.

(2) In the event of a vacancy on the committee by resignation or removal, the bureau shall immediately notify the secretary so as to expedite the appointment of a new member.

(3) The committee may recommend to the secretary the removal of any member for the following reasons:

(a) failing to attend or otherwise participate in two (2) consecutive meetings without a valid reason; or,

(b) any other good cause.

(4) The state EMS medical director shall serve as chair. If he/she is unable to chair a meeting, the chair shall be assumed by a member appointed by the state EMS medical director.

(5) The bureau shall serve as staff for the committee.

C. Meetings: The committee shall meet as needed, but not less than semiannually. Minutes of the meetings shall be taken and maintained at the bureau.

D. Reconsideration process: If a recommendation made by the committee is not accepted by the bureau:

(1) the bureau shall communicate in writing to the committee as to the reasons for that recommendation not being accepted.

(2) at the request of the committee, the decision shall be submitted for reconsideration to the director of the public health division of the department and subsequently to the secretary.

(3) any decision made pursuant to a request for reconsideration shall be communicated in writing by the department to the committee.

[3/16/95, 1/1/97, 4/1/98; Recompiled 10/31/01]

7.27.3.9 MEDICAL DIRECTION GUIDELINES:

A. General: These guidelines provide overall guidance for the performance of medical direction in New Mexico. The guidelines set forth the qualifications, responsibilities and activities of a system’s designated medical director. The guidelines will also define a process for notifying the EMS bureau of the withdrawal of medical control by a physician from a provider, and specifying requirements for medical direction of intermediate and advanced life support personnel and basic life support personnel with special skills approval. Finally, the guidelines with set forth the legal requirements for an EMS system to maintain “jumpkits” under the authorization of the EMS medical director. Each guideline in Paragraphs 9 and 10 are prefaced by either the word “mandatory” or the word “recommended”. Mandatory items are required, while recommended items are highly recommended.

B. Medical director oversight:

(1) (Mandatory) A designated medical director shall be required for all the situations outlined below:

(a) a certified ambulance carrier as defined in state corporation commission (SCC) Regulation 18 NMAC 4.2 [now 18.4.2 NMAC], or such other rules as may be promulgated by the SCC or its successor agency;

(b) all advanced life support and intermediate life support EMTs;

(c) all basic life support EMTs who provide advanced life support skills, medications, and/or techniques authorized under the scope of practice or special skills authorizations; and

(d) all EMTs or first responders who provide semi-automatic defibrillation services.

(2) (Recommended) All other services operating on a basic life support (BLS) level are urged to have a local or system-wide medical director as feasible by local situations and availabilities.

C. Medical director qualifications: The qualifications for an EMS medical director are provided below. A medical director:

(1) (Mandatory) shall be an M.D. or D.O. licensed or otherwise authorized to practice medicine in New Mexico;

(2) (Mandatory) shall, if a new medical director, complete one of the below listed medical direction education/training methods within one year of assuming the responsibilities of a medical director; current medical directors shall complete one of the below listed methods of medical direction education/training within two years of the effective date of this regulation:

(a) a nationally-recognized EMS medical director’s course; or

(b) a bureau-recognized orientation course; or

(3) (Mandatory) The bureau shall be notified within thirty (30) days when a new EMS medical director assumes responsibilities or when a medical director is no longer providing those duties for a service.

(4) (Recommended) may be familiar with the design and operation of EMS systems;

(5) (Recommended) may be experienced in, and possess current knowledge of, emergency care of patients who are acutely ill or traumatized (emergency medicine board-certification and/or certification in recognized training such as advanced cardiac life support (ACLS), advanced trauma life support (ATLS), or pediatric advanced life support (PALS) are recommended);

(6) (Recommended) may be actively involved and knowledgeable in:

(a) the emergency management of acutely ill or injured patients;

(b) the training and continuing education of EMS personnel under the medical director’s supervision at their level of certification;

(c) the quality assurance program of a service including, but not limited to, medical audit, review and critique of basic and advanced level EMS personnel;

(d) the administrative and legislative processes affecting regional and/or state pre-hospital EMS organizations; and

(e) the laws and regulations affecting local, regional and state EMS services and personnel.

D. Administrative and system oversight responsibilities: The EMS medical director, in conjunction with the local EMS service director and other local advisory boards or committees shall provide the responsibilities outlined below (any element of these responsibilities may be delegated as appropriate to other qualified individuals within the EMS system):

(1) advise the program administrator on all elements of the EMS program as to their medical appropriateness and to assure the quality medical services are being provided;

(2) approve the level of pre-hospital care which may be rendered locally by each of the EMS personnel employed by and/or volunteering with the services under the medical director’s supervision;

(3) regardless of an EMS provider’s level of state certification or licensure, approve the level that each EMS provider may function at locally, before the provider is permitted to perform pre-hospital care to the public;

(4) establish and monitor field performance standards for EMS personnel in the service;

(5) assist in development of local disaster and mass casualty plans;

(6) develop and sign a contract or letter of agreement between the medical director and the EMS service outlining the specific responsibilities, authorities and, if appropriate, compensation of the EMS medical director;

(7) develop procedures with the service on a method by which the medical director may withdraw medical control for an EMS provider who is non-compliant with these guidelines, other relevant laws and regulations and accepted medical standards. The procedure shall be outlined in the contract or letter of agreement between the medical director and the service; shall reflect any internal procedures of that EMS service and due process afforded individual providers, if any, as outlined by the service; and

(8) establish local medical standards for dispatch procedures to assure the appropriate EMS response units are dispatched to the medical emergency scene. This should include development of a relevant emergency medical dispatch system with the local agency providing dispatch for the EMS service.

E. Protocol development: The medical director shall:

(1) develop, implement, and revise written treatment protocols and standing orders governing pre-hospital care and medical aspects of patient triage, transport, transfer, dispatch, extrication, rescue and radio telephone communication by the EMS service; and

(2) establish written protocols under which circumstances the EMS service may:

(a) not transport a patient when there has been an initial call for services;

(b) transport a patient against his/her will, in accordance with state law including procedure, appropriate forms and review process;

(d) interaction with an intervening health care provider at the scene of an emergency;

(e) not begin or terminate life support measures in patients with EMS do not resuscitate (DNR) orders, hospice protocols and other legally recognized advanced directives; and

(f) triage and transport trauma patients consistent with state patient triage criteria and transport protocols.

F. Training responsibilities: The medical director shall:

(1) establish and monitor the training standards of a service for initial and continuing medical education; and

(2) provide, as appropriate, educational sessions for EMS personnel within the service.

G. Quality assurance/improvement responsibilities: The medical director shall plan, develop and implement a system for ongoing medical audit of pre-hospital patient care rendered by the EMS service and its personnel. This auditing system shall provide for, but not be limited to:

(1) an organized method for internal collection of operational and patient care data, including access to both pre-hospital and outcome records to permit identification and resolution of problems impacting the quality of patient care;

(2) a comprehensive mechanism for receipt, investigation and resolution of medically-related complaints about the EMS service;

(3) regular review and on-site evaluation of EMS personnel operating within the service; and

(4) regular review of the overall system to assure compliance with state corporation commission Regulation 18 NMAC 4.2 [now 18.4.2 NMAC], or such other rules as may be adopted by the SCC or its successor agency.

H. Medical liaison responsibilities: The medical director shall:

(1) function as the liaison between the EMS system and the local medical community, medical facilities and regional/state EMS medical directors; and

(2) as needed, be available to represent the medical aspects of an EMS service to local, regional or state boards/committees, as well as political subdivisions such as municipal governing bodies or legislatures.

I. Notification of withdrawal or restriction of medical support: An EMS medical director may withdraw or restrict all or any of the medical control authorized to a provider under his/her medical direction in the following manner:

(1) the withdrawal or restriction shall be made in writing and sent to the EMS provider, EMS service director and operations section of the bureau within five (5) working days of the action; and

(2) the bureau shall perform a preliminary investigation and decide, after consultation with the EMS medical director and service director, whether or not the matter shall be referred to the commission for investigation with potential impact on licensure or be handled locally within the service.

J. Medication control and storage: The EMS medical director shall: if appropriate for the local service, develop a program whereby reasonable quantities of dangerous drugs may be possessed and transported to other locations by authorized personnel in “jumpkits”. These “jumpkits” will be kept at the authorized personnel’s residence(s) or vehicle(s) and will be stored according to the New Mexico board of pharmacy regulations (i.e., temperature control and security).

(1) The specific dangerous drugs and the quantities allowed in “jumpkits” will be determined and approved by the EMS medical director and made available to the New Mexico board of pharmacy or its staff, as requested.

(2) A list of authorized personnel who maintain “jumpkits” shall be made available at the request of the New Mexico board of pharmacy or its staff.

(3) An inventory of all dangerous drugs, including controlled substances, issued to authorized personnel for “jumpkits” will be kept for a period of three (3) years and will include the following:

(a) date issued;

(b) name of authorized personnel;

(4) The “jumpkits” will be made available during consulting pharmacist inspections, as requested, and with advance notice, to the New Mexico board of pharmacy inspectors.

(5) “Jumpkits” which are authorized by the EMS medical director, to including [sic] specifically approved quantities of controlled substances, shall be on the EMT’s person or double-locked and secure. Controlled substances shall not be stored in unattended vehicles.

[3/16/95, 1/1/97, 4/1/98; Recompiled 10/31/01]

HISTORY OF 7.27.3 NMAC:

Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:

DOH Regulation 95-02 (CHSD), Regulations Governing Emergency Medical Services Medical Direction for the State of New Mexico, 3/16/95.

History of Repealed Material: [RESERVED]