title: Physician medical direction and clinical performance at an established emergency medical services system.
abstract: OBJECTIVE
  Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time.
  
  
  METHODS
  Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced.
  
  
  RESULTS
  Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001).
  
  
  CONCLUSIONS
  We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.
authors.affiliation: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. munkm@upmc.edu
authors.forename: Marc-David
authors.initials: MD
authors.lastname: Munk
authors.forename: Shaun D
authors.initials: SD
authors.lastname: White
authors.forename: Malcolm L
authors.initials: ML
authors.lastname: Perry
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Platt
authors.forename: Mohammed S
authors.initials: MS
authors.lastname: Hardan
authors.forename: Walt A
authors.initials: WA
authors.lastname: Stoy
mesh_terms: D016001:Confidence Intervals; D004632:Emergency Medical Services / Q000592:standards / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D016017:Odds Ratio; D010414:Pennsylvania; D008486:Physician Executives; D010819:Physician's Role; D015397:Program Evaluation