Out-of-Hospital Medical Direction and the Intervener Physician

Revised June 2024
Approved January 2016
Rescinded October 2015
Revised April 2015 titled “Out-of-Hospital Medical Direction and the Intervener Physician,” April 2008 titled “Direction of Out-of-Hospital Care at the Scene of Medical Emergencies”
Reaffirmed October 2001, October 1997
Revised October 1993 titled “Direction of Prehospital Care at the Scene of Medical Emergencies”
Originally approved April 1984 titled “Control of Advanced Life Support at the Scene of Medical Emergencies”

The American College of Emergency Physicians (ACEP) believes that the direction of out-of-hospital care at the scene of a medical emergency should be the responsibility of the individual in attendance who is most appropriately trained and knowledgeable in providing out-of-hospital emergency care and transport. This is typically a licensed and credentialed EMS clinician acting as part of the responding EMS agency.

The out-of-hospital clinician is responsible for care of the patient and is generally under the oversight of an EMS physician medical director.

This document should guide but not usurp local protocols specifically addressing these issues. This position does not apply when the intervener is an EMS physician within the given EMS system.

Notwithstanding the special situations noted below, the EMS clinician:

• shall act only within the clinician’s scope of practice.
• has a duty to establish direct EMS physician medical oversight if the clinician believes that the emergency care proposed by the scene physician is inconsistent with standard of care.
• reverts to EMS system protocols or direct EMS physician medical oversight for the continued management of the patient at any time when the scene physician is no longer in attendance or if the treatment at the emergency scene differs from existing EMS protocols and is contradictory to quality patient care.

However, in some cases, a physician on scene may assume responsibility for patient care and provide medical direction. If the private physician is present (as may occur in a physician’s office) and assumes responsibility for the patient’s care, the out-of-hospital clinician should defer to the orders of the private physician if approved through direct EMS physician oversight by phone, radio, or telehealth connection if that capability exists. Contact with direct EMS physician medical oversight also provides documentation of the approval and possible collaboration with the treating physician. If an intervener physician is present and on-line medical direction is not available, the EMS clinician at an emergency scene should relinquish responsibility for patient management when the intervener physician has:

• been properly identified
• agreed to assume responsibility for patient care
• agreed to document the intervention in a manner acceptable to the local emergency medical services system (EMSS)
• agreed to accompany the patient to the hospital and provide hand-off to the appropriate medical team, with the potential exception of a mass casualty incident or disaster

When all of these conditions exist, the EMS clinician should defer to the intervenor physician on the scene. Despite the presence of this physician on scene, the EMS clinician shall only act to the limit of their scope of practice. If an intervener physician is present and direct EMS physician medical direction is available, the on-line EMS physician is ultimately responsible. It is the on-line EMS physician’s option to manage the case entirely, work with the intervener physician, or allow the intervener physician to assume responsibility.

In the event:

• of disagreement between the intervener physician and the on-line physician, the EMS clinician should take orders from the on-line EMS physician and place the intervener physician in contact with the on-line EMS physician.
• the intervener physician assumes responsibility, the EMS clinicians should report all of these orders to the on-line EMS oversight. The intervener physician should document the intervention in a manner acceptable to the local EMS system.
• the EMS clinician or on-line EMS medical oversight physician believes that the emergency care rendered by the intervener physician is inconsistent with EMS protocols and quality patient care, on-line medical direction should be re-established. The decision of the intervener physician to accompany the patient to the hospital should be made in consultation with the on-line physician. If a disaster or mass casualty situation exists, an EMS physician shall provide medical oversight within the established command and control system.