On-line medical direction: a prospective study.

OBJECTIVES: To determine the frequency with which physician, on-line medical direction (OLMD) [direct medical control] of prehospital care results in orders, to describe the nature of these orders, and to measure OLMD time intervals. METHODS: Blinded, prospective study. SETTING: A university hospital base-station resource center. PARTICIPANTS: Ten emergency physicians, 50 advanced life support providers. INTERVENTIONS: Prehospital treatment was directed by both standing orders and OLMD physician orders. Independent observers recorded event times and the characteristics of OLMD. RESULTS: Physician orders were given in 47 (19%) of the 245 study cases, and covered a variety of interventions, including many already authorized by standing orders. Mean OLMD radio time was four minutes (245 +/- 216 seconds [sec]), and time from beginning of OLMD to hospital arrival averaged 12 minutes (718 +/- 439 sec). Mean transport time in this system was 13 minutes. CONCLUSION: Despite detailed standing orders, OLMD results in orders for clinical interventions in 19% of cases. On-line medical direction requires about four minutes of physician time per call. This constituted about one-third of the potential field treatment time interval in this system. Thus, OLMD appears to play an important role in providing quality prehospital care.

Comparison of interventions in prehospital care by standing orders versus interventions ordered by direct [on-line] medical command.

OBJECTIVE: The aim of this study was to compare the patient care measures provided by paramedics according to standing orders versus measures ordered by direct [on-line] medical command in order to determine the types and frequency of medical command orders. DESIGN: Prospective identification of patient care measures done as part of a prehospital quality assurance program. SETTING: An urban paramedic service in the northeast United States with direct medical command from three local hospitals. PARTICIPANTS: One thousand eight paramedic reports from October 1992 through March 1993. INTERVENTIONS: All patient care interventions recorded as done by standing orders or by direct medical command orders. Errors in patient care were determined by the same criteria as in the prior two studies of the same system. RESULTS: Direct medical command gave orders in 143/1,008 (14.2%) cases. Paramedics performed 2,453/2,624 (93.5%) of the total patient care interventions using standing orders. In 61 cases (6.1%), medical command ordered a potentially beneficial intervention not specified by standing orders or not done by the paramedic. 21/171 (12.3%) command orders were for additional doses of epinephrine or atropine in cardiac arrest cases (where the initial doses had been given under standing orders), and 59/171 (34.5%) were for interventions already mandated or permitted by standing orders. The paramedic error rate was 0.6%, and the medical command error rate was 1.8% (unchanged form the prior study of the same standing-orders system). CONCLUSION: Direct medical command gave orders in 14% of cases in this standing-orders system, but 35% of command orders only reiterated the standing orders. More selective and reduced uses of on-line command could be done in this system with no change in the types or numbers of patient care interventions performed.