ASTM F1149-22

Standard Practice for Qualifications, Responsibilities, and Authority of Individuals and Institutions Providing Medical Direction of Emergency Medical Services

SIGNIFICANCE AND USE
4.1 Implementation of this practice will ensure that the EMS system has the authority commensurate with the responsibility to ensure adequate medical direction of all pre-hospital providers, as well as personnel and facilities that meet minimum criteria to implement medical direction of pre-hospital services.  
4.1.1 The state will develop, recommend, and encourage use of a plan that would ensure the standards outlined in this document can be implemented as appropriate at the local, regional, or state level (see Guide F1086).  
4.1.2 This practice is intended to describe and define responsibility for medical directions during transfers. It is not intended to determine the medical or legal, or both, appropriateness of transfers under the Consolidated Omnibus Budget Reconciliation Act and other similar federal or state laws, or both.
SCOPE
1.1 This practice covers the qualifications, responsibilities, and authority of individuals and institutions providing medical direction of emergency medical services.  
1.2 This practice addresses the qualifications, authority, and responsibility of a Medical Director (off-line) and the relationship of the EMS (Emergency Medical Services) provider to this individual.  
1.3 This practice also addresses components of on-line medical direction (direct medical control) including the qualifications and responsibilities of on-line medical physicians and the relationship of the pre-hospital provider to on-line medical direction.  
1.4 This practice addresses the relationship of the on-line medical physician to the off-line Medical Director.  
1.5 The authority for control of medical services at the scene of a medical emergency is addressed in this practice.  
1.6 The requirements for a Communication Resource are also addressed within this practice.  
1.7 This international standard was developed in accordance with internationally recognized principles on standardization established in the Decision on Principles for the Development of International Standards, Guides and Recommendations issued by the World Trade Organization Technical Barriers to Trade (TBT) Committee.

General Information

• Status: Published
• Publication Date: 14-Mar-2022
• ICS: 11.160 - First aid
• Technical Committee: F30 - Emergency Medical Services
• Drafting Committee: F30.03 - Organization/Management

Relations

• Refers: ASTM F1086-94(2016) - Standard Guide for Structures and Responsibilities of Emergency Medical Services Systems Organizations
• Effective Date: 01-Jun-2016
• Refers: ASTM F1031-00(2012) - Standard Practice for Training the Emergency Medical Technician (Basic)
• Effective Date: 01-Jul-2012
• Refers: ASTM F1086-94(2008) - Standard Guide for Structures and Responsibilities of Emergency Medical Services Systems Organizations
• Effective Date: 01-Feb-2008
• Refers: ASTM F1031-00(2006) - Standard Practice for Training the Emergency Medical Technician (Basic)
• Effective Date: 01-Mar-2006
• Refers: ASTM F1031-00 - Standard Practice for Training the Emergency Medical Technician (Basic)
• Effective Date: 10-Oct-2000
• Refers: ASTM F1086-94(2002) - Standard Guide for Structures and Responsibilities of Emergency Medical Services Systems Organizations
• Effective Date: 15-Oct-1994
• Refers: ASTM F1086-94 - Standard Guide for Structures and Responsibilities of Emergency Medical Services Systems Organizations
• Effective Date: 15-Oct-1994

Overview

ASTM F1149-22 is an international standard that outlines the qualifications, responsibilities, and authority of individuals and institutions providing medical direction of Emergency Medical Services (EMS). Issued by ASTM, this practice ensures that EMS systems have both the authority and responsibility to provide adequate medical direction for all pre-hospital providers, personnel, and facilities. The standard fosters best practices in both off-line (system medical director) and on-line (direct physician communication) medical direction, supporting quality patient care and operational efficiency in emergency settings.

Key Topics

• Roles and Authority of Medical Directors
  • Describes the appointment, qualifications (licensed M.D. or D.O.), and system-wide medical accountability for EMS medical directors.
  • Specifies the development and implementation of medical protocols, oversight of EMS personnel, and the authority to suspend or recommend certification/decertification.
• Responsibilities of Pre-Hospital Providers
  • Covers the accountability of individuals such as EMTs, nurses, and dispatchers to the medical director and their operational scope under delegated practice.
• On-Line and Off-Line Medical Direction
  • Details the relationship between EMS providers and both on-line (real-time physician guidance) and off-line medical directors.
  • Outlines protocols for pre-hospital providers to follow during communication with on-line medical direction, including during interfacility transfers and unique situations with intervener physicians.
• Communication Resource Requirements
  • Establishes criteria for designated communication centers (medical control resources) to ensure qualified staffing, responsive support, and efficient medical order relay.
  • Highlights regular case conferences, continuous education, and cooperation with EMS systems for data quality and confidentiality.
• Scene Authority and Interfacility Transfers
  • Clarifies control at emergency scenes, the role of private and intervener physicians, and responsibilities during patient transfers between facilities.

Applications

ASTM F1149-22 is widely applicable to:

• EMS Agencies and Systems: Establishes standardized practices for medical oversight, ensuring clear authority and responsibility at all organizational levels, from local to state.
• State and Regional Medical Regulators: Supports the creation and implementation of local, regional, or state plans for medical direction as referenced in ASTM Guide F1086.
• Emergency Medical Directors and Physicians: Provides a framework for qualifications, responsibility delineation, and authority for both off-line and on-line medical control roles, enhancing patient care and legal compliance.
• Pre-Hospital Care Providers (e.g., Paramedics, EMTs, Nurses): Offers guidance on medical accountability, protocol adherence, and chain of command during medical emergencies and communications.
• Health Communication Centers: Ensures EMS communications are managed by trained professionals and that care instructions are delivered rapidly and according to established protocols.
• Hospitals and Medical Transport Providers: Guides processes for safe, legal, and coordinated patient transfers, emphasizing proper documentation and care continuity.

Related Standards

• ASTM F1086: Guide for Structures and Responsibilities of Emergency Medical Services Systems Organizations.
• ASTM F1031: Practice for Training the Emergency Medical Technician (Basic).

Keywords: emergency medical services, EMS medical direction, medical director, on-line medical control, off-line medical direction, pre-hospital care, communication resource, interfacility transfer, emergency scene authority, medical protocols, ASTM F1149-22.

By applying ASTM F1149-22, organizations can promote effective EMS operations, ensure the highest standards for medical oversight, and enhance patient outcomes in emergency medical care. For complete guidance, refer to the latest published version of the standard from ASTM International.

Standards Content (Sample)

This international standard was developed in accordance with internationally recognized principles on standardization established in the Decision on Principles for the
Development of International Standards, Guides and Recommendations issued by the World Trade Organization Technical Barriers to Trade (TBT) Committee.
Designation:F1149 −22
Standard Practice for
Qualifications, Responsibilities, and Authority of Individuals
and Institutions Providing Medical Direction of Emergency
Medical Services
This standard is issued under the fixed designation F1149; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope F1031 Practice for Training the Emergency Medical Tech-
nician (Basic)
1.1 This practice covers the qualifications, responsibilities,
F1086 Guide for Structures and Responsibilities of Emer-
and authority of individuals and institutions providing medical
gency Medical Services Systems Organizations
direction of emergency medical services.
1.2 This practice addresses the qualifications, authority, and
3. Terminology
responsibility of a Medical Director (off-line) and the relation-
3.1 Definitions of Terms Specific to This Standard:
ship of the EMS (Emergency Medical Services) provider to
3.1.1 communication resource—an entity responsible for
this individual.
implementation of direct medical control. (Also known as
1.3 This practice also addresses components of on-line
medical control resource.)
medical direction (direct medical control) including the quali-
3.1.2 delegated practice—only physicians are licensed to
fications and responsibilities of on-line medical physicians and
practice medicine; pre-hospital providers must act only under
the relationship of the pre-hospital provider to on-line medical
the medical direction of a physician.
direction.
1.4 This practice addresses the relationship of the on-line 3.1.3 direct medical control—when a physician or autho-
medical physician to the off-line Medical Director. rizedcommunicationresourcepersonnel,underthedirectionof
a physician, provides immediate medical direction to pre-
1.5 The authority for control of medical services at the
hospital providers in remote locations. (Also known as on-line
scene of a medical emergency is addressed in this practice.
medical direction.)
1.6 The requirements for a Communication Resource are
3.1.4 emergency medical services system (EMSS)—all com-
also addressed within this practice.
ponents needed to provide comprehensive pre-hospital and
1.7 This international standard was developed in accor-
hospital emergency care including, but not limited to: Medical
dance with internationally recognized principles on standard-
Director, transport vehicles, trained personnel, access and
ization established in the Decision on Principles for the
dispatch, communications, and receiving medical facilities.
Development of International Standards, Guides and Recom-
3.1.5 intervener physicians—a licensed M.D. or D.O., hav-
mendations issued by the World Trade Organization Technical
ing not previously established a doctor/patient relationship
Barriers to Trade (TBT) Committee.
with the emergency patient and willing to accept responsibility
for a medical emergency scene, and can provide proof of a
2. Referenced Documents
2 current medical license.
2.1 ASTM Standards:
3.1.6 medical direction—when a physician is identified to
develop, implement, and evaluate all medical aspects of an
This practice is under the jurisdiction ofASTM Committee F30 on Emergency EMS system. (syn. medical accountability.)
Medical Services and is the direct responsibility of Subcommittee F30.03 on
3.1.7 medical director off-line—a physician responsible for
Organization/Management.
Current edition approved March 15, 2022. Published March 2022. Originally
allaspectsofanEMSsystemdealingwithprovisionofmedical
approved in 1988. Last previous edition approved in 2013 as F1149 – 98 (2013),
care. (Also known as System Medical Director.)
which was withdrawn January 2022 and reinstated in March 2022. DOI: 10.1520/
F1149-22.
3.1.8 on-line medical physician—a physician immediately
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
available, when medically appropriate, for communication of
contact ASTM Customer Service at [e-mail]. For Annual Book of ASTM
medical direction to non-physician pre-hospital providers in
Standards volume information, refer to the standard’s Document Summary page on
the ASTM website. remote locations.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
F1149−22
3.1.9 pre-hospital provider—all personnel providing emer- 5.2.1.5 Active involvement in the training of pre-hospital
gency medical care in a location remote from facilities capable personnel.
of providing definitive medical care.
5.2.1.6 Activeinvolvementinthemedicalaudit,review,and
critique of medical care provided by pre-hospital personnel.
3.1.10 protocols—standards for EMS practice in a variety of
5.2.1.7 Knowledge of the administrative and legislative
situations within the EMS system.
process affecting the local, regional, or state pre-hospital EMS
3.1.11 standing orders—strictly defined written orders for
system, or combinations thereof.
actions, techniques, or drug administration when communica-
5.2.1.8 Knowledge of laws and regulations affecting local,
tion has not been established with an on-line physician.
regional, and state EMS.
4. Significance and Use
5.3 Authority of a Medical Director includes but is not
4.1 ImplementationofthispracticewillensurethattheEMS
limited to:
system has the authority commensurate with the responsibility
5.3.1 Establishing system-wide medical protocols (includ-
to ensure adequate medical direction of all pre-hospital
ing standing orders) in consultation with appropriate special-
providers, as well as personnel and facilities that meet mini-
ists.
mum criteria to implement medical direction of pre-hospital
5.3.2 Recommending certification or decertification of non-
services.
physician pre-hospital personnel to the appropriate certifying
4.1.1 The state will develop, recommend, and encourage
agencies.
use of a plan that would ensure the standards outlined in this
5.3.2.1 Every system shall have an appropriate review and
document can be implemented as appropriate at the local,
appeals mechanism, when decertification is recommended, to
regional, or state level (see Guide F1086).
ensure due process in accordance with law and established
4.1.2 This practice is intended to describe and define re-
local policies. The Director shall promptly refer the case to the
sponsibility for medical directions during transfers. It is not
appeals mechanism for review, if requested.
intended to determine the medical or legal, or both, appropri-
5.3.3 Requiring education to the level of approved profi-
ateness of transfers under the Consolidated Omnibus Budget
ciency for personnel within the EMS system. This includes all
Reconciliation Act and other similar federal or state laws, or
pre-hospital personnel, EMTs at all levels, pre-hospital emer-
both.
gency care nurses, dispatchers, educational coordinators, and
physician providers of on-line direction (see Practice F1031).
5. Medical Director
5.3.4 Suspending a provider from medical care duties for
5.1 Position—System Medical Director (off-line Medical
due cause pending review and evaluation.
Director).
5.3.4.1 Because the pre-hospital provider operates under the
5.1.1 Each EMS system shall have an identifiable Medical
license (delegated practice) or direction of the Medical
Director who, after consultation with others involved and
Director, the director shall have ultimate authority to allow the
interested in the system, is responsible for the development,
pre-hospital provider to provide medical care within the
implementation, and evaluation of standards for provision of
pre-hospital phase of the EMS system.
medical care within the system.
5.3.4.2 Whenever a Medical Director makes a decision to
5.1.1.1 All pre-hospital providers (including EMT (Emer-
suspend a provider from medical care duties, the process shall
gency Medical Technician) basics) shall be medically account-
be prescribed by previously established criteria.
able for their actions and are responsible to the Medical
5.3.5 Establishing medical standards for dispatch proce-
Director of the EMS agency (local, regional, or state) that
dures to ensure that the appropriate EMS response unit(s) are
approves their continued participation.
dispatched to the medical emergency scene when requested
5.1.1.2 All pre-hospital providers, with levels of certifica-
and the duty to evaluate the patient is fulfilled.
tion above EMT basic, shall be responsible to an identifiable
physician who directs their medical care activity. 5.3.6 Establishing under what circumstances non-transport
might occur.
5.1.2 The Medical Director shall be appointed by and
accountable to the appropriate EMS agency in accordance with
5.3.6.1 All decisions by pre-hospital providers regarding
Guide F1086.
non-transport shall be based on defined protocol or on-line
communications.
5.2 Requirements of a Medical Director:
5.3.6.2 Develop a procedure for record keeping when the
5.2.1 The medical aspects (see 5.3) of an emergency medi-
reason for non-transport was the result of a patient’s refusal,
cal service system shall be managed by physicians who meet
including the appropriate forms and review process.
the following requirements:
5.3.7 Establishing under which circumstances a patient may
5.2.1.1 Licensed physician, M.D. or D.O.
be transported against his or her will in accordance with state
5.2.1.2 Experiencein,andcurrentknowledgeof,emergency
law, including procedure, appropriate forms, and review pro-
care of patients who are acutely ill or traumatized.
cess.
5.2.1.3 Knowledge of and access to local mass casualty
plans. 5.3.8 Establishing criteria for level of care and type of
5.2.1.4 Familiarity with Communication Resource opera- transportation to be used in pre-hospital emergency care (that
tions where applicable, including communication with and is, advanced life support versus basic life support, ground, air,
direction of pre-hospital emergency units. or specialty unit transportation).
F1149−22
5.3.9 Establishing criteria for selection of patient destina- 7. Authority for Control of Medical Services at the Scene
tion. of Medical Emergency
5.3.10 Establishing educational and performance standards
7.1 General:
for Communication Resource personnel.
7.1.1 Control of a medical emergency scene shall be the
5.3.11 Establishing operational standards for Communica-
responsibility of the individual in attendance who is most
tion Resource.
appropriately trained and knowledgeable in providing pre-
5.3.12 Conducting effective system audit and quality assur-
hospital emergency stabilization and transport.
ance.
7.1.2 When an advanced life support (ALS) squad, under
5.3.12.1 The Medical Director shall have access to all medical direction, is requested and dispatched to the scene of
relevant EMS records needed to accomplish this task. These an emergency, a doctor/patient relationship has been estab-
documents shall be considered quality assurance documents lished between the patient and the physician providing medical
and shall be privileged and confidential information. direction.
7.1.3 The pre-hospital provider is responsible for the man-
5.3.13 Ensuring the availability of educational programs
agement of the patient and acts as the agent of medical
within the system and that they are consistent with accepted
direction.
local medical practice.
5.3.14 May delegate portions of his or her duties to other
7.2 Patient’s Private Physician Present:
qualified individuals.
7.2.1 When the patient’s private physician is present and
assumes responsibility for the patient’s care, the pre-hospital
6. Direct Medical Control (On-Line Medical Direction)
provider should defer to the orders of the private physician if
they do not conflict with established system protocols and the
6.1 The Practice of Direct Medical Control:
private physician documents the orders in a manner acceptable
6.1.1 On-line medical direction capabilities shall exist and
to the EMS system.
be available within the EMS system, unless impossible due to
7.2.2 The Communication Resource shall be contacted for
distance or geographic considerations.
record keeping purposes to notify the on-line medical physi-
6.1.1.1 All pre-hospital providers above the certification of
cian.
EMT-basic shall be assigned to a specific on-line communica-
7.2.3 When the medical orders of the private physician
tion resource by a predetermined policy.
differ from system protocol, the Communication Resource
6.1.2 Specific local protocols shall exist which define those
shall be contacted and the private physician placed in commu-
circumstances under which on-line medical direction is re-
nication with the on-line physician. If the private physician and
quired.
the on-line physician are unable to agre
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