Clinical Field Supervision of EMS Providers

The clinical practice of EMS medicine encompasses the inherent risk of patient harm caused by errors in medical decision-making. The risk environment includes interpretation of difficult diagnostic testing, performance of invasive clinical interventions, and administration of potentially harmful medications, all of which occur in challenging, often suboptimal, clinical, and operational situations. Fortunately, it is possible to mitigate some of these risks by utilizing proper clinical oversight and supervision of clinical practices, beginning with oversight provided by active and involved EMS physician medical directors.

Although ideally clinical field supervision should be available during every operational period, it is not feasible to expect an EMS physician medical director to be available to provide real-time clinical supervision for every patient encounter. However, such continuously available clinical supervision can and should be accomplished through deployment of dedicated EMS clinical field supervisors that are empowered as an extension of the medical director. Importantly, these supervisors' span of control should be consistent with national incident command standards. Utilization of such a role in the command structure of an EMS agency can thus enhance patient safety by exercising best medical practices employed in other fields of medicine.

The recognition by the American Board of Medical Specialties that EMS is a bona fide practice of medicine highlights the importance of patient safety as a responsibility of an EMS agency. The National EMS Management Association has produced EMS supervisor position guidance with their Seven Pillars of National EMS Officer Competencies (National EMS Management Association, 2014). Yet, with no formal national standard or regulatory requirement, many EMS agencies still fail to implement EMS clinical field supervision into their command structure. Moreover, some agencies utilize providers with a lower level of scope of practice to supervise medical care performed by providers that have a higher scope of practice. In such an arrangement, the supervisor may lack the appropriate level of understanding to recognize clinical errors and correct mistakes. Lastly, some agencies require EMS clinical field supervisors to oversee a number of providers far exceeding the accepted span of control, which is neither manageable nor sustainable, and does not allow for optimal performance of this vital role.

The purpose of this position statement is to highlight the need for appropriate EMS clinical field supervision and to define the ideal characteristics of an EMS clinical field supervisor as a patient safety measure in the growing field of EMS medicine.

The NAEMSP believes that:

•	Clinical field oversight begins with active and involved EMS physician medical directors who, in addition to indirect medical oversight, have the ability to provide real-time medical oversight in the field.
•	EMS clinical field supervision should be implemented into the command structure for all operational EMS programs and utilize a span of control that meets national incident command standards.
•	At a minimum, the EMS clinical field supervisor: ○ serves as a real-time extension of the EMS physician medical director. ○ must be credentialed at or above the level of those they are supervising and approved as a field supervisor by the medical director. ○ will provide direct and indirect clinical oversight as part of a formalized quality improvement program. ○ must have advanced knowledge of EMS clinical and operational practices, EMS regulations, medical terminology, EMS equipment, and local medical systems of care.
•	The model EMS clinical field supervisor: ○ is a provider with experience and leadership skills above rank and file, and the mental aptitude to handle emergencies and manage multiple tasks at once. ○ will provide clinical oversight, as well as supplement the emergency medical response as an additional clinician. Their critical-thinking, problem-solving, and analytical abilities, along with additional training, including that of airway and cardiac arrest management, should allow them to handle both routine and critical calls. ○ should serve as mentors and educators, both in the field and in the classroom, for providers of all ages and experience levels. They should be a ready source of consultation in adverse situations and post-incident briefings. ○ should serve as a liaison to hospitals, clinics, and other community members, dealing with all types of customer-relation issues and quality feedback.