OEMS Advisory 23-11-01 M&M Rounds for all EMS Personnel

TO: Massachusetts Licensed Ambulance Services
FROM: Susan Lewis, NRP, Director
DATE: November 21, 2023
RE: Mortality and Morbidity (M&M) Rounds Required for All EMS Personnel
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The Department of Public Health (Department) is issuing this Advisory to clarify the applicability of the Mortality &Morbidity (M&M) rounds requirement, which must be included in affiliation agreements between ambulance services and hospitals for EMT-Basics as well as paramedics and Advanced EMTs. The purpose of this Advisory is to make clear that affiliation agreements must make M&M rounds available to all EMS
personnel, including EMT-Basics.
Under 105 CMR 170.300(B) of the EMS System regulations, which took effect on July 1, 2016, “BLS affiliation agreements shall meet all the requirements of 105 CMR 170.300(A), in accordance with these services’ licensure level.” The purpose of this requirement is to ensure better medical oversight at the BLS level, and to extend to EMT-Basics all the medical oversight provisions of a full affiliation agreement, in
place of the more limited memoranda of agreement (MOA) that previously applied at the BLS level before this regulatory requirement was in place.
The requirement stated in 105 CMR 170.300(A)(7) about M&M rounds refers to EMS personnel providing ALS services: “Regular consultation between medical and nursing staffs and EMS personnel providing ALS services including, but not limited to, attendance at morbidity and mortality rounds and chart reviews.” In adding the requirement in 105 CMR 170.300(B), the Department’s intent is that all the provisions of an affiliation agreement listed in 105 CMR 170.300(A) apply to EMT-Basics.
The Department’s intent is supported by the section within the Department’s Hospital Licensure regulation that lists the duties of a medical control service hospital. Specifically, 105 CMR 130.1502(K) requires that a hospital that provides medical control service shall “Make available to the hospital’s emergency department physicians and nurses and the EMS personnel employed by the service with which the hospital has an
affiliation agreement, morbidity and mortality rounds and chart reviews at a frequency specified in the affiliation agreement.” In referring to EMS personnel and not just EMS personnel providing ALS services,
the Hospital Licensure regulations make clear that affiliation agreements must make the M&M rounds available to EMT-Basics as well as ALS-level EMTs.
Ambulance services with any questions in this regard may contact Zoe Smith, NRP, Deputy Director, at oems.ambulances@mass.gov.