Controlled medical acts are specified in the Regulated Health Professions Act, 1991 (RHPA) as acts which may only be performed by authorized regulated health professionals. Examples of controlled acts include but are not limited to:

1. Administering a substance by injection or inhalation (ex. naloxone)
2. Applying or ordering the application of a form of energy prescribed by the regulations under the RHPA (ex. Defibrillation).

Delegation is a mechanism that allows a regulated health professional (ex. a physician) who is authorized to perform a controlled act to temporarily grant that authority to another person (whether regulated or unregulated) who is not legally authorized to perform the act independently (ex. paramedics, firefighters). Delegation is intended to provide physicians with the ability to extend their capacity to serve patients by temporarily authorizing an individual to act on their behalf. Delegation is intended to be a physician extender, not a physician replacement. Physicians must only delegate controlled acts when doing so is in the best interest of the patient. This includes only delegating when the act can be performed safely, effectively, and ethically. Therefore, physicians must only delegate when:

• the patient’s health and/or safety will not be put at risk;
• the patient’s quality of care will not be compromised by the delegation; and
• delegating serves at least one of the following purposes:
  • promotes patient safety,
  • facilitates access to care where there is a need,
  • results in more timely or efficient delivery of health care, or
  • contributes to optimal use of healthcare resources.

In the prehospital setting medical directives are the most common modality used to delegate controlled acts. Medical directives are written orders by physician(s) to other care provider(s) that pertain to any patient who meets the criteria set out in the medical directive. When a medical directive calls for acts that need to be delegated, it provides the authority to carry out the treatments, procedures, or other interventions that are specified in the directive, provided that certain conditions and circumstances exist.

With Tiered Response Agreements, firefighters can respond to certain medical calls through an organized response (9-1-1 activation). In these calls, firefighters may be called upon to provide controlled acts (ex. defibrillation to a patient in cardiac arrest) as part of the organized response.

Historically, some Fire Services have argued that their staff do not require medical oversight to perform controlled acts as they feel they are covered under the Chase McEachern and Good Samaritan Act. The Chase McEachern Act was introduced in 2006 and protects people from liability if they assisted someone, using a defibrillator, at an emergency (under certain conditions).

The legal opinion obtained by many Base Hospitals (which provide medical delegation and oversight to paramedics and other prehospital providers) is that the Act does not cover those for whom it is an expectation of the job to complete this controlled act. Firefighters are responding to these calls as part of the 9-1-1 emergency response system and are not deemed to be lay citizens who are providing care during a medical emergency.

Furthermore, medical delegation and medical oversight for Fire Services allows for:

• access to the most up to date evidence-based prehospital medicine for emergency medical calls that firefighters may attend and provide care at
• seamless transition of care between firefighters and paramedics, as medical directors are familiar with the paramedic medical directives to ensure care provided by firefighters is in keeping with the care that paramedics will provide once they assume care
• medical expertise to assist with appropriate medical equipment purchases
• ongoing continued medical education for controlled acts and medical quality assurance/improvement for medical care provided to community members by firefighters

The Southwest Centre for Prehospital Medicine (SWCPM) provides medical delegation and oversight for multiple Fire Services in Southwest Ontario. This program includes yearly Continuing Medical Education and re-certification, ongoing quality assurance program with the ability to identify areas for potential quality improvement, and a team that has Prehospital and Transport Medicine expertise. The SWCPM Medical Director and Program Director are members of the Ontario Base Hospital Group Medical Advisory Committee (OBHG MAC) that provides medical advice to the Ministry of Health Emergency Health Regulation and Accountability Branch (EHRAB) which oversees paramedic care in Ontario. As a result, our team is up to date on the latest evidence, best care practices, and a robust understanding of the prehospital care landscape in Ontario and how care should be provided so that it flows seamlessly from one care provider to another (ex. firefighter to paramedic to emergency medicine care team).

Sincerely,