Ill. Admin. Code tit. 77, § 515.330 - EMS System Program Plan
An EMS System Program Plan shall contain the following information:
a) The name, address and
fax number of the Resource Hospital;
b) The names, resumes, and contact
information that includes address, phone, and email addresses of the following
persons:
1) The EMS MD;
2) The Alternate EMS MD;
3) The EMS Administrative Director;
4) The EMS System Coordinator;
c) The name, address and fax
number of each Associate or Participating Hospital (see subsection
(i));
d) The name, email address,
and primary address of each transport and non-transport provider, as well as
vehicle locations participating within the EMS System;
e) A map of the EMS System's service area
indicating the location of all hospitals, licensed healthcare facilities, and
transport and non-transport providers participating in the EMS
System;
f) Current letters of
commitment from the following persons at the Resource Hospital that describe
the commitment of the writer and his or her office to the development and
ongoing operation of the EMS System, and that state the writer's understanding
of and commitment to any necessary changes, such as emergency department
staffing and educational requirements:
1) The
Chief Executive Officer of the hospital;
2) The Chief of the Medical Staff;
and
3) The Director of the Nursing
Services;
g) A letter of
commitment from the EMS MD that describes the EMS MD's agreement to:
1) Be responsible for the ongoing education
of all System personnel, including didactic and clinical experience;
2) Develop and authorize written standing
orders (treatment protocols, standard operating procedures) and certify that
all involved personnel will be knowledgeable and competent in emergency
care;
3) Be responsible for
supervising all personnel participating within the System, as described in the
System Program Plan;
4) Be
responsible for developing or approving a system complaint form and submitting
the following to the Department on a monthly basis:
A) Number of EMS patient care complaints,
including a brief synopsis of the issue;
B) Outcome of the system investigation;
and
C) Names and licenses of the
EMS personnel involved in sustained allegations.
5) Develop or approve one or more patient
care reports covering all types of patient care responses performed by System
providers;
6) Pursuant to Sec.
515.310(k), EMS Systems utilizing an approved EMS provider short patient care
report form will require, at a minimum, the following data elements to be left
at the receiving hospital:
A) Name of
patient;
B) Age;
C) Vital Signs;
D) Chief complaint;
E) List of current medications;
F) List of allergies;
G) All treatment rendered;
H) Date;
I) Time of patient contact; and
J) Mechanism of injury.
7) Develop a policy to ensure that patient
care reports are filed and either transmitted or dropped off at the receiving
hospital within 4 hours when a short form is not provided and 12 hours when a
short form is provided;
8) Ensure
that the Department has access to all records, equipment and vehicles under the
authority of the EMS MD during any Department inspection, investigation or site
survey;
9) Notify the Department of
any changes in personnel providing pre-hospital care in accordance with the EMS
System Program Plan approved by the Department;
10) Be responsible for the total management
of the System, including the enforcement of compliance with the System Program
Plan by all participants within the System;
11) Direct the applicant to the Department's
Division of EMS website for access to an independent renewal form for EMS
Personnel within the System who have not been recommended for relicensure by
the EMS MD; and
h) A description of the method of providing
EMS services, which includes:
1) Single
vehicle response and transport;
2)
Dual vehicle response;
3) Level of
first response vehicle;
4) Level of
transport vehicle;
5) A policy
identifying when and how a patient may be transported directly to an
EMS-System-approved mental health facility if that patient.
A) has no immediate life-threatening
injuries or illness;
B) is
not under the influence of drugs or alcohol;
C) has no immediate or obvious need
for transport to an emergency department; and
D)
has an immediate need for
transport to an EMS-approved mental health facility. (Sec. 3.155(i) of
the EMS System Act)
6) A
policy identifying when a patient may be transported to an
EMS-System-approved urgent care or immediate care facility that meets
the proper criteria and is approved by Online Medical Control or the
EMS Medical Director or Emergency Communications Registered
Nurse. (Sec. 3.155(i) of the Act)
7) A policy that describes in-field service
level upgrade, using advanced level EMS vehicle service providers;
8) A policy that describes ambulance service
provider and vehicle service provider upgrade - rural population
(optional);
9) A policy for
Alternative Staffing Models for private ambulance providers consistent with
Section 515.830(k);
10) Use of mutual aid agreements;
and
11) Informing the caller
requesting an emergency vehicle of the estimated time of arrival when this
information is requested by the caller;
i) A letter of commitment from each Associate
Hospital, Participating Hospital or Veterans Health Administration facility
within the System that includes the following:
1) Signed statements by the hospital's Chief
Executive Officer, Chief of the Medical Staff and Director of the Nursing
Service describing their commitments to the standards and procedures of the
System;
2) A description of how the
hospital will relate to the EMS System Resource Hospital, its involvement in
the ongoing planning and development of the program, and its use of the
education and continuing education aspects of the program;
3) Only at an Associate Hospital, a
commitment to meet the System's educational standards for ECRNs;
4) An agreement to abide by the system policy
regarding the exchange of all medications and equipment with all pre-hospital
providers participating in the System or other EMS System whose ambulances
transport to them;
5) An agreement
to use the standard treatment orders as established by the Resource
Hospital;
6) An agreement to follow
the operational policies and protocols of the System;
7) A description of the level of
participation in the education and continuing education of EMS
Personnel;
8) An agreement to
collect and provide relevant data as determined by the Resource
Hospital;
9) A description of the
hospital's or facility's data collection and reporting methods and the
personnel responsible for maintaining all data;
10) An agreement to allow the Department
access to all records, equipment and vehicles relating to the System during any
Department inspection, investigation or site survey;
11) If the hospital is a participant in
another System, a description of how it will interact within both Systems and
how it will ensure that communications interference as a result of this dual
participation will be minimized; and
12) The names, email addresses, and resumes
of the Associate Hospital EMS MD and Associate Hospital EMS
Coordinator;
j) A letter
of commitment from each ambulance provider participating within the System that
indicates compliance with Section
515.810;
k) Descriptions and documentation of each
communications requirement provided in Section
515.400;
l) The Program Plan shall consist of the EMS
System Manual, which shall be made accessible to all System Participants and
shall include the following Sections:
1)
Education
A) Curricula and standards for all
education programs for EMS Personnel offered or authorized within the System
shall be consistent with national EMS education standards, including any
necessary transitional or bridge education to align System personnel with the
current national EMS education standards.
B) Education, testing and credentialing
requirements for ECRN, PHRN, PHPA, and PHAPRN.
C) Continuing education for EMS Personnel,
including:
i) System requirements (hours,
types of content, etc.);
ii) A plan
for measurement of ongoing competency for all System Participants (i.e.,
quality assurance);
iii)
Requirements for approval of academic course work;
iv) Didactic programs offered by the
System;
v) Clinical opportunities
available within the System; and
vi) Recordkeeping requirements for
participants, which must be maintained at the Resource Hospital.
D) Renewal Protocols
i) System examination requirements for EMS
Personnel;
ii) Procedures for
approval and the renewal of EMS Personnel;
iii) Requirements for submission of
transaction cards for EMS Personnel meeting renewal requirements; and
iv) Department renewal application forms for
EMS Personnel who have not met renewal requirements according to System
records.
E) System
Participant education and information, including:
i) Distribution of System Manual
amendments;
ii) In-services for
policy and protocol changes;
iii)
Methods for communicating updates on System and regional activities, and other
matters of medical, legal and/or professional interest; and
iv) Locations of library/resource materials,
forms, schedules, etc.
F)
A plan that describes how Emergency Medical dispatch agencies and EMRs
participate within the EMS System Program Plan (see Sections
515.710 and
515.725).
G) A System may require that up to one-half
of the continuing education hours that are required toward relicensure, as
determined by the Department, be earned through attendance at System-required
courses.
H) A didactic continuing
education offering or course that has received a State site code or has been
approved by other Department-approved national accrediting bodies shall be
accepted by the System, subject only to the requirements of subsection
(l)(1)(C).
2) Medications
and Equipment
A) A list of all medications and
equipment required for each type of System vehicle;
B) Procedures for obtaining replacements at
System hospitals; and
C) Policies
for appropriate storage and security of medications.
3) Personnel Requirements for EMS Personnel
A) Minimum staffing for each type and level
of vehicle; and
B) Guidelines for
EMS Personnel patient interaction.
4) EMS Protocols, including medical-legal
policies, but not limited to:
A) The Regional
Standing Medical Orders; and
B)
Administrative, Legal and EMS Protocols and Guidelines (Appendix D).
5) Communications standards and
protocols, including:
A) The information
contained in the System Program Plan relating to the requirements of Sections
515.410(a)(1), (2), (3) and
(4) and
515.390(b) and
(c);
B) Protocols ensuring that physician
direction and voice orders to EMS vehicle personnel and other hospitals
participating in the System are provided from the operational control point of
the Resource or Associate Hospital;
C) Protocols ensuring that the voice orders
via radio and using telemetry shall be given by or under the direction of the
EMS MD or the EMS MD's designee, who shall be either an ECRN or
physician;
D) Protocols defining
when an ECRN should contact a physician; and
E) A policy requiring that all on-line
medical direction calls are to be recorded for retrospective review for a
minimum of 365 days, or consistent with the hospital's record retention policy,
whichever is longer.
6)
The EMS System shall have a quality improvement plan which describes how
quality indicators and quality benchmarks are selected and how results and
improved processes are communicated to the system participants.
7) The plan shall also include quality
improvement measures for both adult and pediatric patient care that shall be
performed on a quarterly basis and be available upon Department request;
ambulance operation and System educational activities, including, but not
limited to, monitoring educational activities to ensure that the instructions
and materials are consistent with national EMS education standards for EMTs and
Section 3.50 of the Act; unannounced
inspections of pre-hospital services; and peer review.
8) Data collection and evaluation methods
that include:
A) The process that will
facilitate problem identification, evaluation, patient care gaps,
disease/injury surveillance, and monitoring in reference to patient care and/or
reporting discrepancies from hospital and pre-hospital providers;
B) A policy identifying any additional
required data elements that the EMS provider shall include in their patient
care report;
C) Identified
benchmarks or thresholds that should be met;
D) A copy of the evaluation tool for the
short reporting form, if used, and the pre-hospital reporting form;
and
E) A sample of the required
information and data submitted by the provider to be reported to the Department
summarizing System activity (see Section
515.350).
9) Operational policies that delineate the
respective roles and responsibilities of all providers in the System regarding
the provision of emergency service, including policies identified in Appendix
D.
10) Each EMS System shall
develop an administrative policy that provides the IDPH Division of EMS and
Highway Safety and its State Regional EMS Coordinator with notification the
next business day when an Illinois licensed EMS crew member is killed in the
line of duty.
11) The
responsibilities of the EMS MD.
12)
The responsibilities of the Alternate EMS MD.
13) The responsibilities of the EMS
Administrative Director.
14) The
responsibilities of the EMS System Coordinator, as designated by the EMS MD and
Resource Hospital, including, but not limited to, data evaluation, quality
management, complaint investigation, supervision of all didactic education,
clinical and field experiences, and physician and nurse education as required
by Section 515.320(h);
m)
Written protocols for the
bypassing of or diversion to any hospital, trauma center or regional trauma
center, STEMI center, Comprehensive Stroke Center, Primary Stroke
Center, Acute Stroke-Ready Hospital or Emergent Stroke Ready Hospital,
which provide that a person shall not be transported to a facility
other than the nearest hospital, regional trauma center or trauma
center, STEMI center, Comprehensive Stroke Center, Primary Stroke
Center, Acute Stroke-Ready Hospital or Emergent Stroke Ready Hospital
unless the medical benefits to the patient reasonably expected from the
provision of appropriate medical treatment at a more distant facility outweigh
the increased risks to the patient from transport to the more distant facility,
or the transport is in accordance with the System's protocols for patient
choice or refusal. (Section
3.20(c)(5) of
the Act) The bypass status policy shall include criteria to address how the
hospital will manage pre-hospital patients with life threatening conditions
within the hospital's then-current capabilities while the hospital is on bypass
status. In addition, a hospital can declare a resource limitation, which is
further outlined in the System Plan, for the following conditions:
1) There are no critical or monitored beds
available in the hospital; or
2) An
internal disaster occurs in the hospital;
n) Bypass status may not be honored or deemed
reasonable if multiple hospitals in a geographic area are on bypass status and
transport time by an ambulance to the nearest facility identified in the
regional or system bypass plan exceeds 15 minutes;
o) Each hospital shall have a policy
addressing peak census procedures and a surge capacity plan.
p) The EMS Medical Director may allow for the
Administration of an Initial Occupational Safety and Health Administration
(OSHA) Respirator Medical Evaluation Questionnaire on behalf of fire personnel
provided the following is in place:
1) A
licensed EMT, AEMT, EMT-I, Paramedic, PHRN, PHAPRN, or PHPA may administer the
OSHA respiratory medical evaluation questionnaire according to the employer's
written respiratory protection program and if permitted by the EMS System
Medical Director and according to the policy submitted to the Department for
approval as part of the System Plan;
2) The licensed EMT, AEMT, EMT-I, Paramedic,
PHRN, PHAPRN, or PHPA must have the appropriate training and education to
administer the respiratory evaluation questionnaire;
3) Training and education on the
administration of the respiratory evaluation questionnaire is the
responsibility of the employer;
4)
Any individual who administers the respiratory evaluation questionnaire shall
make the appropriate referrals for medical examination with a Licensed
Physician, APRN, or Physician Assistant as indicated in the Employer's
Respiratory Protection Program;
5)
The employer must maintain all records regarding training and education of EMS
personnel designated to administer the respiratory medical evaluation
questionnaire and EMS Medical Director approval of their ability to administer
the medical evaluation questionnaire at their agency. All records shall be made
available to the EMS System or the Department upon request.
Notes
Amended at 37 Ill. Reg. 19610, effective November 20, 2013
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.