Section 515.330  EMS System Program Plan

 

An Emergency Medical Services (EMS) System Program Plan shall contain the following information:

 

a)         The name, address and fax number of the Resource Hospital;

 

b)         The names and resumes of the following persons:

 

1)         The EMS Medical Director,

 

2)         The Alternate EMS Medical Director,

 

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) of this Section);

 

d)         The name and address of each ambulance provider participating within the EMS System;

 

e)         A map of the EMS System's service area indicating the location of all hospitals and ambulance providers participating in the System;

 

f)          Current letter(s) of commitment from the following persons at the Resource Hospital, which describe the commitment of the writer and his or her office to the development and ongoing operation of the EMS System, and which 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 Medical Director that describes the EMSMD's agreement to:

 

1)         Be responsible for the ongoing education of all System personnel, including coordinating didactic and clinical experience;

 

2)         Develop written standing orders (treatment protocols, standard operating procedures) to be used in the EMSMD's absence and certify that all involved personnel will be knowledgeable in emergency care and capable of providing treatment and using communications equipment once the program is operational;

 

3)         Be responsible for supervising all personnel participating within the System, as described in the System Program Plan;

 

4)         Develop or approve one or more ambulance emergency run reports (run sheets) covering all types of ambulance runs performed by System ambulance providers;

 

5)         Ensure that the Department has access to all records, equipment and vehicles under the authority of the EMSMD during any Department inspection, investigation or site survey;

 

6)         Notify the Department of any changes in personnel providing pre-hospital care in accordance with the EMS System Program Plan approved by the Department;

 

7)         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;

 

8)         Ensure that a copy of the application for renewal (a form supplied by the Department) is provided to every EMT-B, EMT-I or EMT-P within the System who has not been recommended for relicensure by the EMS Medical Director; and

 

9)         Be responsible for compliance with the provisions of Sections 515.400 and 515.410 of this Part;

 

h)         A description of the method(s) 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)         use of mutual aid agreements; and

 

6)         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 or Participating Hospital 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 provide exchange of all drugs 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 training and continuing education of pre-hospital personnel;

 

8)         An agreement to collect and provide relevant data as determined by the Resource Hospital;

 

9)         A description of the hospital'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 and resumes of the Associate Hospital EMS Medical Director and Associate Hospital EMS Coordinator;

 

j)          A letter of commitment from each ambulance provider participating within the System, which indicates compliance with Section 515.810 of this Part;

 

k)         Descriptions and documentation of each communications requirement provided in Section 515.400 of this Part;

 

l)          The Program Plan shall consist of the EMS System Manual, which shall be provided to all System participants and shall include the following Sections:

 

1)         Education and Training

 

A)        Content and curricula of training programs for EMT, Emergency Medical Dispatcher, First Responder, Pre-Hospital RN, ECRN and Lead Instructor candidates, including:

 

i)          Entrance and completion requirements;

 

ii)         Program schedules;

 

iii)         Goals and objectives;

 

iv)        Subject areas;

 

v)         Didactic requirements, including skills laboratories;

 

vi)        Clinical requirements;

 

vii)        Testing formats;

 

B)        Training program for Prearrival Medical Instructions, if applicable, including:

 

i)          Entrance and completion requirements;

 

ii)         Description of course materials;

 

iii)         Testing formats;

 

C)        Continuing education for EMTs, Pre-Hospital RNs, ECRNs, including:

 

i)          System requirements (hours, types of programs, etc.);

 

ii)         System program for System participants:  types of activities covered (e.g., telemetry review, and morbidity and mortality conferences) and protocols for enrollment and completion;

 

iii)         Requirements for approval of academic course work;

 

iv)        Didactic programs offered by the System;

 

v)         Clinical opportunities available within the System;

 

vi)        Record-keeping requirements for participants, which must be maintained at the Resource Hospital;

 

D)        Renewal Protocols

 

i)          System examination requirements for EMTs, Pre-Hospital RNs, ECRNs;

 

ii)         Procedures for renewal of Pre-Hospital RN and ECRN approvals;

 

iii)         Submission of transaction cards for EMTs meeting renewal requirements;

 

iv)        Providing Department renewal application forms to EMTs 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;

 

iv)        Locations of library/resource materials, forms, schedules, etc.;

 

F)         A plan for phasing in Emergency Medical Dispatcher and First Responder registration requirements over a five-year period for Emergency Medical Dispatchers and First Responders who choose to be included in the Program Plan (see Sections 515.710 and 515.720 of this Part);

 

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-taught courses;

 

H)        A didactic continuing education course that has received a State site code shall be accepted by the System, subject only to the requirements of subsection (l)(1)(C) of this Section;

 

2)         Drugs and Equipment

 

A)        A list of all drugs and equipment required for each type of System vehicle;

 

B)        Procedures for obtaining replacements at System hospitals;

 

3)         Personnel Requirements for EMTs

 

A)        Minimum staffing for each type and level of vehicle;

 

B)        Guidelines for EMT patient interaction;

 

4)         In-Field Protocols, including medical-legal policies but not limited to:

 

A)        The Regional Standing Medical Orders;

 

B)        System Standing Medical Orders as listed in Section 515.Appendix D;

 

C)        Appropriate interaction with law enforcement on the scene;

 

D)        When and how to notify a coroner or medical examiner;

 

E)         Appropriate interaction with an independent physician/nurse on the scene;

 

F)         The use of restraints;

 

G)        Consent for treatment of minors;

 

H)        Patient choice and refusal regarding treatment, transport, and/or destination;

 

I)          The duty to perform all services without unlawful discrimination;

 

J)         Offering immediate and adequate information regarding services available to victims of abuse, for any person suspected to be a victim of domestic abuse;

 

K)        Patient abandonment;

 

L)         Emotionally disturbed patients;

 

M)       Patient confidentiality and release of information;

 

N)        Durable power of attorney for health care;

 

O)        Do Not Resuscitate (DNR) orders (see Section 515.380 of this Part); and

 

P)         A policy concerning the use of latex-free supplies;

 

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 (g) of this Part;

 

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 the voice orders via radio and using telemetry shall be given by or under the direction of the EMS Medical Director or the EMSMD's designee, who shall be either an ECRN, or physician; and

 

D)        Protocols defining when an ECRN should contact a physician;

 

6)         Quality improvement measures for both adult and pediatric patient care should be performed on a quarterly basis and be available upon Department request; ambulance operation and System training activities, including but not limited to monitoring training activities to ensure that the instructions and materials are consistent with United States Department of Transportation training standards for EMTs and Section 3.50 of the Act; unannounced inspections of pre-hospital services; and peer review;

 

7)         Data collection and evaluation methods that include:

 

A)        The process that will facilitate problem identification, evaluation and monitoring in reference to patient care and/or reporting discrepancies from hospital and pre-hospital providers;

 

B)        A copy of the pre-hospital reporting form;

 

C)        A sample of the information and data to be reported to the Department summarizing System activity (see Section 515.350 of this Part);

 

8)         Operational policies that delineate the respective roles and responsibilities of all providers in the System regarding the provision of emergency service, including:

 

A)        Resource Hospital overrides (situations in which Associate Hospital orders are overruled by the Resource Hospital);

 

B)        Infectious disease and disinfection procedures, including the policy on significant exposure;

 

C)        Reporting and documentation of problems; and

 

D)        Protocols for ILS/ALS System personnel to assess the condition of a patient being initially treated in the field by BLS personnel, for the purpose of determining whether a higher level of care is warranted and transfer of care of the patient to the ILS or ALS personnel is therefore appropriate.  Such protocols shall include a requirement that neither the assessment nor the transfer of care can be initiated if it would appear to jeopardize the patient's condition, and shall require that such activities of the System personnel be done under the immediate direction of the EMS Medical Director or designee;

 

9)         Any procedures regarding disciplinary and/or suspension decisions and the review of those decisions that the System has elected to follow in addition to those required by the Act;

 

10)       Any System policies regarding abuse of controlled substances or conviction of a felony crime by System personnel whether on or off duty;

 

11)       The responsibilities of the EMS Coordinator(s), as designated by the EMS Medical Director, including data evaluation, supervision of clinical, didactic and field experience training, and physician and nurse education as required; and

 

12)       The responsibilities of the EMS Medical Director;

 

m)        A F4written protocol for the bypassing of or diversion toF2 a F4hospital, trauma center or Regional trauma center other than the nearest hospital, Regional trauma center or trauma center 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.F2 (Section 3.20(c)(5) of the Act)  The bypass status policy should include a statement that for any life-threatening condition a patient may be transported to the closest facility, whether or not that facility 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 if three or more hospitals in a geographic area are on bypass status and transport time by an ambulance to the nearest facility exceeds 15 minutes;

 

o)         Each hospital shall have a policy addressing peak census procedures, such as the model policy developed by the Department.

 

(Source:  Amended at 25 Ill. Reg. 16386, effective December 20, 2001)