TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER f: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 515 EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE
SECTION 515.860 CRITICAL CARE TRANSPORT


 

Section 515.860  Critical Care Transport

 

a)         "Critical care transport" means the pre-hospital or inter-hospital transportation of a critically injured or ill patient by a vehicle service provider, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. When medically indicated for a patient, as determined by a physician licensed to practice medicine in all of its branches, an advanced practice nurse, or a physician's assistant, in compliance with Section 3.155(b) and (c) of the Act, critical care transport may be provided by:

 

1)         Department-approved critical care transport providers, not owned or operated by a hospital, utilizing EMT-Paramedics with additional training, nurses, or other qualified health professionals; or

 

2)         Hospitals, when utilizing any vehicle service provider or any hospital-owned or operated vehicle service provider. Nothing in the Act requires a hospital to use, or to be, a Department-approved critical care transport provider when transporting patients, including those critically injured or ill. Nothing in the Act shall restrict or prohibit a hospital from providing, or arranging for, the medically appropriate transport of any patient, as determined by a physician licensed to practice medicine in all of its branches, an advanced practice nurse, or a physician's assistant. (Section 3.10(f-5) of the Act)

 

b)         All critical care transport providers must function within a Department-approved EMS System. Nothing in this Part shall restrict a hospital's ability to furnish personnel, equipment, and medical supplies to any vehicle service provider, including a critical care transport provider. (Section 3.10(g-5) of the Act)

 

c)         For the purposes of this Section, "expanded scope of practice" includes the accepted national curriculum plus additional training, education, experience, and equipment (see Section 515.360) as approved by the Department pursuant to Section 3.55 of the Act.  Tier I transports are considered "expanded scope of practice".

 

d)         For the purposes of this Section, critical care transport plans are defined in three tiers of care.  Tier II and Tier III are considered Critical Care Transports.

 

e)         Tier I

Tier I provides a level of care for patients who require care beyond the paramedic USDOT Curriculum scope of practice, up to but not including the requirements of Tiers II and III.  Tier I transport includes the use of a ventilator, the use of infusion pumps with administration of medication drips, and maintenance of chest tubes.

 

1)         Personnel Staffing and Licensure

 

A)        Licensure:

 

i)          Licensed Illinois Paramedic or Pre-Hospital Registered Nurse (PHRN);

 

ii)         Scope of practice more comprehensive than USDOT Curriculum, as approved by the Department in accordance with the EMS System Plan (see Sections 515.310 and 515.330); and

 

iii)        Approved to practice by the Department in accordance with the EMS System Plan.

 

B)        Minimum Staffing:

 

i)          EMT-Basic, Intermediate or Paramedic/PHRN as driver; and

 

ii)         Paramedic Expanded Scope of Practice credentialed individual or PHRN, who shall remain with the patient at all times.

 

2)         Education, Certification, and Experience

 

A)        Initial Education:  Documentation of initial education and demonstrated competencies of expanded scope of practice skills as required by Tier I Level of Care and approved by the Department in accordance with the EMS System Plan.

 

B)        Continuing Education Requirements:

 

i)          Annual competencies of expanded scope of practice knowledge, equipment and procedures shall be completed; and

 

ii)         The EMS vehicle service provider shall maintain documentation of competencies and provide documentation to the EMS Resource Hospital upon request.

 

C)        Certifications − Tier I personnel shall maintain all renewable critical care certifications and credentials in active status:

 

i)          Advanced Cardiac Life Support (ACLS);

 

ii)         Pediatric Education for Pre-Hospital Professionals (PEPP) or Pediatric Advance Life Support (PALS); and

 

iii)        International Trauma Life Support (ITLS) or Pre-Hospital Trauma Life Support (PHTLS).

 

D)        Experience:

 

i)          Minimum of one year of experience functioning in the field at an ALS level; and

 

ii)         Documentation of education and demonstrated competencies of expanded scope of practice skills required for Tier I Level of Care, approved by the Department and included in the EMS System Plan.

 

3)         Medical Equipment and Supplies

 

A)        Ventilator; and

 

B)        Infusion pumps.

 

4)         Vehicle Standards

Any vehicle used for providing expanded scope of practice care shall comply at a minimum with Section 515.830 (Ambulance Licensing Requirements) or Sections 515.900 (Licensure of SEMSV Programs –General) and 515.920 (SEMSV Program Licensure Requirements for All Vehicles) regarding licensure of SEMSV programs and SEMSV vehicle requirements, including additional medical equipment and ambulance equipment as defined in this Section. Any vehicle used for expanded scope of practice transport shall be equipped with an onboard alternating current (AC) supply capable of operating and maintaining the AC current needs of the required medical devices used in providing care during the transport of a patient.

 

5)         Treatment and Transport Protocols shall address the following:

 

A)        EMS System Medical Director or Designee present at established Medical Control;

 

B)        Communication points for contacting Medical Control and a written Expanded Scope of Practice Standard;

 

C)        Written operating procedures and protocols signed by the EMS MD and approved for use by the Department in accordance with the System Plan; and

 

D)        Use of a ventilator, infusion pumps with administration of medication drips, and maintenance of chest tubes.

 

6)         Quality Assurance Program

 

A)        The Tier I transport provider shall develop a written Quality Assurance (QA) Plan approved by the EMS System and the Department in accordance with subsection (e)(6)(D).  The provider shall provide quarterly QA reports to the assigned EMS Resource Hospitals for the first 12 months of operation.

 

B)        The EMS System shall establish the frequency of quality reports after the first year if the System has not identified any deficiencies or adverse outcomes.

 

C)        A Medical Director shall oversee the QA Program.

 

D)        The QA Plan shall evaluate all expanded scope of practice activity for medical appropriateness and thoroughness of documentation. The review shall include:

 

i)          Review of transferring physician orders and evidence of compliance with those orders;

 

ii)         Documentation of vital signs and frequency and evidence that abnormal vital signs or trends suggesting an unstable patient were appropriately detected and managed;

 

iii)        Documentation of any side effects/complications, including hypotension, extreme bradycardia or tachycardia, increasing chest pain, dysrhythmia, altered mental status and/or changes in neurological examination, and evidence that interventions were appropriate for those events;

 

iv)        Documentation of any unanticipated discontinuation of a catheter or rate adjustments of infusions, along with rationale and outcome;

 

v)         Review of any Medical Control contact for further direction;

 

vi)        Documentation that any unusual occurrences were promptly communicated to the EMS System; and

 

vii)       A root cause analysis of any event or care inconsistent with standards. The EMS System educator shall assess and carry out a corrective action plan.

 

E)        The QA Plan will be subject to review as part of an EMS System site survey and as deemed necessary by the Department (e.g., in response to a complaint).

 

f)         Tier II

Tier II provides a level of care for patients who require care beyond the USDOT Curriculum and expanded scope of practice ALS (paramedic) transport program, and who require formal advanced education for ALS paramedic staff. Tier II transport includes the use of a ventilator, infusion pumps with administration of medication drips, maintenance of chest tubes, and other equipment and treatment, such as, but not limited to: arterial lines; accessing central lines; medication-assisted intubation; patient assessment and titration of IV pump medications, including additional active interventions necessary in providing care to the patient receiving treatment with advanced equipment and medications.

 

1)         Personnel Staffing and Licensure

 

A)        Licensure − Licensed Illinois Paramedic or PHRN:

 

i)          Expanded scope of practice more comprehensive than USDOT Curriculum and expanded scope Tier I level; and

 

ii)         Approved to practice by the EMS System and the Department in accordance with the EMS System Plan.

 

B)        Minimum Staffing:

 

i)          Paramedic/PHRN; and

 

ii)         Paramedic or PHRN who is critical care prepared, who shall remain with the patient at all times.

 

2)         Education, Certification and Experience

 

A)        Initial Advanced Formal Education:

 

i)          80 hours established higher collegiate education or equivalent critical care education based on existing university program models; and

 

ii)         Demonstrated competencies, as documented by the EMS System.

 

B)        Continuing Education Requirements:

 

i)          The EMS System shall document and maintain annual competencies of expanded scope of practice knowledge, equipment and procedures;

 

ii)         The following current credentials, as a minimum, shall be maintained: ACLS, PEPP or PALS, ITLS or PHTLS;

 

iii)        Twelve hours of critical care level education shall be completed annually;

 

iv)        The EMS provider shall maintain documentation of compliance with subsections (f)(2)(B)(i) through (iii) and shall provide documentation to the EMS Resource Hospital upon request; and

 

v)         Critical care certification (from formal education) shall be maintained when criteria are available for renewal status of certification.

 

C)        Certifications − Tier II personnel shall maintain the following renewable critical care certifications and credentials in active status:

 

i)          ACLS;

 

ii)         PEPP or PALS; and

 

iii)        ITLS or PHTLS.

 

D)        Experience − Minimum of two years experience functioning in the field at an ALS level for paramedic or PHRN.

 

3)         Medical Equipment and Supplies

 

A)        Ventilator; and

 

B)        Infusion pumps.

 

4)         Vehicle Standards

Any vehicle used for providing critical care transport shall comply at a minimum with Section 515.830 (Ambulance Licensing Requirements) or Sections 515.900 (Licensure of SEMSV Programs – General) and 515.920 (SEMSV Program Licensure Requirements for All Vehicles) regarding licensure of SEMSV programs and SEMSV vehicle requirements, including additional medical equipment and ambulance equipment as defined in this Section. Any vehicle used for critical care transport shall be equipped with an onboard AC supply capable of operating and maintaining the AC current needs of the required medical devices used in providing care during the transport of a patient.

 

5)         Treatment and Transport Protocols shall address the following:

 

A)        EMS System Medical Director or designee present at established Medical Control communication points and a written Expanded Scope of Practice Standard Operating Procedure signed by the EMS MD and approved for use by the Department in accordance with the System Plan;

 

B)        The use of a ventilator, infusion pumps with administration of medication drips, maintenance of chest tubes, and other equipment and treatment, such as, but not limited to: arterial lines, accessing central lines, and medication-assisted intubation; and

 

C)        Patient assessment and titration of IV pump medications, including additional active interventions necessary in providing care to the patient receiving treatment with advanced equipment and medications.

 

6)         Quality Assurance Program

 

A)        The Tier II transport provider shall develop a written QA Plan approved by the EMS System and the Department in accordance with subsection (f)(6)(D).  The participating provider shall provide quarterly reports to the assigned EMS Resource Hospitals for the first 12 months of operation.

 

B)        The EMS System shall establish the frequency of quality reports after the first year if the System has not identified any deficiencies or adverse outcomes.

 

C)        A Medical Director shall oversee the QA Program.

 

D)        The QA Plan shall evaluate all expanded scope of practice activity for medical appropriateness and thoroughness of documentation. The review shall include:

 

i)          Review of transferring physician orders and evidence of compliance with those orders;

 

ii)         Documentation of vital signs and frequency, and evidence that abnormal vital signs or trends suggesting an unstable patient were appropriately detected and managed;

 

iii)        Documentation of any side effects/complications, including hypotension, extreme bradycardia or tachycardia, increasing chest pain, dysrhythmia, altered mental status and/or changes in neurological examination, and evidence that interventions were appropriate for those events;

 

iv)        Documentation of any unanticipated discontinuation of a catheter or rate adjustments of infusions, along with rationale and outcome;

 

v)         Review of any Medical Control contact for further direction;

 

vi)        Documentation that unusual occurrences were promptly communicated to the EMS System; and

 

vii)       A root cause analysis of any event or care inconsistent with standards. The EMS System educator shall assess and carry out a corrective action plan.

 

E)        The QA Plan shall be subject to review as part of an EMS System site survey and as deemed necessary by the Department (e.g., in response to a complaint).

 

g)         Tier III

Tier III provides the highest level of ground transport care for patients who require nursing level treatment modalities and interventions.

 

1)         Minimum Personnel Staffing and Licensure

 

A)        EMT-B/I/P (as driver); and

 

B)        Two critical care prepared providers, who shall remain with the patient at all times:

 

i)          Paramedic or PHRN; and

 

ii)         RN.

 

2)         Education, Certification, and Experience: Paramedic or PHRN

 

A)        Initial Advanced Formal Education

 

i)          Approval to practice by EMS System and the Department in accordance with the EMS Program Plan;

 

ii)         80 hours established higher collegiate education or equivalent critical care education based on existing university program models; and

 

iii)        Approved scope of practice more comprehensive than USDOT Curriculum and expanded scope of practice of Tier II Level.

 

B)        Continuing Education Requirements

 

i)          Current certifications shall be maintained;

 

ii)         12 hours of critical care level education shall be completed annually; and

 

iii)        The EMS vehicle service provider shall maintain documentation of compliance with subsections (g)(2)(B)(i) and (ii) and shall provide documentation to the EMS Resource Hospital upon request.

 

C)        Certifications

Tier III personnel shall maintain the following renewable critical care certifications and credentials in active status:

 

i)          ACLS;

 

ii)         PEPP or PALS; and

 

iii)        ITLS or PHTLS.

 

D)        Experience

 

i)          Minimum of two years experience functioning in the field at an ALS Level;

 

ii)         Documented demonstrated competencies; and

 

iii)        Completion of annual competencies of expanded scope knowledge, equipment and procedures.

 

3)         Education, Certification and Experience − Nurse:

 

A)        Continuing Education Requirements

 

i)          12 hours of critical care level education shall be completed annually;

 

ii)         The EMS provider shall maintain documentation of compliance with subsection (g)(3)(A)(i) and shall provide documentation to the EMS Resource Hospital upon request; and

 

iii)        Annual competencies of expanded scope of practice knowledge, equipment and procedures shall be completed.

 

B)        Certifications

Tier III personnel shall maintain the following renewable critical care certifications and credentials in active status:

 

i)          ACLS;

 

ii)         PALS, PEPP or ENPC;

 

iii)        ITLS, PHTLS, TNCC or TNS; and

 

iv)        ECRN or equivalent.

 

C)        Advanced Certifications Preferred but not Required

 

i)          Certified Emergency Nurse (CEN);

 

ii)         Critical Care Registered Nurse (CCRN);

 

iii)        Critical Care Emergency Medical Technician-Paramedic (CCEMT-P);

 

iv)        Certified Registered Flight Nurse (CFRN); and

 

v)         Certified Transport Registered Nurse (CTRN).

 

D)        Experience

 

i)          Two years of experience with demonstrated competency in a critical care setting; and

 

ii)         Documented demonstrated competencies.

 

4)         Medical Equipment and Supplies

Tier III transport requires nursing level treatment modalities and interventions as agreed upon by the sending physician and the accepting physician at the receiving facility. If either physician is not available for consult, the provider's Medical Director or designee shall direct care.

 

5)         Vehicular Standards

Any vehicle used for providing critical care transport shall comply, at a minimum, with Section 515.830 (Ambulance Licensing Requirements) or Sections 515.900 (Licensure of SEMSV Programs – General) and 515.920 (SEMSV Program Licensure Requirements for All Vehicles) regarding licensure of SEMSV programs and SEMSV vehicle requirements, including additional medical equipment and ambulance equipment as defined in this Section. Any vehicle used for critical care transport shall be equipped with an onboard AC supply capable of operating and maintaining the AC current needs of the required medical devices used in providing care during the transport of a patient.

 

6)         Treatment and Transport Protocols shall address the following:

 

A)        Paramedic or PHRN:  EMS Medical Director or designee present at established Medical Control communication points and written Critical Care Standard Operating procedure signed by the EMS MD and approved for use by the Department in accordance with the System Plan;

 

B)        Registered Nurse: The provider's Critical Care Medical Director may establish standing medical orders for nursing personnel, or the RN may be approved to accept orders from the sending physician and/or receiving physician.

 

7)         Quality Assurance Program

 

A)        The Tier III transport provider shall have a written QA Plan approved by the EMS System and the Department, in accordance with subsection (g)(7)(D). The provider shall provide quarterly reports to the assigned EMS Resource Hospitals for the first 12 months of operation.

 

B)        The EMS System shall establish the frequency of quality reports after the first year if the System has not identified any deficiencies or adverse outcomes.

 

C)        A Medical Director shall oversee the QA Program.

 

D)        The QA Plan shall evaluate all expanded scope of practice activity for medical appropriateness and thoroughness of documentation. The review shall include:

 

i)          Review of transferring physician orders and evidence of

compliance with those orders;

 

ii)         Documentation of vital signs and frequency and evidence that abnormal vital signs or trends suggesting an unstable patient were appropriately detected and managed;

 

iii)        Documentation of any side effects/complications, including hypotension, extreme bradycardia or tachycardia, increasing chest pain, dysrhythmia, altered mental status and/or changes in neurological examination, and evidence that interventions were appropriate for those events;

 

iv)        Documentation of any unanticipated discontinuation of a catheter or rate adjustments of infusions, along with rationale and outcome;

 

v)         Review of any medical control contact for further direction;

 

vi)        Prompt communication of unusual occurrences to the EMS System;

 

vii)       A root cause analysis of any event or care inconsistent with standards. The  EMS System educator shall assess and carry out a corrective action plan.

 

E)        The QA Plan will be subject to review as part of an EMS System site survey and as deemed necessary by the Department (e.g., in response to a complaint).

 

h)         The Department will approve vehicle service providers for critical care transport when the provider demonstrates compliance with an approved EMS System's Critical Care Transport Program Plan for Tier II or Tier III transports.  Only Department approved agencies may advertise as Critical Care Transport providers.

 

i)          The Department will suspend a vehicle service provider's approval for critical care transport if any part of the provider's QA plan is not followed or if a situation exists that poses a threat to the public health and safety.  The Department will provide a notice of suspension of critical care transport approval and an opportunity for hearing.  If the vehicle service provider does not respond to the notice within 10 days after receipt, approval will be revoked.

 

j)          The Director may summarily suspend any licensed provider's authorization to perform critical care transports under this Part if the Director or designee determines that continued critical care transport by the provider poses an imminent threat to the health or safety of the public.  Any order for suspension will be in writing and effective immediately upon service of the provider or its lawful agent.  Any provider served with an order of suspension shall immediately cease accepting all critical care transport cases and shall have the right to request a hearing if a written request is delivered to the Department within 15 days after receipt of the order of suspension.  If a timely request is delivered to the Department, then the Department will endeavor to schedule a hearing in an expedited manor, taking into account equity and the need for evidence and live witnesses at the hearing.  The Department is authorized to seek injunctive relief in the circuit court if the Director's order is violated.

 

(Source:  Added at 36 Ill. Reg. 880, effective January 6, 2012)