Section 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 and 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, 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, healthcare facilities, and transport and non-transport providers participating in the 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 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; and


I)         Time.


7)         Develop a policy to ensure that patient care reports are filed or either faxed or dropped off at the receiving hospital within 2 hours of patient being brought to the receiving hospital;


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 IDPH 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


12)       Be responsible for compliance with the provisions of Sections 515.400 and 515.410;


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 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 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 APRN.


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)         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; 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;


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 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, 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 bypass plan exceeds 15 minutes;


o)         Each hospital shall have a policy addressing peak census procedures and a surge capacity plan.


(Source:  Amended at 46 Ill. Reg. 20898, effective December 16, 2022)