77 Ill. Adm. Code 515.330
EMS System Program Plan
Section 515
Section 515.330Â EMS System Program Plan
An EMS System Program Plan shall contain the following
information:
a)Â Â Â Â Â Â Â Â The name, address and
fax number of the Resource Hospital;
b)Â Â Â Â Â Â Â Â The
names, resumes, and contact information that includes address, phone, and email
addresses of the following persons:
1)Â Â Â Â Â Â Â Â The EMS
MD;
2)Â Â Â Â Â Â Â Â The
Alternate EMS MD;
3)Â Â Â Â Â Â Â Â The EMS
Administrative Director;
4)Â Â Â Â Â Â Â Â The EMS
System Coordinator;
c)Â Â Â Â Â Â Â Â The
name, address and fax number of each Associate or Participating Hospital (see subsection
(i));
d)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â The
Chief Executive Officer of the hospital;
2)Â Â Â Â Â Â Â Â The
Chief of the Medical Staff; and
3)Â Â Â Â Â Â Â Â The
Director of the Nursing Services;
g)Â Â Â Â Â Â Â Â A
letter of commitment from the EMS MD that describes the EMS MD's agreement to:
1)Â Â Â Â Â Â Â Â Be
responsible for the ongoing education of all System personnel, including
didactic and clinical experience;
2)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Be
responsible for supervising all personnel participating within the System, as
described in the System Program Plan;
4)Â Â Â Â Â Â Â Â Be
responsible for developing or approving a system complaint form and submitting
the following to the Department on a monthly basis:
A)Â Â Â Â Â Â Â Number
of EMS patient care complaints, including a brief synopsis of the issue;
B)Â Â Â Â Â Â Â Outcome of the system
investigation; and
C)Â Â Â Â Â Â Â Names
and licenses of the EMS personnel involved in sustained allegations.
5)Â Â Â Â Â Â Â Â Develop
or approve one or more patient care reports covering all types of patient care
responses performed by System providers;
6)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Name
of patient;
B)Â Â Â Â Â Â Â Age;
C)Â Â Â Â Â Â Â Vital
Signs;
D)Â Â Â Â Â Â Â Chief
complaint;
E)Â Â Â Â Â Â Â List
of current medications;
F)Â Â Â Â Â Â Â Â List
of allergies;
G)Â Â Â Â Â Â Â All
treatment rendered;
H)Â Â Â Â Â Â Â Date;
I)Â Â Â Â Â Â Â Â Time
of patient contact; and
J)Â Â Â Â Â Â Â Â Mechanism
of injury.
7)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â 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)Â Â Â Â Â Â 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
12)Â Â Â Â Â Â Be
responsible for compliance with the provisions of Sections 515.400 and 515.410;
h)Â Â Â Â Â Â Â Â A description of the method
of providing EMS services, which includes:
1)Â Â Â Â Â Â Â Â Single
vehicle response and transport;
2)Â Â Â Â Â Â Â Â Dual
vehicle response;
3)Â Â Â Â Â Â Â Â Level
of first response vehicle;
4)Â Â Â Â Â Â Â Â Level
of transport vehicle;
5)Â Â Â Â Â Â Â Â A
policy identifying when and how a patient may be transported directly to
an
EMS-System-approved mental health facility
if that patient.
A)Â Â Â Â Â Â Â has
no immediate life-threatening
injuries or illness
;
B)Â Â Â Â Â Â Â is
not under the influence
of drugs or alcohol;
C)Â Â Â Â Â Â Â 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
.Â
(Sec. 3.155(i) of the EMS System Act)
6)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â A
policy that describes in-field service level upgrade, using advanced level EMS
vehicle service providers;
8)Â Â Â Â Â Â Â Â A
policy that describes ambulance service provider and vehicle service provider
upgrade – rural population (optional);
9)Â Â Â Â Â Â Â Â A
policy for Alternative Staffing Models for private ambulance providers
consistent with Section 515.830(k);
10)Â Â Â Â Â Â Use of
mutual aid agreements; and
11)Â Â Â Â Â Â Informing
the caller requesting an emergency vehicle of the estimated time of arrival
when this information is requested by the caller;
i)Â Â Â Â Â Â Â Â Â A
letter of commitment from each Associate Hospital, Participating Hospital or
Veterans Health Administration facility within the System that includes the
following:
1)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Only
at an Associate Hospital, a commitment to meet the System's educational
standards for ECRNs;
4)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â An
agreement to use the standard treatment orders as established by the Resource
Hospital;
6)Â Â Â Â Â Â Â Â An
agreement to follow the operational policies and protocols of the System;
7)Â Â Â Â Â Â Â Â A
description of the level of participation in the education and continuing
education of EMS Personnel;
8)Â Â Â Â Â Â Â Â An
agreement to collect and provide relevant data as determined by the Resource
Hospital;
9)Â Â Â Â Â Â Â Â A
description of the hospital's or facility's data collection and reporting
methods and the personnel responsible for maintaining all data;
10)Â Â Â Â Â Â 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)Â Â Â Â Â Â 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)Â Â Â Â Â Â The
names, email addresses, and resumes of the Associate Hospital EMS MD and
Associate Hospital EMS Coordinator;
j)Â Â Â Â Â Â Â Â Â A
letter of commitment from each ambulance provider participating within the
System that indicates compliance with Section 515.810;
k)Â Â Â Â Â Â Â Â Descriptions
and documentation of each communications requirement provided in Section
515.400;
l)Â Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Education
A)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Education,
testing and credentialing requirements for ECRN, PHRN, PHPA, and PHAPRN.
C)Â Â Â Â Â Â Â Continuing
education for EMS Personnel, including:
i)Â Â Â Â Â Â Â Â Â System
requirements (hours, types of content, etc.);
ii)Â Â Â Â Â Â Â Â A
plan for measurement of ongoing competency for all System Participants (i.e.,
quality assurance);
iii)Â Â Â Â Â Â Â Requirements
for approval of academic course work;
iv)Â Â Â Â Â Â Â Didactic
programs offered by the System;
v)Â Â Â Â Â Â Â Â Clinical
opportunities available within the System; and
vi)Â Â Â Â Â Â Â Recordkeeping
requirements for participants, which must be maintained at the Resource
Hospital.
D)Â Â Â Â Â Â Â Renewal
Protocols
i)Â Â Â Â Â Â Â Â Â System
examination requirements for EMS Personnel;
ii)Â Â Â Â Â Â Â Â Procedures
for approval and the renewal of EMS Personnel;
iii)Â Â Â Â Â Â Â Requirements
for submission of transaction cards for EMS Personnel meeting renewal
requirements; and
iv)Â Â Â Â Â Â Â Department
renewal application forms for EMS Personnel who have not met renewal
requirements according to System records.
E)Â Â Â Â Â Â Â System
Participant education and information, including:
i)Â Â Â Â Â Â Â Â Â Distribution
of System Manual amendments;
ii)Â Â Â Â Â Â Â Â In-services
for policy and protocol changes;
iii)Â Â Â Â Â Â Â Methods
for communicating updates on System and regional activities, and other matters
of medical, legal and/or professional interest; and
iv)Â Â Â Â Â Â Â Locations
of library/resource materials, forms, schedules, etc.
F)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Medications
and Equipment
A)Â Â Â Â Â Â Â A list
of all medications and equipment required for each type of System vehicle;
B)Â Â Â Â Â Â Â Procedures
for obtaining replacements at System hospitals; and
C)Â Â Â Â Â Â Â Policies
for appropriate storage and security of medications.
3)Â Â Â Â Â Â Â Â Personnel
Requirements for EMS Personnel
A)Â Â Â Â Â Â Â Minimum
staffing for each type and level of vehicle; and
B)Â Â Â Â Â Â Â Guidelines
for EMS Personnel patient interaction.
4)Â Â Â Â Â Â Â Â EMS
Protocols, including medical-legal policies, but not limited to:
A)Â Â Â Â Â Â Â The
Regional Standing Medical Orders; and
B)Â Â Â Â Â Â Â Administrative,
Legal and EMS Protocols and Guidelines (Appendix D).
5)Â Â Â Â Â Â Â Â Communications
standards and protocols, including:
A)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Protocols
defining when an ECRN should contact a physician; and
E)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Data
collection and evaluation methods that include:
A)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â A
policy identifying any additional required data elements that the EMS provider
shall include in their patient care report;
C)Â Â Â Â Â Â Â Identified benchmarks or
thresholds that should be met;
D)Â Â Â Â Â Â Â A copy
of the evaluation tool for the short reporting form, if used, and the pre-hospital
reporting form; and
E)Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â 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)Â Â Â Â Â Â The
responsibilities of the EMS MD.
12)Â Â Â Â Â Â The
responsibilities of the Alternate EMS MD.
13)Â Â Â Â Â Â The
responsibilities of the EMS Administrative Director.
14)Â Â Â Â Â Â 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)Â 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)Â Â Â Â Â Â Â Â There
are no critical or monitored beds available in the hospital; or
2)Â Â Â Â Â Â Â Â An
internal disaster occurs in the hospital;
n)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Each
hospital shall have a policy addressing peak census procedures and a surge
capacity plan.
p)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â Training
and education on the administration of the respiratory evaluation questionnaire
is the responsibility of the employer;
4)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â 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.