836 IAC 2-4.1-2 General requirements

Sec. 2. Hospitals seeking commission certification shall meet the following minimum requirements: (1) Have an emergency department open and staffed by a physician twenty-four (24) hours a day. (2) The hospital's administration shall have approved a written agreement, or interdepartmental memo if provider organization is hospital-based, with one (1) or more emergency medical services provider organizations that furnish advanced life support or emergency medical technician-basic advanced services. The agreement or interdepartmental memo shall include a detailed description whereby the hospital agrees to provide the following services to the certified emergency medical service provider organization: (A) Continuing education to include the following: (i) Frequency of training. (ii) Length of training. (iii) Attendance policies. (iv) Policy on acceptance of training obtained outside of supervising hospital. (B) Audit and review to include items listed in subdivision (5). (C) Medical control and direction to include the following: (i) Procedure to assure medical control available at all times. (ii) How hospital personnel are trained on provider organization protocols. (D) Provision and supervision of arrangements that allow the emergency medical services clinical personnel affiliated with the supervised emergency medical service provider organization to function within appropriate hospital departments in order to obtain continuing education and remediation in their clinical skills. (3) Provide and maintain a voice communication system between the emergency medical service provider organization response personnel and the hospital's emergency department. The communication system shall include the following: (A) A system capable to provide UHF (ultrahigh frequency) communications. (B) A system capable to communicate on the frequency of 155.340 MHz to operate on the Indiana Hospital Emergency Radio Network. The communications system shall be licensed by the Federal Communications Commission. If the method of UHF communication is wireless, the hospital shall maintain a dedicated telephone number with answering points in the emergency department directly accessible to emergency department personnel. (4) The hospital shall provide a physician or physician designate who is at all times immediately available to supervise the medical procedures performed by the emergency medical service provider organization's clinical personnel via the voice communication system. (5) The hospital shall establish a process for the audit and review of medical procedure performed by the clinical personnel of the emergency medical service provider organization. Audit and review shall be conducted at least quarterly. Requirements for audit and review are as follows: (A) The audit shall ensure an appropriate level of compliance with medical protocols and appropriate level of skill in the performance of medical techniques by those personnel. (B) The results of the audit shall be reviewed with the emergency medical service personnel. (C) Documentation for the audit shall include the following: (i) The criteria used to select audited runs. (ii) Problem identification and resolution. (iii) Date of review. (iv) Attendance at the review. (v) A summary of the discussion at the review. (D) The audit and review shall be conducted by the medical control committee as defined in subdivision (9). (6) The supervising hospital shall review and approve the inservice of the certified paramedics affiliated with the emergency medical services provider organization. (7) Send annually during the last quarter of each calendar year a roster of clinical personnel whose sole advanced life support affiliation is with the supervising hospital and personnel affiliated with the emergency medical service provider organizations supervised by the hospital. (8) The supervising hospital shall report in writing any changes, including affiliated clinical personnel, within thirty (30) days. (9) The supervising hospital shall establish a medical control committee for audit and review of medical procedures perform by the advanced life support personnel and establish policies for medical direction and control. The membership of the medical control committee shall include the following: (A) Medical director of provider organization. (B) One (1) or more emergency department supervisory personnel. (C) One (1) or more provider organization supervisory personnel. (D) EMS educator. (E) One (1) or more advanced life support personnel of appropriate level from provider organization.