Free dph7463b - emt-basic operational plan components outline - Wisconsin

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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7463B (Rev. 02/06)

STATE OF WISCONSIN Adm. Code Chapter 110 (608) 266-1568

The following information must be compiled and submitted in similar outline format with a completed EMS Provider Application and Operational Plan form. Written approval of this plan by the State EMS Office is mandatory prior to implementation.

I. Demographics A. Provide a general description of the population and community characteristics of the primary service area. HFS 110.08(2)(e) II. Operations (staffing, response, protocols, policies and procedures) A. Provide a description of how the provider will use Medical First Responders and/or EMTs (all levels) in the system. (Describe staffing, call schedule, call response, etc.)
HFS 110.04(1)(c) and HFS 110.08

B. Describe how the provider uses EMTs to assure that 24/7 prompt and efficient emergency (9-1-1) response is available to the primary service area covered by the provider.
HFS 110.04(1)(c)

C. Provide a written commitment that the ambulance service provider shall ensure the ambulance is staffed with a minimum of 2 qualified persons when a patient is being transported.
HFS 110.04(1)(b)

D. Submit a roster of personnel to be utilized. (If new service, submit license applications for all EMT and Medical First Responder personnel.)
HFS 110.08(2)(n)

E. Provide copies of all personnel operating policies, procedures and guidelines.
HFS 110.04(1)(e)

F. Describe the relationship between this service and other emergency medical and public safety services in the geographical area (including Medical First Responder groups).
HFS 110.08(2)(l)

G. Describe how this service will integrate with the local, county or regional disaster preparedness plans.
HFS 110.08(2)(j)

H. Provide copies of written mutual aid and backup agreements with other ambulance services in the area.
HFS 110.08(2)(s)


Provide evidence of local commitment to this emergency medical service program to include letters of endorsement from local and regional medical, governmental and emergency medical services agencies and authorities.
HFS 110.08(2)(k) HFS 110.08(2)(v)

J. Identify the regional trauma advisory council (RTAC) that the service has chosen for membership. K. Submit protocols (approved and signed by the medical director) that identify use of: - Specific medications allowed within the scope of practice for EMTs-Basic - Specific equipment allowed within the scope of practice for EMTs-Basic - Skills and procedures (Protocols must describe how medical treatment will be provided and at what point in a protocol direct voice authorization of a physician is required.)
HFS 110.08(2)(o)

L. Submit a request for the use of advanced skills (as noted on the Scope of Practice for EMT-Basic) to include: - A signed statement from the service medical director and service director accepting the new skills/medications - Identification of the instructor(s) to be used in training existing EMTs and his/her qualifications. - Agreement to use the existing approved training modules. - Copies of the protocol for each skill/medication being used, signed and dated by the service medical director. - Plan for training and skill retention HFS 110.05(4)(b)

DPH 7463B (Rev. 02/06) Page 2

III. Infection Control Federal bloodborne and airborne guidelines can be referenced in 29CFR1910.1030 and 29CFR1910.134, respectively. Occupational health and safety guidelines for public employers are included in Wisconsin Administrative Code Comm 30 and Comm 32. A. Provide a statement indicating that your service has an infection control plan and policies.
HFS 110.08(2)(t)

B. Provide a statement indicating that your service has a Bloodborne and Airborne Exposure Control Plan
and provides annual training on that plan in accordance with applicable state and federal guidelines. C. Describe your service's post-exposure procedures. D. Describe your service's review and use of safety engineered devices. E. Identify date that your Exposure Control Plan was last reviewed and updated. F. Identify date of last training on your service's Exposure Control Plan. IV. Communications/Dispatch A. Provide a description of the communication system between medical control and the EMS unit.
HFS 100.08(2)(f)

B. Is two-way communication available and operational from the patient side?
HFS 110.08(2)(f)

C. Describe how calls area dispatched and answered.
HFS 110.08(2)(g)

D. Describe the local dispatch policies and procedures or insert a copy of these policies.
HFS 110.08(2)(g)

E. Describe who does the dispatching.
HFS 110.08(2)(g)

F. Are dispatchers medically trained?
HFS 110.08(2)(g)

G. Do dispatchers provide pre-arrival instructions?
HFS 110.08(2)(g)

V. Transportation A. Provide evidence that all ambulances to be used by the service have been inspected within the last 2 years (6 months for newly acquired vehicles) and are in compliance with Trans 309 equipment requirements and those necessary to effectively render EMT-Basic services as described in this plan. (State Patrol Ambulance Inspector (608)-220-3246.)
HFS 110.08(2)(g)

B. Describe procedure to determine destination hospital.
HFS 110.04(1)(e)

VI. Education and Training/Competency A. Describe the methods by which continuing education and continuing competency of personnel will be assured. (Provide type of education and/or testing, frequency, instructor, etc.)
HFS 110.08(2)(h)

B. Describe continuing education required by the provider.
HFS 110.04(1)(e)

C. Identify the certified EMT training center(s) that are used by this service to provide EMT training.

VII. Quality Assurance (Training program and formal run review to improve future performance.) A. Describe the providers' quality assurance and improvement plan, including copies of policies and procedures to be used in the medical control, implementation and evaluation of the service.
HFS 110.08(2)(l)

DPH 7463B (Rev. 02/06) Page 3

VIII. Data Collection A. Describe the method of data collection being used by the provider.
HFS 110.08(2)(m)

B. Provide a statement that agrees to submit data to the Department when requested.
HFS 110.08(2)(m)

C. Describe the ambulance report form being used by this provider. If other than the Department approved form, submit a copy of the form for review.
HFS 110.08(2)

IX. Interfacility (Optional ­ for services desiring Interfacility license approval only) A. Notify EMS Section that your ambulance service is conducting interfacility transfers.
HFS 110.08(2)(u)

B. Describe assurances that 9-1-1 emergency response will not be interrupted (if applicable).
HFS 110.08(2)(u

C. Describe what types of patients are transported (critical or stable).
HFS 110.08(2)(u)

D. Identify to which hospital(s) or other facilities patients are transported
HFS 110.08(2)(u)

E. Include specific protocols detailing interfacility transfers based on the scope of practice for your level of service
HFS 110.08(2)(u)

F. Describe how you will ensure that EMT personnel are not put in jeopardy by transporting unstable patients or patients that have IVs or other interventions beyond their scope of practice.
HFS 110.08(2)(u)

G. Describe the kind of personnel used on interfacility transfers (use of non-EMS licensed health care personnel (nurses, physicians, etc.) during transfers for patients whose condition demands a higher level of care).
HFS 110.08(2)(u)

H. Include written protocols under which non-EMT health care professionals will operate.
HFS 110.08(2)(u)


The interfacility transport plan must address hospital to nursing home and return, hospital to hospital, hospital to home, etc. types of calls.
HFS 110.08(2)(u)

X. Special Events Coverage Approval (Optional ­ for services desiring Special Events license approval for service provided at a specific site for the duration of a temporary event which is outside the ambulance service provider's primary service area.) A. Describe how the special event differs from the existing approved operational plan. (If special event coverage differs from existing operation plan or protocols or staffing levels, a plan amendment must be submitted to the department at least 60 days prior to the event.)
HFS 110.06(6)

B. Provide copies of the agreements with the primary ambulance service provider, the local medical director and the receiving hospital(s) in the area that describes how services will be integrated.
HFS 110.06(6)

C. Provide a description of how the special event ambulance provider will interface with the local service. Provide a description of how dispatch, communication and ALS intercept will be accomplished.
HFS 110.06(6)