Free EMT-Intermediate Operational Plan Components Outline, DPH7463D - Wisconsin

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

STATE OF WISCONSIN Adm. Code Chapter 111 (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. PROGRAM COMPONENTS I. Demographics A. Completed feasibility study submitted and approved by DHFS-EMS.
HFS 111.07(2)

B. Provide a general description of the population and community characteristics of the primary service area.
HFS 111.07(2)(e)

II. Operations (staffing, response, infection control, protocols, policies and procedures) A. Provide a description of how the provider will use Medical First Responders and/or EMTs (of all levels) in the system.
HFS 111.07(2)(i)

B. Describe how the provider uses EMTs-Intermediate 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 111.07(2)(u)

C. Describe the relationship between this service and other emergency medical and public safety services in the geographical area. HFS 111.072(I) D. Describe how this service will integrate with local, county or regional disaster preparedness plans.
HFS 111.07(2)(j)

E. 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 111.07(2)(k)


Identify the Regional Trauma Advisory Council (RTAC) that the service has chosen for membership.
HFS 111.07(2)(v)

G. Submit a roster of licensed personnel to be utilized. If new service, submit license applications for all EMT personnel.
HFS 111.07(2)(n)

H. Submit protocols, signed and approved by the medical director, that identify use of: a. Specific medications allowed within the scope of practice for EMTs-Intermediate b. Specific equipment allowed within the scope of practice for EMTs-Intermediate c. Skills and procedures Protocols must describe how medical treatment will be provided by all levels of EMT and at what point in a protocol direct voice authorization of a physician is required.
HFS 111.07(2)(o)


Provide copies of written mutual aid and backup agreements with other ambulance services in the area.
HFS 111.07(2)(s) HFS 111.07(2)(l)

J. Provide copies of all personnel operating policies, procedures and guidelines. K. Provide a copy of the controlled substances plan that will be used for acquiring and storing controlled medications.
HFS 111.07

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 112.07

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

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 111.07(2)(f)

B. Does each ambulance owned and operated by this service have two-way radio equipment operating on the 155.340 and 155.400 Mhz? HFS 111.07(2)(f) C. Is two-way communications available and operational from the patient's side?
HFS 111.07(2)(f)

D. Describe how calls are dispatched and answered.
HFS 111.07(2)(g)

E. Describe local dispatch policies and procedures or insert a copy of these policies.
HFS 111.07(2)(g)

F. How are Medical First Responders dispatched?
HFS 111.07(2)(g)

G. Describe who does the dispatching.
HFS 111.07(2)(g)

H. Are dispatchers medically trained?
HFS 111.07(2)(g)


Do dispatchers provide pre-arrival instructions?
HFS 111.07(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 with all required EMTIntermediate equipment. (State Ambulance Inspector (608)-220-3246.)
HFS 111.07(2)(q)

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, testing, frequency, instructor, etc.)
HFS 111.07(2)(l)

B. Describe who will assure EMT-Intermediate personnel competency?
HFS 111.07(2)(l)

VII. Quality Assurance A. Submit a plan describing how the service will provide quality assurance and improvement.
HFS 111.07(2)(l)

B. Provide copies of policies and procedures to be used in medical control implementation and evaluation of the quality assurance program.
HFS 111.07(2)(l)

C. Provide a description of the benchmarks to be used by the service to assure competency of all field personnel.
HFS 111.07(2)(l)

VIII. Data Collection A. Describe the method of data collection being used by the provider.
HFS 111.07(2)(m)

B. Provide a statement that agrees to submit data to the Department when requested.
HFS 111.07(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)(r)

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

24-MONTH PHASE IN OF FULL-TIME COVERAGE Service provider wanting to provide EMT-Intermediate coverage over a phase-in period shall submit an operational plan to the Department that includes all of the elements under HFS 111.07(2) and all of the following: IX. Operations A. Service provider must show evidence of hardship which requires request for 24-month phase in.
HFS 111.07(3)(a)

B. A description in detail of why the phase-in period is necessary, how the phase-in will be accomplished and the specific date (not to exceed 24 months form the initiation of the part-time EMT-Intermediate service) by which full-time service will be achieved.
HFS 111.07(3)(a)

C. A description of how quality assurance and Intermediate skill proficiency will be evaluated during the phase-in period.
HFS 111.07(3)(b)

D. Provide a statement that during the phase-in period all regulatory requirements for EMTs-Intermediate shall be met except for the requirement to provide 24-hour-per-day, 7-day-per-week coverage.
HFS 111.07(3)(b)

E. Provide a statement that an EMT-Intermediate ambulance service provider that does not achieve full-time coverage within the approved phase-in period (24-months maximum) shall cease providing EMT-Intermediate service and shall revert back to previous level providing EMT-Intermediate Technician or EMT-Basic service.
HSF 111.07(3)(c)

INTERFACILITY PLAN APPROVAL (EMT-Intermediate interfacility coverage means scheduled or prearranged transportation and non-emergent or emergent care of a patient between healthcare facilities.) X. Operations - An EMT-Intermediate interfacility operation plan shall include all the elements under HFS 111.07(2) and the following: A. Describe how interfacility EMT-Intermediate services will be provided.
HFS 111.07(4)(c)

B. Describe the types of patients who will be transported.
HFS 111.07(4)(d)

C. Describe the crew configuration and personnel to be used on specific type of patient transfers based upon the patient's condition.
HFS 111.07(4)(c)

D. Provide written protocols specific to interfacility transfers.
HFS 111.07 E. Provide written protocols under which non-EMT healthcare professionals will operate. HFS 111.07

F. Provide a statement indicating the understanding that providing interfacility transports will not interrupt 9-1-1 emergency response.
HFS 111.07

G. The interfacility transport plan must address hospital to nursing home and return, hospital to hospital, hospital to home, etc. types of calls.
HFS 111.07

XI. Education A. Describe the methods by which continuing education and competency of personnel will be assured. (Interfacility requirements differ from typical 9-1-1responses and education and training should reflect this.)
HFS 111.07(4)(c)

SEASONAL EMT-INTERMEDIATE PLAN (Seasonal EMT-Intermediate coverage means pre-hospital EMTIntermediate service provided during specific times of the year when the population of an area has substantially increased for a minimum of 30 consecutive days and the EMT-Intermediate service is maintained on a 24-hour-perday, 7-days-per-week basis for the duration of the population influx.) To be approved, an EMT-Intermediate operational plan for seasonal EMT-Intermediate coverage shall meet all the requirements under HFS 111.07(2) and the following: XII. Operations A. Submit annually a letter and any changes in operation to the original plan. The letter shall also include an updated roster of EMTs-Intermediate, proof of insurance coverage and proof of vehicle inspection under Trans 309, Wis. Administrative Code. HFS 111.07(6)(c)

DPH 7463D (Rev. 02/06) Page 4

B. Describe the dates during which population increases take place and Intermediate service would be available and how the public is notified of the change in level of service.
HFS 111.07(6)(d)

C. Describe the approximate population served during the increase.
HFS 111.07(6)(d)

D. Describe the reason for the population increase.
HFS 111.07(6)(d)

E. Describe EMT-Intermediate staffing including: - number of EMTs-Intermediate required to provide full-time coverage - how EMT-Intermediate personnel will be provided - number and location of ambulances
HFS 111.07(6)(d)

F. Include agreements with the primary ambulance service provider (if different), the local medical director and receiving healthcare facilities that describe how services will be integrated or mutual aid provided.
HFS 111.07(6)(d)

G. Describe in detail why EMT-Intermediate service is not feasible or necessary in the area on a full-time yearround basis.
HFS 111.07(6)(d)

SPECIAL EVENT EMT-INTERMEDIATE COVERAGE APPROVAL (This section means pre-hospital EMTIntermediate service provided at a specific site for the duration of a temporary event which is outside the ambulance service provider's primary service area or at a higher license level within the provider's primary service area). If the special event license application is at a higher level of care than the service is currently licensed to provide, a specific operational plan for special events shall be submitted and approved that includes all the elements under HFS 111.07(2) that differ from the existing approved plan. XIII. Operations A. Describe how the special event differs from the existing approved operational plan.
HFS 111.07(5)(b)

B. Describe how the ambulance service applying for special event coverage will work in conjunction with the primary emergency response ambulance service in the area.
HFS 111.07(5)(c)

C. Provide letters of support from the primary ambulance service provider indicating they are aware of and agree to allow the special event ambulance provider to operate within the primary service area.
HFS 111.07(5)(b)

D. Provide written protocols for patient care for the special event.
HFS 111.07(5)(b)

E. Provide a letter from the medical director responsible for EMT-Intermediate services during the special event indicating acknowledgement of responsibilities.
HFS 111.07(5)(b)