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

STATE OF WISCONSIN Adm. Code Chapters 110 and 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. B. Provide a general description of the population and community characteristics of the primary service area.
HFS 110.08(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 110.08(2)(e)

B. Describe how the provider uses EMT-Intermediate Technicians 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 110.08

C. Describe the relationship between this service and other emergency medical and public safety services in the geographical area.
HFS 110.08(2)(j)

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


Identify the regional trauma advisory council (RTAC) that the service has chosen for membership.
HFS 110.08(2)(v)

G. Submit a roster of licensed personnel to be utilized. If new service, submit license applications for all EMT personnel.
HFS 110.08(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 EMT-Intermediate Technicians b. Specific equipment allowed within the scope of practice for EMT-Intermediate Technicians 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 110.08(2)(o)


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

J. Provide copies of all personnel operating policies, procedures and guidelines. 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

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.

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

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 110.08(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? C. Is two-way communications available and operational from the patients' side?
HFS 110.08(2)(f)

D. Describe how calls are dispatched and answered.
HFS 110.08(2)(g)

E. Describe local dispatch policies and procedures or insert a copy of these policies. F. How are Medical First Responders dispatched? G. Describe who does the dispatching.
HFS 110.08(2)(g)

H. Are dispatchers medically trained?
HFS 110.08(2)(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 with all required paramedic equipment. (State Ambulance Inspector (608)-220-3246.)
HFS 110.08(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 110.08

B. Describe who will assure EMT-Intermediate Technician personnel competency?
HFS 110.08

VII. Quality Assurance A. Submit a plan describing how the service will provide quality assurance and improvement.
HFS 110.08(2)(l)

B. Provide copies of policies and procedures to be used in medical control implementation and evaluation of the quality assurance program.
HFS 110.08(2)(l)

C. Provide a description of the benchmarks to be used by the service to assure competency of all field personnel. 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. D.
HFS 110.08(2)(r)

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

12-MONTH PHASE IN OF FULL-TIME COVERAGE Service providers wanting to provide EMT-Intermediate Technician coverage over a phase-in period shall submit an operational plan to the Department that includes all of the elements under HFS 110.04 and all of the following: IX. Operations A. Service provider must show evidence of hardship which requires request for 12-month phase in. 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 12 months form the initiation of the part-time EMT-Intermediate Technician service) by which full-time service will be achieved. C. A description of how quality assurance and EMT-Intermediate Technician skill proficiency will be evaluated during the phase-in period. D. Provide a statement that all regulatory requirements for EMT-Intermediate Technicians shall be met during the phase-in period except for the requirement to provide 24-hour-per-day, 7-day-per-week coverage. E. Provide a statement that an EMT-Intermediate Technician ambulance service provider that does not achieve full-time coverage within the approved phase-in period (12-months maximum) shall cease providing EMTIntermediate Technician service and shall revert back to previous license level providing EMT-Basic service. INTERFACILITY PLAN APPROVAL (EMT-Intermediate Technician interfacility coverage means scheduled or prearranged transportation and non-emergent or emergent care of a patient between healthcare facilities.) X. Operations: An EMT-Intermediate Technician interfacility operation plan shall include all the elements under HFS 110.04 and all of the following: A. Describes how interfacility services will be provided. B. Describe the types of patients who will be transported. C. Describe the crew configuration and personnel to be used on specific type of patient transfers based upon the patient's condition. D. Provide written protocols specific to interfacility transfers. E. Provide written protocols under which non-EMT healthcare professionals will operate. F. Provide a statement indicating the understanding that providing interfacility transports will not interrupt 9-1-1 emergency response. G. The interfacility transport plan must address hospital to nursing home and return, hospital to hospital, hospital to home, etc. types of calls. SPECIAL EVENT EMT-INTERMEDIATE TECHNICIAN COVERAGE APPROVAL (This section means pre-hospital EMT-Intermediate Technician service provided at a specific site for the duration of a temporary event which is outside the ambulance service provider's primary service area). XI. Operations A. Describe how the special event differs from the existing approved operational plan. 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 110.08(6)(b)

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 110.08(6)(b)

D. Provide written protocols for patient care for the special event. E. Provide a letter from the medical director responsible for EMT-Intermediate Technician services during the special event indicating acknowledgement of responsibilities.