HomeMy WebLinkAboutAgreement A-16-063 with Valley Childrens Hospital.pdf Agreement No. 16-063
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 2nd day of February 12016,
3 by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
4 hereinafter referred to as "COUNTY," and VALLEY CHILDREN'S HOSPITAL, a California non-
5 profit public benefit corporation, whose address is 9300 Valley Children's Place, Madera, CA 93638-
E 8762, hereinafter referred to as "CONTRACTOR" (collectively, "the Parties").
7 WITNESSETH:
8 WHEREAS, COUNTY's Department of Public Health's Emergency Medical Services (EMS)
9 Division, is the designated Local EMS Agency (hereinafter referred to as the "EMS Agency") for the
10 Counties of Fresno, Kings, Madera and Tulare, as provided in Health & Safety Code section 1797.200;
11 and
12 WHEREAS, COUNTY and EMS Agency recognize a continuous need for a Level 11 Pediatric
13 Trauma Center to serve pediatric trauma victims in Fresno, Kings, Madera and Tulare Counties; and
14 WHEREAS, CONTRACTOR desires that the local EMS Agency designate CONTRACTOR as
15 a Level II Pediatric Trauma Center in accordance with Title 22, Division 9, Chapter 7 of the California
16 Code of Regulations, entitled "Trauma Care Systems" (§§ 100236 et seq.; hereinafter referred to as the
17 "Trauma Care Regulations"), and the Emergency Medical Services System and the Prehospital
18 Emergency Medical Care Personnel Act (Health& Safety Code, §§ 1797 et seq.; hereinafter referred
19 to as the "EMS Act"); and
20 WHEREAS, in order for CONTRACTOR to be designated by the EMS Agency as a Level lI
21 Pediatric Trauma Center, CONTRACTOR is required to have a written agreement with the EMS
22 Agency for the provision of such services, as provided by Trauma Care Regulation, section 100255(g);
23 and
24 WHEREAS, CONTRACTOR represents that it will maintain and operate a qualifying trauma
25 center, in accordance with the Trauma Care Regulations and the EMS Act, and is agreeable to such
26 designation by the EMS Agency subject to the terms and conditions provided herein; and
27 NOW, THEREFORE, in consideration of their mutual covenants and conditions, and other
28 valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties hereto
1 - COUNTY OF FRESNO
Fresno, CA
1 agree as follows:
2 1. THE EMS SYSTEM/DESIGNATION OF CONTRACTOR
3 A. The parties acknowledge and agree that the EMS Agency has the authority to
4 plan, implement and evaluate an emergency medical services system in Fresno, Kings, Madera, and
5 Tulare Counties pursuant to Health and Safety Code sections 1797.200 and 1797.204.
6 B. The parties acknowledge and agree that the EMS Agency has the authority to
7 implement and update a trauma care system for the EMS System, including the authority to designate a
8 Level II Pediatric Trauma Center for the EMS System, pursuant to Health& Safety Code sections
9 1798.160 et seq. of the EMS Act, and the Trauma Care Regulations.
10 C. The parties acknowledge and agree that the EMS Agency Medical Director
11 (including his or her Assistant Medical Directors) of the EMS Agency has the authority of medical
12 control of the EMS System, including the trauma care system, and the authority to assure medical
13 accountability through the planning, implementation and evaluation of the EMS System, including the
14 trauma care system, set forth in Health and Safety Code section 1797.202.
15 D. The parties acknowledge and agree that the service area for the CONTRACTOR's
16 Level I1 Pediatric "Trauma Center is Fresno, Kings, Madera, and Tulare Counties.
17 E. CONTRACTOR acknowledges and agrees that neither the COUNTY nor the
18 EMS Agency makes any representation, warranty or guarantee, and cannot and do not assure
19 CONTRACTOR that any minimum number of trauma patients will be delivered or referred to
20 CONTRACTOR's facilities.
21 F. CONTRACTOR acknowledges and agrees that the EMS Agency's designation of
22 CONTRACTOR as a Level II Pediatric Trauma Center for the EMS System is made on a non-exclusive
23 basis, and that the EMS Agency reserves the right to designate any other qualifying hospitals, at any
24 time, as a Level I, II, III or IV Trauma Center or Level I or II Pediatric Trauma Center for the EMS
2 5 System. CONTRACTOR acknowledges that the EMS Agency has previously designated Community
26 Regional Medical Center as a Level I Trauma Center and Kaweah Delta Medical Center, in Visalia, as
27 a Level III Trauma Center for the EMS System, as provided in the Regional Trauma Plan.
28
2 - COUNTY OF FRESNO
Fresno, CA
1 2. RESPONSIBILITIES OF CONTRACTOR
2 CONTRACTOR shall, at its own expense, at all times during the term of this Agreement:
3 A. Operate and function as a Level II Pediatric Trauma Center for all patients
4 presenting at CONTRACTOR's facilities, regardless of their ability to pay.
5 B. Provide and maintain the following as required to provide trauma center services
6 as a Level II Pediatric Trauma Center under this Agreement:
7 1. All facilities and resources, including, but not limited to, all necessary
8 utilities, supplies, equipment and furniture; and
9 2. All physician, nurse and other professional personnel, and such technical,
10 administrative, allied and supportive paramedical personnel and such other personnel.
11 In this regard, CONTRACTOR specifically covenants that it will at all times comply
12 with, Trauma Care Regulations sections 100261 (entitled, "Level I and Level II Pediatric Trauma
13 Centers") which is incorporated herein by reference.
14 C. Take al necessary action to maintain the designation as a Level II Pediatric
15 Trauma Center in accordance with the EMS Act, the Trauma Care Regulations, and the EMS Agency
16 Policies and Procedures now in effect, or which may hereafter come into effect, all of which are
17 incorporated herein by reference.
-8 D. Provide trauma center services as a Level II Pediatric Trauma Center in
-9 accordance with all Federal, State, and local laws, and regulations now in effect, or which may
20 hereafter come into effect (including, but not limited to, the EMS Act and Trauma Center Regulations),
21 all of which are incorporated herein by reference.
22 E. Comply with all EMS Agency Policies and Procedures now in effect, or which
23 may hereafter come into effect, including, but not limited to, those policies and procedures related to
24 trauma care (EMS Agency Policies #330—Trauma System Overview, #331 —Trauma Facility
25 Designation, #332 —Trauma System Monitoring, #333 —Trauma Center Criteria, and 9334—Trauma
26 Registry Data Collection) and with the EMS System's continuous quality improvement process
27 requirements now in effect, or which may hereafter come into effect (EMS Agency Policies#703 and
28 9704 adopted pursuant Trauma Care Regulation, sec. 100265, entitled "Quality Improvement"), all of
- 3 - COUNTY OF FRESNO
Fresno, CA
1 which are attached hereto as Exhibit A and incorporated herein by reference.
2 F. Within twenty-four (24) months from the COUNTY's execution of this
3 Agreement, obtain and continuously maintain, without interruption, American College of Surgeons
4 Committee on Trauma (ACS-COT) verification as a Level II Pediatric Trauma Center.
5 G. Actively and cooperatively participate as a member of the Regional Trauma Audit
6 Committee and the Central Region Trauma Coordinating Committee.
7 H. Develop and/or conduct periodic instructional and educational programs for the
8 benefit of the hospitals and pre-hospital care personnel throughout the EMS System that are related to
9 pre-hospital and in-hospital trauma care for patients.
10 I. Provide and maintain radio and communications equipment in CONTRACTOR's
11 facilities for communications with pre-hospital ambulance providers and hospitals throughout the EMS
12 region.
13 J. Maintain all licenses, permits and certificates necessary to operate as an acute
14 care hospital, which, at minimum, includes basic or comprehensive emergency services available,
15 pursuant to the Trauma Care Regulation, section 100261(c), and to maintain accreditation by the Joint
16 Commission on Accreditation of Healthcare Organizations, pursuant to Trauma Care Regulation,
17 section 100248, entitled, "Trauma Care Regulation."
18 K. Provide all appropriate medical direction and control as a Base Hospital, when
19 necessary, to emergency medical services personnel in the field in accordance with EMS Agency
20 Policies and Procedures, now in effect, or which may hereafter come into effect, including but not
21 limited to EMS Policy 4311 —Base Hospital Criteria, attached hereto as Exhibit B and incorporated
22 herein by this reference.
23 L. Take corrective action where there is a failure of CONTRACTOR to comply with
24 the Trauma Center Standards set forth in EMS Policy 4333 (See Exhibit A). The minimum acceptable
25 period of time to correct a deviation from or deficiency in complying with the standard or standards
26 shall be determined by the EMS Agency's Director on a case-by-case basis applicable to the situation.
27 CONTRACTOR's failure to take such corrective action within the time specified by the EMS Agency
28 may, upon declaration thereof by COUNTY, result in breach of this Agreement.
- 4 - COUNTY OF FRESNO
Fresno, CA
1 L. Perform all other obligations of CONTRACTOR under this Agreement.
2 3. RESPONSIBILITIES OF COUNTY
3 COUNTY shall, at its own expense, at all times during the term of this Agreement cause
4 and/or request the EMS Agency to:
5 A. Develop, implement and monitor trauma care system policies and procedures.
6 B. Develop and implement triage procedures,which include injury severity
7 assessment and the determination of patient destination.
8 C. Provide appropriate information and data to CONTRACTOR on the Trauma Care
9 System.
10 D. Perform periodic announced or unannounced site visits to CONTRACTOR's
11 facilities for the purpose of monitoring CONTRACTOR's performance under and compliance with this
12 Agreement. Site visits shall not unnecessarily interrupt CONTRACTOR or CONTRACTOR's
13 personnel.
14 E. Develop and implement, with input from CONTRACTOR, a Trauma Registry
15 Program and Trauma Registry database for the purpose of data collection, monitoring of trauma
16 centers' compliance with the Trauma Center Standards in the Regional Trauma Plan and evaluation of
17 the trauma care system.
18 F. Perform all other obligations of COUNTY under this Agreement.
19 4. TERM
20 This Agreement shall become effective at 12:00 a.m. on February 2, 2016, and shall
21 terminate on the 30th day of June, 2018.
22 5. TERMINATION
23 A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
24 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
25 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
26 terminated at any time by giving CONTRACTOR thirty(30) days advance written notice.
2 7 Notwithstanding anything stated to the contrary in this Agreement, the provisions of this Section 5.A.
28 shall not be construed as imposing any obligations on COUNTY or the EMS Agency to compensate
- 5 - COUNTY OF FRESNO
Fresno, CA
1 CONTRACTOR for any service it may provide, or function or activity that it may perform or undertake
2 in connection with this Agreement.
3 B. Breach of Contract - The COUNTY may immediately suspend or terminate this
4 Agreement in whole or in part, where in the determination of the COUNTY there is:
5 1) A failure to comply with any term of this Agreement;
6 2) A substantially incorrect or incomplete report submitted to the COUNTY;
7 or
8 3) Improperly performed service.
9 C. Without Cause - Under circumstances other than those set forth above,this
10 Agreement may be terminated by either party upon the giving of thirty (30) days advance written notice
11 of an intention to terminate.
12 6. NO MONETARY COMPENSATION
13 CONTRACTOR's Level II Pediatric Trauma Center functions, services and activities
14 conducted pursuant to the terms and conditions of this Agreement shall be performed without the
15 payment of any monetary compensation by COUNTY to CONTRACTOR. COUNTY shall not be
16 liable for any costs or expenses incurred by CONTRACTOR to satisfy its obligations under this
17 Agreement.
18 The parties acknowledge and agree that their respective covenants made to the other
19 party and benefits received from the other party under this Agreement shall form the basis of the
20 consideration exchanged between them under this Agreement.
21 7. INDEPENDENT CONTRACTOR
22 A. In order to establish that COUNTY is not a co-employer of CONTRACTOR's
23 officers, agents or employees, the parties agree to the provisions of this Section 7.
24 B. In performance of the work, duties, and obligations assumed by CONTRACTOR
25 under this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all
26 of CONTRACTOR's officers, agents, and employees, will at all times be acting and performing as an
27 independent contractor, and shall act in an independent capacity and not as an officer,agent, servant,
28 employee,joint venturer, partner, or associate of COUNTY. COUNTY shall retain the right to
- 6 - COUNTY OF FRESNO
Fresno, CA
1 administer this Agreement so as to verify that CONTRACTOR is performing its obligations in
2 accordance with the terms and conditions thereof. CONTRACTOR and COUNTY shall comply with
3 all applicable provisions of law and the rules and regulations, if any, of governmental authorities
4 having jurisdiction over matters which are directly or indirectly the subject of this Agreement.
5 C. Because of its status as an independent contractor, CONTRACTOR shall have
6 absolutely no right to employment rights and benefits available to COUNTY employees.
7 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees
8 all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and
9 save COUNTY harmless from all matters relating to payment of CONTRACTOR's employees,
10 including compliance with Social Security,withholding, and all other regulations governing such
11 matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be providing
12 services to others unrelated to the COUNTY or to this Agreement.
13 g. MODIFICATION
14 Any matters of this Agreement may be modified from time to time by the written consent
15 of all the parties without, in any way, affecting the remainder.
16 9. NON-ASSIGNMENT
17 Neither party shall assign, transfer or sub-contract this Agreement nor their rights or
18 duties under this Agreement without the prior written consent of the other party.
19 10. HOLD HARMLESS
20 A. CONTRACTOR agrees to protect, defend, indemnify and hold harmless
21 COUNTY, its elective and appointive boards, officers, agents, employees, EMS Agency, and EMS
22 Agency Medical Director(s), from any and all claims, suits, liabilities, expenses, costs, damages, or
23 judgments of any nature, including attorney fees, for injury to, or death of, any person, and for injury to
24 any property, including consequential damages of any nature resulting therefrom, arising out of, or in
2 5 any way connected with any negligent or wrongful acts or omissions by, or on behalf of
26 CONTRACTOR, its officers, employees, agents or contractors in performing or failing to perform any
27 services or functions provided for or referred to or in any way connected with any work, services, or
28 functions to be performed by CONTRACTOR, its officers, employees, agents, or contractors under this
- 7 - COUNTY OF FRESNO
Fresno, CA
1 Agreement. The foregoing clause shall in no way obligate CONTRACTOR to provide such protection,
2 indemnification, or defense to the extent of acts or omissions by COUNTY, its officers, employees,
3 agents, or contractors.
4 B. COUNTY agrees to protect, defend, indemnify and hold harmless
5 CONTRACTOR, its elective and appointive boards, officers, agents and employees from any and all
6 claims, suits, liabilities, expenses, costs, damages, or judgments of any nature, including attorney's
7 fees, for injury to, or death of, any persons, or for injury to any property, including consequential
8 damages of any nature resulting therefrom, arising out of, or in any way connected with the negligent
9 or wrongful acts or omissions by, or on behalf of COUNTY, its officers, employees, agents or
10 contractors in performing or failing to perform any services or functions provided for or referred to or
11 in any way connected with any work, services, or functions to be performed by COUNTY, its officers,
12 employees, agents or contractors under this Agreement. The foregoing clause shall in no way obligate
13 COUNTY to provide such protection, indemnification, or defense to the extent of acts or omissions by
14 CONTRACTOR, its officers, employees, agents, or contractors.
15 C. The aforesaid indemnity and hold harmless clauses by CONTRACTOR and
16 COUNTY shall apply to all damages and claims for damages of every kind suffered, or alleged to have
17 been suffered by the party to be indemnified, including but not limited to attorney fees, by reason of the
18 aforesaid operations of the indemnifying party, regardless of whether or not the insurance policies of
19, the indemnifying party shall have been determined to be applicable to any such damages or claims for
20 damages.
21 In addition, each party agrees to indemnify the other party for Federal, State of California
22 and/or local audit exceptions resulting from non-compliance herein on the part of the indemnifying
23 ply.
24 11. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
25 COUNTY and CONTRACTOR each consider and represent themselves as covered
26 entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
27 104-191(1 IPAA) and agree to use and disclose protected health information as required by law.
28
- COUNTY OF FRESNO
Fresno, CA
1 COUNTY and CONTRACTOR acknowledge that the exchange of protected health
2 information between them is only for treatment, payment, and health care operations.
3 COUNTY and CONTRACTOR intend to protect the privacy and provide for the security
4 of Protected Health Information (PHI)pursuant to the Agreement in compliance with HIPAA, the
5 Health Information Technology for Economic and Clinical Health Act, Public Law 111-005
6 (HITECH), and regulations promulgated thereunder by the U.S. Department of Health and Human
7 Services(HIPAA Regulations) and other applicable laws.
8 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
9 CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
10 as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code
11 of Federal Regulations (CFR).
12 12. INSURANCE
13 Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or
14 any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the
15 following insurance policies throughout the term of this Agreement:
16 A. Commercial General Liability
17 Commercial General Liability Insurance with limits of not less than One Million
18 Dollars ($1,000,000)per occurrence with an annual aggregate of Five Million
Dollars ($5,000,000). This policy shall be issued on a per occurrence basis. This
19 policy shall include coverage for bodily injury, broad form property damage,
20 personal injury, products and completed operations, and blanket contractual
coverage including, but not limited to, liability assumed under the Indemnification
21 provisions of this Agreement.
22 B. Automobile Liability
23 Comprehensive Automobile Liability Insurance with a combined single limit of
24 not less than One Million Dollars($1,000,000)per accident. Coverage should
25 include owned and non-owned vehicles used in connection with this Agreement.
26 C. Worker's Compensation
27 A policy of worker's compensation insurance as may be required by the California
Labor Code.
28 D. Professional Liability
- 9 - COUNTY OF FRESNO
Fresno, CA
1 If CONTRACTOR employs licensed professional staff(e.g., Ph.D., R.N.,
2 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with
limits of not less than One Million Dollars($1,000,000)per occurrence, Five
3 Million Dollars ($5,000,000) annual aggregate. Contractor agrees that it shall
maintain, at its sole expense, in full force and effect for a period of three (3)years
4 following the termination of this Agreement, one or more policies of professional
5 liability insurance with limits of coverage as specified therein.
6
7 Such insurance policy for Commercial General Liability insurance shall name the County
8 of Fresno, its officers,agents, and employees, individually and collectively, as additional insured, but
9 only insofar as the operations under this Agreement are concerned. Such coverage for additional
10 insured shall apply as primary insurance and any other insurance, or self-insurance, maintained by
11 COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance
12 provided under CONTRACTOR's policies herein. This insurance shall not be cancelled or changed
13 without a minimum of thirty(30) days advance written notice given to COUNTY. CONTRACTOR
14 shall obtain endorsements to the Commercial General Liability insurance policy naming COUNTY as
15 an additional insured and providing for an unrestricted thirty (30) day prior written notice of
16 cancellation or change in terms or coverage.
17 Prior to the commencement of performing its obligations under this Agreement,
18 CONTRACTOR shall provide certificates of insurance and upon request from COUNTY, formal
19 endorsements, for the foregoing policies, as required herein, to the County of Fresno, 1221 Fulton Mall,
20 Fresno, California, 93721,Attention: Contracts Section, stating that such insurance coverages have
21 been obtained and are in full force;that the County of Fresno, its officers, agents and employees will
22 not be responsible for any premiums on the policies;that such Commercial General Liability insurance
23 names the County of Fresno, its officers, agents and employees, individually and collectively, as
24 additional insured, but only insofar as the operations under this Agreement are concerned; that such
25 coverage for additional insured shall apply as primary insurance and any other insurance, or self-
2 6 insurance, maintained by COUNTY, its officers, agents and employees, shall be excess only and not
27 contributing with insurance provided under CONTRACTOR's policies
28 herein; and that this insurance shall not be cancelled or changed without a minimum of thirty(30) days
- 10 - COUNTY OF FRESNO
Fresno, CA
I advance, written notice given to COUNTY.
2 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
3 herein provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
4 Agreement upon the occurrence of such event.
5 All policies shall be with admitted insurers licensed to do business in the State of
6 California. Insurance purchased shall be purchased from companies possessing a current A.M. Best,
7 Inc. rating of A FSC VII or better.
8 13. CONFIDENTIALITY
9 All services performed by CONTRACTOR under this Agreement shall be in strict
10 conformance with all applicable Federal, State of California and/or local laws and regulations relating
11 to confidentiality, now in effect, or which may hereafter come into effect.
12 14. NON-DISCRIMINATION
13 During the performance of this Agreement, CONTRACTOR shall not unlawfully discriminate against
14 any employee or applicant for employment, or recipient of services, because of race, religious creed,
15 color, national origin, ancestry, physical disability, mental disability, medical condition, genetic
16 information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or
17 military and veteran status, pursuant to all applicable State of California and Federal statutes and
18 regulations.
19 15. DISCLOSURE OF SELF-DEALING TRANSACTIONS
20 This provision is only applicable if the CONTRACTOR is operating as a corporation (a
21 for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
22 changes its status to operate as a corporation.
23 Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing
24 transactions that they are a party to while CONTRACTOR is providing goods or performing services
25 under this agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR
26 is a party and in which one or more of its directors has a material financial interest. Members of the
27 Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
28 and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit C and
COUNTY OF FRESNO
Fresno, CA
1 incorporated herein by reference, and submitting it to the COUNTY prior to commencing with the self-
2 dealing transaction or immediately thereafter.
3 16. RECORDS/REPORTS
4 CONTRACTOR shall develop and maintain a Trauma Registry Program which is
5 approved by the EMS Agency. The Trauma Registry Program shall include all appropriate trauma
6 patient information and "hospital data" (as that term is defined in Trauma Regulation, section
7 100257(c)) concerning such patients as set forth in EMS Policy#332—Trauma System Monitoring
8 and the Regional Trauma Plan(See Exhibit A). All such records shall be complete and accurate. The
9 EMS Agency shall have access to all such records upon request. CONTRACTOR shall provide trauma
10 registry data and/or reports to the EMS Agency upon request and/or on a regularly scheduled timetable
11 such as monthly, quarterly, or annually,which will be agreed upon between the EMS Agency and
12 CONTRACTOR. In the event that the EMS Agency develops the capability to directly access and
13 retrieve trauma registry records through computer technology, CONTRACTOR shall, at no cost to the
14 EMS Agency, assist the EMS Agency in achieving such access and retrieval of CONTRACTOR's
15 Trauma Registry Program through such means.
16 17. LICENSES/CERTIFICATES
17 CONTRACTOR shall, at its own cost, throughout the term of this Agreement, maintain
18 all necessary licenses,permits and certificates necessary for the provision of services hereunder and
19 now or hereafter required by Federal, State and local laws and regulations, the EMS Agency and any
20 other applicable government agencies. This shall include, but not be limited to: 1) being licensed as a
21 general acute care hospital, and 2) holding a special permit for basic or comprehensive emergency
22 services.
23 18. AUDITS AND INSPECTIONS
24 CONTRACTOR shall at any time during business hours, and as often as COUNTY and
2 5 the EMS Agency may deem necessary, make available to COUNTY and the EMS Agency for
26 examination all of its records and data with respect to the matters covered by this Agreement.
27 CONTRACTOR shall, upon request by COUNTY and the EMS Agency, permit COUNTY to audit and
28 inspect all such records and data necessary to ensure CONTRACTOR's compliance with the terms of
- 12 - COUNTY OF FRESNO
Fresno, CA
1 this Agreement.
2 19. NOTICES
3 The persons having authority to give and receive notices under this Agreement and their
4 addresses include the following:
5 COUNTY CONTRACTOR
6 Director, Fresno County President and CEO
7 Department of Public Valley Children's Hospital
Health 9300 Valley Children's Place
8 P. O. Box 11867 Madera, CA 93638-8762
Fresno, CA 93775
9 Any and all notices between the COUNTY and the CONTRACTOR provided for or
10 permitted under this Agreement, or by law, shall be in writing and shall be deemed duly served when
11 personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
12 United States Mail, postage prepaid, addressed to such party.
13 20. GOVERNING LAW
14 The parties agree that for the purposes of venue, performance under this Agreement is to
15 be in Fresno County, California.
16 The rights and obligations of the parties and all interpretation and performance of this
17 Agreement shall be governed in all respects by the laws of the State of California.
18 21. THIRD PARTY BENEFICIARIES
19 The parties hereto agree that the covenants made and benefits received between them
20 (and for the benefit of the EMS Agency under this Agreement) are only between them (and for the
21 benefit of the EMS Agency), and that there are no intended third party beneficiaries of this Agreement,
22 provided however, for purposes of this Section 12, the EMS Agency shall be deemed to be an intended
23 beneficiary of this Agreement.
24 22. ENTIRE AGREEMENT
25 This Agreement constitutes the entire agreement between the CONTRACTOR and
26 COUNTY with respect to the subject matter hereof and supersedes all previous agreement negotiations,
27 proposals, commitments, writings, advertisements, publications, and understandings of any nature
28 whatsoever unless expressly included in this Agreement.
- 13 - COUNTY OF FRESNO
Fresno, CA
I IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
3 ATTEST:
4 CONTRACTOR: COUNTY OF FRESNO:
5 VALLEY CHILDREN'S HOSPITAL
6
By By E__�
7 Chairman, Board of Srupervisors
8 Print Name: V%C
9 Title: JU -nl7 Date:
Chainnarl of the Board, or
10 President, or any Vice President
11
Date: BERNICE E. SEIDEL, Clerk
12 Board of Supervisors
13 By
14 �n ' " �W�� W Print Name: `V� 0d By
15
Title: tr'o Date: I tip
16 Secretary (of Corporation), or
17 any Assistant Secretary, or
Chief Financial Officer, or
18 any Assistant Treasurer
19 Date: ` 1 to PLEASE SEE ADDITIONAL
20 SIGNATURE PAGE ATTACHED
21
22
23
Mailing Address:
24 9300 Valley Children's Place
25 Madera, CA 93638-8762
26
27
28
- 14 - COUNTY OF FRESNO
Fresno, CA
1 APPROVED AS TO LEGAL FORM:
2 DANIEL C. CEDERBORG, COUNTY COUNSEL
3
4 By
5
6
7 REVIEWED AND RECOMMENDED FOR APPROVAL:
8
9
By
10 David Pomaville
11 Director
Department of Public Health
12
13
14 Fund/Subclass: 0001/10000
Organization: 56201695
15
JW
16
17
18
19
20
21
22
23
24
25
26
27
28
- 15 - COUNTY OF FRESNO
Fresno, CA
EXHIBIT A
CENTRAL CALIFORNIA
EMERGENCY MEllICAL SERVICES
A DiNki0U of the Fresno County Department of Public 1Icalth
Manual Policy
Emergency Medical Services Number 330
Administrative Policies and Procedures
Page 1 of
Subject Trauma System Overview
F,t1'ective
References California Code of Regulations 11.01.20O2
Title 22. Social Security
Division 9.Prehospital Emergency Medical Serviecs
Cha ter 7.Trauma Care S stems
1_ POLICY
The Central California Emergency Medical Services Trauna Services System shall operate in accordance with
Health and Safety Code Division 2.5,and the California Code of Regulations Title 22, Division 9,Chapter 7 and
shall be implemented,monitored and evaluated by the EMS Agency.
llte Central California Emergency Medical Services Trau[na System maintains a trauma plan and EMS policies and
procedures required by Section 100255 of the California Code of Regulations.The intent of the Trauma Plan and
EMS policies and procedures is to provide a clear understanding of the structure of the trauma system in a frianner
that effectively utilizes the systems resources.
The following is a list of the policies required by Section 100255 of the California Code of Regulations and includes
brief description of the policy and a reference where further policy information can be located.
A. Svstem Orcanizaticm,8pd Management
The EMS Division of the Fresno County Department of Public Health is the designated local EMS agency
for Fresno, Kings, Madera and Tulare Counties. The EMS Division is responsible for monitoring the
ongoing operation of the regional trauma care system. This is accomplished through the development of
EMS policies and procedures and by participating in the various E.MS committees, including the Regional
Trauma Audit Committee. The EMS agency staff supervises,the collection and analysis of trauma data,
including ong;Ling deve]opntent of thr trauma patient 1, .51y.
A Level I Trauma Center,Community Regional Medical Center(RMC:), is located in Fresno and directly
receives prehospi[al trauma patients from within the region often bypassing other receiving hospitals.
A Level 111 'Trauma Center, Kaweah Della Medical Center(KDMC), is located in VLsalia and receives
prchospital trauma patients from within Tulare County and adjacent counties.
Approved By Revision
EMS Director j` 01/01/2015
EMS Medical Director
Page 2 of 4
Subject Trauma System Overview Policy
Number 330
E. Trauma Care Coordination Within the Trauma System
The prehospital care and treatment of trauma patienti shall be in accordance with CMS policy and
procedures to insure consistent application of traunta services through-out the EMS region.These policies
include EMS Policy R 332—Trauma System Monitoring,EMS Policy r510-Basic Life Support Protocols,
EMS Policy t;530-Paramedic Treatment Protocols, EMS Policy 6547 Patient Destination,and other
EMS policies and procedures.
C. Trauma Care Coordination wilt Vcialthnr ng;_Jurisdictions
Coordination of Trauma Care with reighboring jurisdictions is addressed in the prehospital setting;and also
the hospital setting.F,!rMS Policy h 406—EMS Dispatch Policy -Out of County Responses,and CMS Policy
4408—I lelicopter Dispatch Policy,address the coordination of trauma response in the neighboring
jurisdictions outside of the Central California EMS region.Coordination of trauma care with neighboring
jurisdictions in the hospital setting;is addressed in EMS Policy 4341 Patient Transfers Between Acute
Care Facilities,and EMS Policy.342—Transfer Agreements Between Acute Care Hospitals.
D. Collection and Management of Data
The designated trauina centers and non-trauma centers are responsible for submitting all required data to
the EMS Agency on a monthly basis or as determined by the EMS Agency. The minimum data set as
defined in the State Trauma Regulation Section 100257, is required by all participatingtauma hospitals.
Collection and management of data for the Central California Emergency Medical Services Trauma System
is outlined in EMS Policy 14332.and Policy #334. The trauma nurse coordinatorsimanagers provide trauma
registry data,which is used by the Trauma Audit Committee and EMS Agency and is submitted to the
State's data system(CEMSIS:"�IEMSIS).
F. Trauma Center Fecs.fpr Desi:nation'Redesiaitation'Fvatuation
There are currently no fees for trauma center designation,redesignation, or traunta center evaluation in the
Central California Emergency Medical Services region.
l . Estshlishment of Service Areas for Trauma Centers
Community Regional Medical Center is the designated Level I trauma center in the Central California EMS
region- The service area encompasses the entirety of the Central California EMS region.In very specific
circumstances,such as airway compromise,a trauma patient may be transported to a receiving hospital for
stabilization he.l«re proceeding to the trauma center. Kaweah Delta Medical Center is a designated Level
111 Trauma Center and is the primary trauma destination for trauma patients in Tulare County.
G, D si natiStn and Re-designation of a Trauma Centerlincludirta Agrccmrnt�
The Local EMS Agency designates Trauma Centers within the EMS Region.Trauma center designation is
based upon the need for local and regional trauma care services.Trauma facility designation is outlined in
EMS Policy!.331 -Trauma Facility Designation,
K Triage to the Appropriate Facilnt%,
The prehospital triage and transport decision process is very similar to the Centers for Disease Control
(CDC)field triage process and involves an assessment not only of the physiology and anatomy of the injury
but also the mechanism of the injury and special patient considerations. Seriously and moderately injured
patients are transported directly to RMC or KDMC. EMS Policy#547—Patient Destination outlines the
required patient destination procedure for both trauma and medical patients.
Page 3 of 4
Subject Trauma System Overview Policy
Number 330
1. Repatriation(if Stable Trauma Service Health Pian Members
EMS Policy 4547 Patient Destination mcluires prehospital personnel to attempt to transport stable patients
to the patient's health plan's participating facility. in 2008,The ENIS Agency partnered with the Hospital
Council of i;orthern California and hospitals within the 4-county Eh4S region to create a patient transfer
committee.This committee meets regularly to discuss the issues and barriers with repatriation of patients.
Recognized as a best practice,the Committee developed an agreement signed by all hospitals that agrees to
criteria and conditions on repatriating patients in an effort to increase capacity at the Trauma Centers and
keep local patients in the local areas.
J. !Etter-trauma Center& Inter-facility,Transfer of the Trauma Patient
The F.MS policies and procedures strictly address the coordination and management of Inter-traurna center
and inter-facility transfers of the trauma patient and arc addressed in EMS Policy#341 --Patient Transfers
Between Acute Care facilities, EMS Policy�042—Transfer Agreements Between Acute Care Hospitals,
and EMS Police r',155.E Ai.S lnterfacility'i'ranslers.
K. Role of the Pediatric Trauma Ccntcr
Community Regional Medical Center is the Level I l'rauma Center and is the designated destination for all
pediatric trauma.
1.1. Resources for Trauma Team Res pon.�q-__Equipment R Staff
Trauma Centers are required by ERAS Policy 4333—Trauma Center Criteria to have internal hospital
policies and procedures governing"Trauma Center Medical and Physician Services',which include the
resources and staff required for a trauma team response.
M. Criteria for Activation of the`I rauna Tarn
Trauma Centers are required by EMS Policy I'333—Trauma Center Criteria,to have internal hospital
policies and procedures outlining the specific criteria for trauma tearn activation.
N. ;'Availability of I rauma Specialists
'(Trauma Centers are required by EMS Policy h3 33—Trauma Center Criteria to have internal hospital
policies and procedures outlining the availability of trauma team personnel and specialists.
C3. Quality Intptc,vement and System! tialuatic}n include Multidisei}�linary Peer Review Committee
Quality Improvement is a combined effort of hospitals,providers,and the EMS Agency. 1?MS Policies
4703 - Continuous Quality Improvement,and#704 Quality Improvement Reporting address the access to
the continuous quality improvement process.The trauma services system is monitored through the
continuous quality improvement process and also through F..MS policy 4332—Trauma System Monitoring.
The trauma system is also monitored by a peer review conttnittee,which is outlined in EMS Policy#703—
Crmlinuous Quality Improvement,
P. ldentification and Transn ation ofthe Adult and Pediatric Trauma Center Candidate
Trauma center patients are identified by a decision process that is very similar to the Centers for Disease.
Control(CDC)field triage process and involves an assessment not only of the physiology and anatomy of
the injury but also the ntechanisrn ofthe injury and special patient considerations.Once the patient is
identified as a trauma center patient,the prehospital personnel transport the patient directly to the trauma
center in accordance with EMS Policy 9547—Patient Destination.
Page 4 of4
Subject Trauma System Overview Policy
Number 330
Q. Traum Triage Training of Prehospital_Personnel
Prehospital Personnel and MICT's are trained in trauma triage through continuing education courses
available throughout the.EMS System.Continuing education courses must be in accordance with LNIS
Policy;:701 Continuing Education.
R, Public Information and Education on Trauma.Systems
All public information and education requirements and services relative to the design, implementation,and
operational effectiveness ol'the trauma system will he coordinated through the CMS Agency. Public
information and educational activities will encompass trauma system design,citizen access,trauma system
capabilities,and mechanism for follow up and incident review as requested by the public andior medical
community. Additional requirements will include:
I. A commitment to the establishment of a traunta system that supports the promotion of iniury prevention
and safety education.
2. The facilitation of speakers to address public groups and serves as a resource for trauma information
and education.
3. Provide assistance to community and proiessional groups in the development and dissemination of
education to the public on such topics as injury prevention. safety education programs and access to the
traunta care system.
4. Each designated facility trust participate in the development of public awareness and education
campaigns for their service area.
S. Provider Marketina and.Adv rtissinw
California I iealth and Safety Code,Division 2.5,states in part,4'no health care provider shall use the term
"trauma facility,""trauma hospital,""trauma center,""trauma care.provider,""trauma care vehicle,"or
similar terminology in its signs or advertisements,or in printed materials and information it furnishes to the
general public,unless its use has been authorized by the EMS Agency.
All marketing and promotional plans, with respect to trauma center designation,shall be submitted to the
EMS Agency for review and approval,prior to implementation.
T. collaborative Miury Prevention i:fforic with the Puhlie:_Private Sector
I rauma Centers shall participate in injury prevention programs with public and private agencies. Trauma
Centers may produce their own Iniury Prevention Programs based upon data analysis of the,trauma center
review at their facility. Trauma Centers may utilize information developed by the EMS Agency as a result
of system review to produce injury prevention programs for the public and private sector in their
cotntnunities.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A DiAslnn of the Fresno County Depariment of Pnblic Ileatth
Manual Policy
Emergency Medical Services Number 331
Administrative Policies and Procedures
Page I of 3
Subiect Trauma Facility Designation
References California Code of Regulations, Title 22.Social Security Effective
Division 9. Prehospital Emergency Medical Services 1 l?01;84
Chapter 7.Trauma Care Systems
1. POLICY
Trauma Centers for the Central California EMS Region are designated by the. local FIRS Agency bawd upon the
need for local and regional EMS trauma care services.
11, DESIGNATED TRAUMA CENTERS
'rhe following hospitals have been designated as Trauma Centers-
Date of Original
Trauma Center Level of Designation Designation
Community Regional Medical Center Level 1 Trauma Center June 19, 1994
kaweah Delta Medical Center level Ill Trauma Center January 2 ,2010
Ill. PROCEDURE FOR DESIGNATION
A. The EMS Agency shall develop and update a plan for the provision of trauma care within the four county
region. This plan shall minimally address the provision of trauma care services,triage mechanisms for
patient routing,the nuinber and type of trauma hospitals needed for local andlor regional trauma care needs,
and the evaluation process for the trauma system.
B. The Regional Trauma Audit Committee will f'ortnalize recommendations to the EMS Agency concerning all
aspects of the trauma sysumi, including the number and type of trauma hospitals needed for effective system
operation.
C. Any hospital wishing to gain a trauma designation shall notify the F.MS Agency, in writing,of its intent to
seek trauma center designation. This documentation shall include the hospital's justification,plan,proposed
trauma patient volume.,and anticipated timetable for implementation,
App
roved B}} �`j Revision
EMS Director `f
0110112015
F..\9S Medical Director
Vag 2 or 3
Subject Trauma Facility Desiga.ation Policy
LNumher 331
D_ Prior to designation as a trauma center,the hospital shall submit to the EMS Agency:
I. The Application fbr Trauma Designation with required documents.
2. A copy ol'th: American College of Surgeons Committee on Trauma(ACS-CUT)Consultative
Visit if done prior to designation.
3. Documentation that the Trauma Center Standards in Policy 333 have been met.
F. Applications shall be reviewed fir their compliance with the State of California, local regulations and their
impact on the local trauma systeni. The Regional Trauma ,Audit Committee, Regional Medical Control
Committee,iutd each Emergency Medical Care Committee from each county in the region will be consulted
for its recommendation.
F. If more than one hospital competes for a role in the local system that is deemed necessary by the regional
Trauma Audit Cauntittee and the EMS Agency, a Request for Proposal procedure may be necessary to
determine the successful applicant.
O. After review of the submitted application and documents, the EMS Agency will conduct a site review of the.
13cility as outlined in the Application for Trauma Designation. The cost of the site review shall be the sole
responsibility of the hospital applying for trauma destination.
it. Upon the completion of satisfactory site the EMS Agency will designate the hospital as a Level 1.
11, 111, 1V,or Pediatric I or I trauma center.
1. in the event that the hospital Ca Is to meet the criteria for designation,the F.MS Agency may elect to issue a
conditional designation that will be followed within six(0)to twelve(12)months by another evaluation of
the deficient areas,
J. Upon satisfactory compaction of the second evaluation, the EMS Agency will authorize full designation of
the Trauma Center,
K. If the second evaluation is unsatisractory,the EMS Agency may elect to continue the conditional
designation upon correction of the areas of deficiency or deny designation.
L. The hospital requesting designation and the EMS Agency will enter into a contract for designation of the
trauma center.
M. A designated trauma center shall obtain American College of Surgeons Committee.on Trauma(ACS-COT)
verification within 2(two)years of their initial trauma center designation. The cost of the verification shall
be the sole responsibility of the hospital requesting such verification.
N. The EMS Agency shall determine a plan for Trauma Care Services.
0, Any change in designation will become part orthe revised trauma plan and will he approved by the Local
EN1S Agency prior to submission to the State EMS Authority.
IV PROCEDURE FOR RF.-EVALUATION OF A TRAUMA CL•NTER'S STATUS
A. The EMS Agency shall evaluate the designated Trauma Centers'Status every three}rears for contractual
compliance and compliance with the California Code of Regulations, Title.22, Division 9,Chapter 7.
Page 3 of 3
Subject: Policy
Trauma facility Designation Number: 331
B. Designated Trauma Centers shall maintain verification with the ACS-COT, Trauma Centers shall submit to
the FNIS Agency a copy of the re-verification visit summary fi•om the ACS-COT every three years.
V. PROCliUI;RL',FOR DE-DESIONA'f10\
A. Failure by a hospital to comply with applicable LAwal, State, and ACS-COT trauma requirements or
applicable recommendations by site survey teams approved by the EMS Agency or ACS-COT,may result
in Curfeiture of their trauma designation.
B. failure by a hospital to provide all adequate quality of care,as identified through medical audit and quality
audit procedures,may result in forfeiture of their trauma designation.
CEWxAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A DiyiblUn or(lie Freynu County Department ar Publlc IIcaith
Manual Policy
Linergency Medical Services Number 332
Administrative Policies and Procedures
Page 1 of 4
Subject 'I'rauma System Monitoring
References California Code of Regulations,Title 22.Social Security F.ff' ctive
Division 9, Prehospital Linergency Medical Services 1110111,88
Chapter 7.Trauma Care S 4tems
1. POLICY
The trauma care administered to patients ofthe local tramna care system will be reviewed for appropriateness and
patient outcome. This review will he conducted through the use of the Regional Trauma Audit Corninittee and
Regional Medical Control Committee, both which are composed of health care and trauma care specialists.
il. PROCEDURE
A. TRAUMA REGISTRY
1, Definition
The Trauma Registry is a confidential database of patients who have sustained major injuries or
complications within the regional trauma system.This database is utilized for statistical reporting
on system activities and quality improvement review of patient outcome. Registry data includes
information from prehospital,emergency department,operative and intensive care,and the
patient's final disposition.Trauma centers and non-trauina centers will follow the criteria outlined
in Policy 4334 regarding trauina registry data collection.
H INTERNAL I10SPI TAL REVIEW
The medical records(including prehospital)of each registry patient at rmuma centers will be reviewed by
the Trauma Nurse Coordinator?Manager or designee for completeness,accuracy and presence of any delays
in evaluation and treatment. The hospital's Trauma Surgery Director or designee will review the registry
records for appropriateness of diagnostic procedures relative to the admitting diagnosis,timeliness of core,
appropriateness of operative therapy relative to diagnosis,complications,morbidity, and length of stay
relative to diagnosk,.
The Trauma Surgery Director and Trauma Nurse Coordinator,`Manager will present registry cases that meet
the established criteria to the hospital's appropriate reviewing committee. Trauma centers will utilize a
specific Traunia Review Committee whose membership shall minimally include:
Approved By Revision
EMS Director
01101/201 S
EMS Medical IJilvctor
Page 2 of 4
Subject Trauma System Monitoring Policy
Number 332
TRAUMA CLNTLR TRAUMA REVIEW Ci)MMITTFf
Trauma Su!Vrry Director Neurosurgeon
FtneTEgcy edicine Representative Orthopedic Sur&eon
Trauma Nurse IartaQerlCoordinator Hospital Administration
Emergency De ailment Mana}erlSupervisor Prehospital Liaison Nurse � T
In addition to the members listed above,the.Trauma Center should also consider the following
representatives:
Anesthesiology
Ocn.ral Surgeon
Nurse Manager-OR
Nurse Manager—ICU
Radiotogy Representative
Blood Bank Representative
Medical Records will be availabl:: to allow the committee to review all aspects of the patient's care and course
of hospital stay. The hospital Trauma Review Conunittee is responsible for reviewing the patient's care,
identifying problems, providing feedback to individuals involved in a specific patient's care, formulating
recommendations for hospital trauma operational procedures,and classification of deaths as mortality without
opportunity For improvement. anticipated mortality with opportunity for improvement, or unanticipated
mortality µ°ith opportunity for improvement. The committee shall forward unusual or problem cases to the
Regional.Trauma Audit Committee and formulate recommendations on Trauma Care System and EMS Systern
operation. The definitions for the classifications of death are in accordance with the American College of
Surgeons criteria and are as follows:
1. Mortality without ot?pgou—pity for improvement- An event or complication sequela of a procedure,
disease,illness,or injury for which reasonable and appropriate preventable steps had been taken.
2. Anticipated rnortality with opportunity fur_impr vement—An event or complication that is a sequels
of a procedure, disea;c, illness, or injury that has the potential to he prevented or substantially
ameliorated_
3. Unaraicipa-d mortalih with opportunity TQr improvement — An event or complication that is an
expected or unexpected sequela of a procedure, disease, illness, or injury that could have been
prevented or substantially�vtteliorated.
C. REGIONAL TRAt.MA AUDIT CO%.l.\91 f 1'LL
I. Membership
The Regonal Trauma Audit Committee is an advisory committee to the EMS Agency on issues
related to tratuna care. The membership shall be broad-based and shall represent the participants in
the Trauma System and the local medical community. The Trauma Audit Committee membership
shall minimally include:
L%EA1BI RSHiP OF TILL REGIONAL,TRAUMA AUDIT C0.\91tiI17•TEE tE,6g
Trauma Centers Non-Trauma Hospitals
Trauma Surgery Director Trauma Surgery Director
Emergency Dep rtment Physician : Emergency Department Physician
Trauma Nurse Coordinator,i'Matrager Trauma Nurse Coordinator'PL,N
Page 3 of 4
Subject Trauma System Monitoring Policy
Number 337
EMS Agency Local Medical Coanmun1q,
F.VIS Medical Director Neurosurgeon(from Neurosurgical Society
EMS Director Physician from Rural Area(from Medical Society)
EMS Trauma Coordinator
Each of the agencies listed above shall notify the EMS Medical Director, in writing,of the name cif
the person designated to represent the agency and exercise Committee voting privileges. There will
be one vote per facility.
2. Chairperson?Vice Chgi.Eperson
The Committee shall elect a Chaimman who shall serve a term of one year with new elections each
January,The committee may elect to choose a co-chairperson. The EMS Medical Director will
serve as Vice Chairman in the event of absence of the chairperson(and co-chairperson). Meeting
Minutes will be recorded on topics not related to specific confidential patient care issues.I'he
EN9S Agency will provide staff support for the Regional Trauma Audit Committee.
3_ Committee Responsibilities
The Regional Traurna Audit Committee is responsible for reviewing all aspects of the Trauma
Care System and developing recommendations on system operation for the EMS Agenc}. This
will include system operation,trauma care planning,data analysis, trauma policy development,
hospital assessment and selection and specific patient base reviews.
The Committee's agenda shall include a review and approval of monthly Minutes, case
presentations and specific educational case reviews(e.g.neurologic case review, review of EMS
procedures related to the Trauma Care System). Agenda itenns may occur on a regular schedule
including monthly(e.g.case presentations)or at the request of the Committee members. items not
included in the Committee's written agenda may be added at the beginning of the meeting at the
discretion of the Chairman.
The Trauma Centers wi I I present case presentations each month. Non trauma centers may present
problems transfers or problem cases as needed. Criteria for case presentation to the Regional
Trauma Audit Committee ure included in Attachment A. Specific educational case reviews may be
presented to illustrate new techniques,patient problems,or system operational issues related to a
medical specialty such as neurosurgery,orthopedics or pediatrics.The P%1S Agency will provide
monthly reports to the committee an the regional trauma system.The Committee may provide
feedback on systeun operation or quality improvement issues directly to the EMS Agency,health
care facility or provider,and other traurnivEMS advisory groups.
D, EMS AGLNCY
The local EMS Agency iS responsible for monitoring the operation of the Trauma Cart System, The EMS
Agency may request an onsite review of any designated trauma hospital with repetitive problems to ensure
the problems are being resolved. Additional agency involvement(e.g. State Department of Health Care
Services)may be requested as appropriate.
Page 4 of 4
Subject Trauma System Monitoring Policy
Number 332
AT 1'ACH M ENT A
CASF PRESENTATION CRITERIA
I. Case Presentations shall occur each month at the regional Trauma Audit Committee.The criteria for ease
presentation shall include:
A. Any death classified as unanticipated mortality with opportunity for improvement or anticipated mortality
with opportunity for improvement by the hospital Trauma Review Committee, including:
l. All deaths with initial surgery(required for stabilizarion) 1 hour after arrival at a trauma hospital.
2. All deaths with a delay in the arrival of the surgeon(>10 minutes).
3. All deaths with unanticipated autopsy findings or autopsy findings inconsistent with the admitting
diagnosis.
4. All deaths with inappropriate prolonged prehospital time including on-scene times greater than 10
minutes without explanation,or a transport time greater than 30 minutes if air transport was available.
3. All deaths where probability of survival (PS)>50%based upon'Trauma Score- Injury Severity Score
(TRISS).
B. Major complications(e.g.Grade 2, 3,4 in accordance with ACS Guidelines)which significantly increase
inpatient hospital time or lead to premature death.
C. A comatose patient(Glascow Coma Scale of less than 8)going to CT or, leaving the emergency department
before a definitive airway(endotracheal tube or surgical airway)is established.
D. Patients with epidural or subdural brain henratoma receiving craniotomy more than 4 hours,from arrival at
emergency department to surgical start time,excluding those petformed for intracranial pressure(ICP)
monitoring.
E. Delay to Surgery for laparotoniy:
1. Surgery start time>I hour if hypotensive(systolic blood pressure<90nun Hg)
2. Surgery start time>4 hours if stable
F. Problem Transfers-Any trauma patient transfer of greater titan 6 hours from original time of arrival time at
the sending hospital.
G. Any trauma team activation with a delay in the arrival of the surgeon of greater titan 15 minutes.
H. Any trauma case where the trauma consultant does not respond in the specified time period,
1. Any case which demonstrates system operational problems.
J. Interesting or educational cases.
CENTRAL CALIFORNIA
EmL4 RGENCY MEDICAL SERVICES
A Dirision of the Fresno county Department of Public Health
(Manual Policy
Emergency Medical Services Number 333
Administrative.Policies and Procedures
Page 1 of 2
Subject Trauma Center Criteria
References California Code of Regulations Effective
Title 22. Social Security 11:08.88
Division 9. Prehospital Emergency Medical Services
Chapter 7.Trauma Care Systems
1. POLICY
A traunia center is a licensed hospital,accredited by the Joint Commission on Accreditation of Healthcare
Organizations,which has been designated as a Level 1. 11, 111, IV,or Pediatric Level i or 11 trauma center by the
Local EMS Agency. Designated trauma centers for the Central California EMS Region shall adhere to the minimum
standards set forth in the California Code of Regulations,Title 22, Division 9,Chapter?,Trauma Care Services and
EMS Agency policy and procedure.
11. PROCEDURL
A. Trauma centers shall maintain,at all times,the standards required of its designation as a Level 1, 11, ill,iV,
or Pediatric level 1 or 11 n•auma center in accordance the California Code of Regulations,the Central
California EMS Policies and Procedures,and the American College of Surgeons Committee on Trauma
(ACS-COT)once verified
B. All designated trauma centers shall achieve and maintain ACS-COT verification within two(2)years of
their initial designation as a trauma center. Copies of consultative visits or verification visits by the ACS-
COT shall be submitted to die EMS Agency. Designated trauma centers at the time ofthis policy shall
achieve their ACS-COT verification by January 1,2016.
C. In addition to the requirements listed in the Trauma Center Standards,a designated trauma center for the
CCFMSA EATS Region shall meet and maintain the following additional requirements:
1. Designated trauma centers shall desi-nate a Trauma Program Medical Director,Trauma Nurse
CoordinatorsManagzr,and an emergency department physician who shall regularly attend the EMS
Agency's Regional Trauma Audit Committee.They each shall attend at least nine(9)of the
Regional Trauma Audit Committee tneetings each calendar year. The emergency department
physician representative shall he a board certified in emergency medicine or maintain current
certification in Advanced Trauma Life Support(A'1LS)and be a certified base hospital physician.
2. Trauma eentcrs shall be designated Base Hospitals and shall meet all requirements outlined in
EMS Policy and Procedure.
Approved By Revision
F.MS Director "
01f01J20I5
-'MS Medical Director
Page 2 of 2
Subject Trauma Center Criteria Policy
Number 333
3. Trauma centers are expected to provide a full activation of their team resources for patients that
meet the triage criteria for major trauma patients. Patients that are hemodynamically stable,
without major anatomic injury may be considered for a reduced trauma team response. If a trauma
center chooses to implement a tiered trauma team response, a quality assessment and improvement
process must be in place to monitor the effectiveness of the care delivery.A copy of the Trauma
Centers written procedure on trauma team response, including the process to monitor its
effectiveness,must be on file at the EMS Agency.
4. Designated trauma centers shall implement and maintain an EMS Agency approved trauma
registry data collection program and provide registry data to the EMS agency on a monthly basis.
The trauma registry program used in the CCEMSA is Trauma One by Lancet Technology.
5. Designated trauma centers shall have a written agreement with the Local EMS Agency
6. Designated trauma centers shall have a written transfer agreement with all affiliated trauma care
hospitals and appropriate specialty care facilities. A copy of the written agreement shall be on file
with the EMS Agency.
D. Immediately Available
Immediately available implies the physical presence of the surgeon in a stated location at the time of need
by the trauma patient within 15 minutes 80%of the time,otherwise upon patient arrival with sufficient
advanced notice.
E. Promptly Available
Promptly available is defined in this policy as the return of a notification call within 20 minutes and
available to the Trauma Center within 30 minutes 80%of the time when requested by the trauma team
leader.
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essentiial E*= CCEMSA D = desirable
Level Peds'' is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
-requirements
Institutions/Organization
JACAHO Accreditation E E E E E
Proof of licensure as a general acute care hospital in the State E E E E E
of California
Basic or comprehensive emergency services with special E E E E* D
permits
Shall have equipment and resources needed for initial E E E E E
stabilization and personnel knowledgeable in the treatment of
adult and pediatric trauma (Pediatric TC - pediatric trauma
A trauma center must demonstrate substantial medical, E* E* E* E* E*
administrative, and financial commitment for the level of
designation requested. Commitment must be demonstrated and
include documentation from the hospitals:
Administration
Medical Staff
Nursing
Level I shall have one of the following patient volumes annually; E
minimum of 1200 trauma program hospital admissions or
A minimum of 240 trauma patients per year whose Injury
Severity Score (I SS) is >15, or
n average of 35 trauma patients (ISS >15) per trauma program
surgeon�er yar _
trauma research program E E#
An ACGME approved surgical residency program E j E#
Requirements for Trauma Centers
Pediatric trauma centers must have qualified pediatric
personnel and pediatric specific resources for all areas
Trauma Program Medical Director E E E E E
Qualifications
Board Certified Surgeon or E E E D
Fellow of ACSE * E* E* E*
Board Certified Pediatric Surgeon for Pediatric Trauma Center E#
qualified surgical specialist E
A qualified non-surgical specialist E
Responsibilities include but not limited to:
Recommending trauma team physician privileges E E E E E
1
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
I II PEDS III IV
E = essentlal E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E#= essential for Level I Pediatric TC in addition to Level II
requirements
Working with nursing & administration to support needs of E E E E E
trauma patients
Developing trauma treatment protocol E E E E E
Determining appropriate equipment and supplies 1 E E E E* E*
Ensuring development of policies/procedures for domestic
violence, elder/child abuse/neglect E E E E* E*
Having authority & accountability for QI peer review process E E E E E
Correct deficiencies in trauma care/exclude team members that E E E E E
don't meet standards
Coordinating pediatric trauma care with other E E E E* E*
hospitals/professional services
Coordinating with local and State EMS agencies E E E E* E*
ssisting with the coordination of budgetary processes for E E E E E
trauma program
Identifying representatives from neurosurgery, orthopedic E E E E* E*
surgery, emergency medicine, pediatrics, and other appropriate
disciplines to assist in identifying physicians from their
disciplines who are qualified to be members of the trauma team
Trauma Nurse Coordinator/Manager E E E E E
Qualifications: -
Registered nurse E E E E E
Provide evidence of educational preparation, clinical E E E E E
experience in care of adult and pediatric trauma patients, and
administrative responsibilities
Responsibilities include but not limited to:
organizing services and systems necessary for E E E E E
multidisciplinary care of the injured patient
coordinating day-to-day clinical process & performance E E E E E
improvement of nursing and ancillary personnel
collaborating with trauma program medical director to carry E E E E E
out educational, clinical, research, administrative and
outreach activities of the trauma program
Trauma Service E E E E E
Pediatric TC must provide Pediatric Specialist/Services
Implement requirements of Title 22 and Local policy & E E E E E
coordinate with the EMS agency
2
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
**
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
Capable of providing immediate initial resuscitation and E E E
management of the trauma patient
Capable of providing prompt assessment and stabilization of the E E
rauma patient
Ability to provide treatment or arrange for transportation to a E E
higher level trauma center
Trauma Team E E E E E
A multidisciplinary team responsible for the initial resuscitation E E E E E
and management of the trauma patient.
Pediatric trauma center—the pediatric trauma team leader shall E
be a surgeon with pediatric trauma experience as defined by the
trauma program medical director, and
Remainder of team shall include physician, nursing and support
personnel in sufficient numbers to evaluate, treat, stabilize
pediatric patients
SURGICAL DEPARTMENT (S), DIVISION(S), SERVICE(S),
SECTION(S):
Includes at least the following surgical specialties & staffed
by qualified specialists:
Pediatric TC must provide Pediatric Specialist
General Surgery E E E
Neurologic - ---- -- �E E E - ---
May be provided through a written transfer agreement for E
Level III
Obstetric/Gyne co,logic
May be provided through written transfer agreement for E E E
Pediatric TC
Ophthalmologic E E E
Oral/maxillofacial or head and neck E E E
Orthopedic E E E E
Pediatrics D D E
Plastic E E E
Urologic E E E
Microsurgery/re-implantation (may be through transfer
agreement with a hospital that has a department, division, E
service that provides this service
3
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 Il PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Pods" is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
NON-SURGICAL DEPARTMENT (S), DIVISION(S),
SERVICE(S), SECTION(S):
Which Includes at least the following non-surgical
specialties & staffed by qualified specialists:
Pediatric TC must provide_ Pediatric Specialist
nesthesiology E E E E
Internal Medicine E E
Cardiology E
Critical Care E
Emer ency medicine E
Gastroenterology E
General Pediatrics E
Hematology/Oncology E
Infectious Disease E
Neonatology E
Ne hrolo E
_. _ gY --- _
Neurology E
Pathology E E E
Psychiatry E E E
Pulmonology _ E
Rehabilitation/physical medicine, can be provided by written E E
agreement
Radiology E E _-E
Emergency Department with qualified specialist in emergency E E E
medicine, immediately available
Emergency Department staffed, trauma patients are assured of E E
immediate and aeRropriate initial care
QUALIFIED SURGICAL SPECIALIST(S):
Pediatric TC must have Pediatric specialists in all areas
General Surgeon capable of evaluating & treating adult and E E E D
pediatric trauma patients, Board Certified, Immediately available
In-house* at all times for trauma team activation and promptly
available for consultation
9
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Pods** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level 11
requirements
Pediatric TC may be fulfilled by: E E
staff pediatric surgeon with experience in pediatric trauma, or '
staff trauma surgeon with experience in pediatric trauma, or
A senior surgical resident, who has completed 3 clinical years of
surgical residency (See resident coverage below)
General Surgeon capable of evaluating & treating adult and E
pediatric trauma patients, promptly available at all times
Published on-call schedule E E* E*
Published back up schedule E* E* E* E*
Surgical specialists' requirements may be fulfilled by supervised ; E E E
senior residents as defined in Section 100245 of Title 22 at the
Level I, 11, or pediatric trauma center.
Residency coverage: (Pediatric TC must have pediatric
specialist)
Senior resident must be capable of assessing emergent
situations in their respective specialty, and
Shall be able to provide overall control and surgical E ! E E
leadership including surgical care if needed, and
A supervising, staff trauma surgeon/surgeon with experience
in trauma care shall be on-call and promptly available, and
A supervising, staff trauma surgeon shall be advised of all
trauma patient admissions, participate in major
therapeutic decisions, and be present in the ED for all major
resuscitations and in the OR for a all trauma operative
procedures
Qualified Surgical Specialist On-Call and promptly available
Pediatric TC must have Pediatric specialists In all_areas
Neurologic, Dedicated to one hospital or back up call "` E E E
Level Ill niay be provided throw h a written transfer agreement E
Obstetric/Gynecologic E E E D
Pediatric TC available by Transfer agreement
Ophthalmologic E�E E D
Oral/maxillofacial or head and neck E E E D
Orthopedic, Dedicated to one hospital or back up call E E E E
Plastic - E E E ;D
r
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E#=essential for Level I Pediatric TC in addition to Level it
requirements
Reimplantation/micros u rg ery capability. May be provided E E E
tkqu!gt transfer agreement _
Urologic E E E D
Cardiothoracic E E# D
Pediatrics E
Pediatric neurologic E#
Pediatric ophthalmologic E#
Pediatric oral or maxillofacial or head and neck E#
Pediatric orthopaedic E#
Surgical service- available for consultation or by transfer ? i
agreements
Burns E E E E
Cardiothoracic E E D
-_-_ _.-.__-_______
Pediatrics E E
Re-implantation/Microsurgery E E E
Spinal cord injury E E E D
QUALIFIED NON-SURGICAL SPECIALIST(S):
Emergency Medicine
Board Certified, in-house , immediately available at all times E E E E
Emergency medicine physicians, board certified in emergency E E E
medicine shall not be required to complete ATLS.
Current ATLS is required for all emergency medicine physicians E E E D
who are qualified specialist in a specialty other than emergency
medicine
Residency coverage
Maybe be fulfilled by supervised senior residents as defined in E E
Section 100245 or Title 22, in emergency medicine, who are
assigned to ED and serving in the same capacity.
The senior resident shall be capable of assessing emergency E E E
situation in trauma patients and providing initial resuscitation.
Pediatric trauma center:
May be fulfilled by a qualified specialist in pediatric emergency E
medicine; or
A qualified specialist in emergency medicine with pediatric E
ex erience; or
6
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
I II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** Is requirements for Level li Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
subspecialty resident in pediatric emergency medicine who E
has completed at least one year of subspecialty residency in
pediatric emer enc medicine, and
A supervising qualified specialist in pediatric emergency E
medicine, or emergency medicine with pediatric experience shall
be promptly available,
supervising qualified specialist on-call shall be notified of all E
patients requiring resuscitation, operative surgical intervention or
ICU admission.
nesthesiology
Immediately available at all times, may be fulfilled by senior E D E# D
residents or CRNAs capable of assessing emergent situations, D
providing treatment, and supervised by staff anesthesiologist.
The staff anesthesiologist on-call shall be promptly available at
all times and present for all operations.
Promptly available and must be in operating room when patient E E D
arrives, may be fulfilled by senior residents or CRNAs capable of
assessing emergent situations, providing treatment, and
supervised by staff anesthesiologist. The staff anesthesiologist
on-call shall be promptly available at all times and present for all
operations.
On-call and promptly available and must be in operating room E
when patient arrives, may be fulfilled by senior residents or
CRNAs capable of assessing emergent situations, providing
treatment, and supervised by staff anesthesiologist,
The staff anesthesiologist on-call shall be promptly available at
all times and present for all operations.
Radiology, promptly available E TE E E
Qualified non-surgical specialists available for consultation.
Pediatric trauma centers must have qualified specialists
with pediatric experience; pediatric TC - may be provided
through transfer agreement
Cardiology --- -- E E
- -- - -
Gastroenterology E E
Hematology _ E E _ D _
Infectious Diseases E E D
7
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 ii PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level Il
requirements
Internal medicine E E D
Nephrology E E D
Neurology E E D
Pathology E E D
Pulmonary Medicine E E D
Adolescent medicine E
Child development E
Genetics/dysmorphology E
Neuroradiology E
Obstetrics E
Pediatric allergy and immunology E
Pediatric dentistry E
Pediatric endocrinology E
Pediatric pulmonology E
Rehabilitation/physical medicine E
Pediatric Critiical Care - in-house, immediately available,
fulfilled by:
Qualified specialist in pediatric critical care medicine, or
Qualified specialist in anesthesiology with experience in
pediatric critical care; or
Qualified surgeon with expertise in pediatric critical care, or
A physician who has completed at least 2 years of residency in E
pediatrics.
When a senior resident is responsible for critical patient care,
here shall be a qualified specialist in pediatric critical care or
qualified specialist in pediatric anesthesiology on-call and
promptly available, and,
is advised of all patients requiring admission to the PICU and
participate in all major decisions and interventions.
The qualified pediatric PICU specialist shall be immediately
available, advised of all admitted patients to the PICU, and shall E#
participate in all major therapeutic decisions and interventions
Pediatric trauma centers— qualified specialists with
pediatric experience shall be on hospital staff and available
for consultation, and
Level I Pediatric Trauma Center,qualified pediatric
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
*w
E = essential E*= CCEMSA D = desirable
Level Peds** Is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level 11
requirements
surgical specialist or specialty availability on call and
promptly available:
General pediatrics E
Mental health E
Neonatology E
Nephrology I E
Pathology E
Pediatric anesthesiology E#
Pediatric cardiology E
Pediatric emergency medicine E#
�._ .._- -_
Pediatric gastroenterology E
E#
Pediatric hematology/oncology E
Pediatric infectious disease E
- —- - E#
Pediatric nephrology E#
Pediatric neurology E
- -- E# _
Pediatric pulmonology E#
Pediatric radiology E
E#
SERVICE CAPABILITIES:
Radiological Service
Radiologist technician immediately available in-house*, capable E E E D
of performing lain film and computed tomography imaging. _
Promptly available - angiography and ultrasound E E E
Radiological al technician promptly available E E
_ . _-available
Clinical laboratory Service i
Immediately available at all times, E E E D
Promptly available for Level III and IV, E E
and
Comprehensive blood bank or access to a community central E E E E E
blood bank
Type & cross, coagulation studies, micro-sampling E* E* E*
Surgical Service
Operating suite available for trauma patient or being utilized for E E E f E
3
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
I 11 PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Peds** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level II
requirements
trauma patients
Operating staff- with trauma education", Immediately available E E#
unless operating on trauma patients and backup personnel
promptly available
Operating staff promptly available unless operating on trauma E E
atients and backup staff who are rp omptly available
Operating staff_who are promptly available E
ppropriate surgical equipment/supplies as determined by E E E ! E
trauma pro rg am medical director or EMS_ Agency for Level 111
Cardiopulmonary bypass E j E#
Operating microscope E E#
Nursing Services —staffed by qualified licensed nurses with E
education, experience, and demonstrated clinical competence in I
the care of critically ill and iniured children
Basic Emergency Services per Chapter 1, Division 5 of Title
22: E E E E
Ph sy ician in-house, immediately at all times
Designate emergency physician to be member of trauma team, E E E E*
and
Provide emergency medical services to adult and pediatric E E E E
(pediatric patients for Pediatric TC))atients,and
Trauma trained nursing personnel to provide continual E* E" E* E"
monitoring, and
Equipment and supplies appropriate for adult and pediatric E E E E"
patients as approved by the director of emergency medicine in
collaboration with the trauma program director
Emergency department staffed so that trauma patients are E E E E E
assured of immediate and appropriate initial care
Communication with EMS vehicles E E E E E
SUPPLEMENTAL SERVICES
Pediatric trauma centers shall have Pediatric specialists in
all areas
Intensive Care Service, special permit licensing ICU services, E E E
Cha ter 1, Division 5, of Title 22
Appropriate equipment and supplies determined by physician E E E
res onsible for intensive care service and the trauma_program
;J
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 11 PEDS III IV
FE = essential E*= CCEMSA D = desirable
Level Pads"'* is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level 11
requirements
medical director
Qualified specialist, in-house, immediately available for trauma E D D
patients in ICU
ICU specialist promptly available E E
Qualified specialist may be a resident with 2 years of training, E E E
supervised by the staff intensivist or attending surgeon who
participates in all critical decision making
The qualified specialist shall be a member of the trauma team E E E
Registered Nurses with trauma education 2417 E* E* E* E*
Burn Center
In house or through written transfer agreement with a Burn E E E E
Center
Physical Therapy Service
To include personnel trained in physical therapy and equipped E E E
or acute care of the critically injured atient
Rehabilitation Center
Services to include personnel trained in rehabilitation care and E E E E
equipped for acute care of the critically injured patients. May be
provided through a written transfer agreement with rehabilitation
center
Respiratory Care Service
Services to include personnel trained in respiratory therapy and E E E E'
e ui ped for acute care of the critically injured patient
Acute Hemodialysis Capability E E E
Occupational Therapy Service
o include personnel trained in occupational therapy and E E E
equipped for acute care of the critically injured patient
Speech Therapy Service
To include personnel trained in speech therapy and equipped E E E
for acute care of the critically injured patient _
Social Service E E E D
Services or Programs (Special license or permit not
required__
Pediatric Service —Adult TC who provides in-house pediatric
services, in addition to Chapter 1, Division 5 of Title 22 shall E E
1
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Pods** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level 11
requirements
have the following:
Pediatric Intensive Care Unit (PICU), E E E
Shall be approved by California State Department of Health
Services' California Children Services CC( S) _
Adult hospitals without a PICU shall establish written criteria for E E
consultation and transfer of pediatric patients needing ICU care ,
Have appropriate equipment/supplies approved by the pediatric E
intensive care specialist and pediatric trauma program medical
director
Pediatric intensive care specialist shall be promptly available for E
trauma patients in the PICU _
Qualified specialist shall be a member of the trauma team E�
Have a multidisciplinary team to manage child abuse and E E
neglect. - - -
Pharmacy -----In house, 24 hour availabili with harmacist on call E* E* E* D
Shall be in-house within 30 minutes of call E"
cute Spinal Cord Management Capability E E E
In-house or by transfer agreement
Organ Donor Protocol as described in Div_ 7, Chapter 3.5, Cal, E E E E*
HS Code
Outreach Program, to include
Capability to provide both telephone and on-site consultations E E E E
with physicians in the communityand nd outlying areas, and
Trauma prevention to the general public E E E E*
Public education and illness/injury prevention education E* E* E E*
Continuing Education l
Continuing education in trauma care shall be provided for: E E E E E
Staff physicians
Staff nurses
Staff allied health personnel '
EMS personnel
Community physicians and health care personnel E E E E E
Trauma pl ysicians ( CME, 50% must be extramural) E* E* E* E* E*
General Trauma Surgeon, ATLS completion E* E* E. E*
,Orthopedic Surgeons E* E* E* E*
12
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
I II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Pads** is requirements for Level II Pediatric TC
E# = essential for Level I Pediatric TC in addition to Level Il
requirements
Neurosurgeons E* E* E* E*
Emer ency Medicine E" l E* E` E* E*
Pediatric Trauma Centers -- In addition to special permit
licensing services shall have:
Outreach and injury prevention programs specifically related to E
pediatric trauma andnLury prevention;
suspected child abuse and neglect team (SCAN)_ E
n aeromedical transport plan with designated landing site; and E
Child Life program E
Written Interfacility Transfer Agreements E E E
Transfer agreements with referring and specialty hospitals
Written transfer agreements with Level I or li trauma centers, I E
Level 1 or II pediatric trauma centers or specialty care centers for
the immediate transfer of those patients whose medical care
need additional resources e
Written transfer agreements with Level I, II, or III trauma E
centers, Level I or II pediatric trauma centers or specialty care
centers for the immediate transfer of those patients whose
medical care need additional resources
Trauma Quality Improvement Program
Trauma centers of all levels shall have a quality improvement E E E E E
process to include structure, process, and outcome evaluations,
identify root causes of problems,
intervene to reduce or eliminate root causes and take
appropriate steps to correct the process
Process shall include:
Detailed audit of all trauma-related deaths, major complications, E E E E E
and transfers (including interfacili transfers);
A multidisciplinary trauma peer review committee that includes E E E E E
all members of the trauma team; (CCEMSA* 50% attendance by
reps of Sur , Ortho, Neuro, EM, Anesthesia
Participate in the trauma system data management system; E E E E E
Participate in the local EMS agency trauma evaluation E E E E E
committee;
Have a written system in place for patient, parents of minor E E E E E
13
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUALTIONS, TITLE 22, CHAPTER 7
CRITERIA Level Level Level Level Level
1 II PEDS III IV
E = essential E*= CCEMSA D = desirable
Level Pods** Is requirements for Level ll Pediatric TC
E#= essential for Level I Pediatric TC in addition to Level II
requirements
children who are patients, legal guardian(s) of children who are
patients, and/or primary caretaker(s) of children who are
patients to provide input and feedback to hospital staff regarding
the care provided to the child;
Follow applicable provisions of Evidence Code Section 1157.7 E E E E E
o ensure confidentiality
Appropriately licensed helicopter landing site E* E* E* D
Interfacility Transfer of Trauma Patients
Patients may be transferred between and from trauma centers E E E E E
providing:
Any transfer shall as determined by the trauma center surgeon
of record, be medically prudent;
Be in accordance with local EMS agency inter-facility transfer
policies.
Hospitals shall have written transfer agreements with trauma E E E E E
centers and develop written criteria for consultation and transfer
of patients needing a higher level of care.
Hospitals which have repatriated trauma patients from a E E E E E
designated trauma center shall provide -the information required
by the system trauma registry, as specified by local EMS agency
policies. -- _
Hospitals receiving trauma patients shall participate in system E E E E E
and trauma center quality improvement activities for those
rauma patients who have been transferred.
1�]
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A DivWon of the Fresno County department of Public Health
Manual Policy
Emergency Medical Services Number 334
Administrative Policies and Procedures
Page 1 of 3
Subject Trauma Registry Data Collection
Relbrenccs California Code of Regulations..Title 22,Social Security Effective
Division 9.Prehospital Emergency Medical Services
Chapter 7.Trauma Care Systems 12i 15,2014
1. POLICY
The EMS Agency is responsible for monitoring the Central California EMS Region's Trauma System. Data
collection and management are critical components to monitoring the system,and essential to performance
improvement and patient safety programs. This policy dctines the means of collection of data for Quality
Improvement of the Trauma System.
11. PROCEDURE
A. EMS AGENCY
1. The EMS Agency shall maintain a Trauma Registry and'Trauma Information System. The data
submitted by the hospitals shall be utilized for trauma system monitoring,evaluation,and research.
Data will be used for periodic reports to the kegional'Trauma Audit Committee.
2. The Trauma Registry will be utilized for quality improvement purposes and will be protected front
disclosure per the California Evidence Code,Section l 157.7. The data base is not subject to they
mandated patient authorization procedures of H1PPA_
3_ Data from the.Trauma Registry shall be integrated into the State EMS Authority data management
system as required.
B. TRAUMA CENTERS
I. Trauma Centers shall use the Trauma Registry Program approved by the EMS Agency.
2, Trauma Registry Data will be completed by all trauma centers for all patients who mtict the
inclusion criteria for the trauma registry as outlined in Attachment A. Trauma Nurse Coordinators
Wanagers or Trauma Registrars at the trauma centers will be responsible for completing the
documentation of registry patients.
3. Trauma registries should be concutYent. At a mininunn,80 percent of cases must be entered within
00 days of discharge.
Approved By � � Ravision
EMS Director
EMS Medical Director ` l
Page 2 of 3
Subject Trauma RegislD- Data Collection Policy
Number 334
4. The completed registry data�k-ill be forwarded to the EMS Agency electronically on a monthly
basis. if a trauma registry record is updated at the trauma center,the revised record will be
submitted to the EMS Agency.
C. NON-TRAUMA HOSPITALS
I. Non-trauma hospitals will complete a Non-Trauma Hospital Patient Registry Norm (Attachment
B)on the f)[lowing critical trauma patients who present at a non-trauma hospital:
a. Trauma patients meeting any of the tratuna triage criteria:destination criteria to a
designated trauma center.
b. Trauma patients with a final disposition to a Trauma Center.
c. Trauma transtcrs from other facilities.
d. All traumatic arrests,trauma related deaths in the ED or after hospital admission.
2. Completed registry forms will be emaifed to the FMS As grey.within CO days of patient discharge,
transfer or death.
3. The registry Ibrm is to be completed by designated personncl from the non-trauma hospital. The
names of designated personnel will be forwarded to the EMS Agency,
D. INSTRUCTIONS FOR COINPLETIQT;QF TlTF,T��ON-TRALIMA I IOSPITAL PATI1 N•f R.LG1STRY
FORM _
I Section I —Identification.
a. EMS Number
b. lncident Location: Enter the original location of the incident
C. Hospital: Enter the name of the non-trauma hospital completing the form.
d. Patient: Enter the name of the paticut.
e. Date of birth
f. Age: Fnter the patient's age.
g. Sex: Check male or female.
2. Section 2 Emergency Department Admission Data
a. Date of Arrival: Enter month,date,year admitted to the FD.
b. Time of Arrival: Fnter time of arrival to the ED.
C. Method of Arrival: Check applicable; if"Other",describe-
d, Mechanistn of Injury: Check one; if"Other",describe.
e, Vital Signs Upon Arrival: Fnter initial GCS and vital signs taken in the ED.
Pam 3 or-3,
FS ubjecr Trauma Registry Data Collection Policy
Number 334
f. Procedures: Check any applicable procedure and enter time; if"Other",describe.
i. Blood products; Enter time of first unit and the total number of units
given, ifany products were Given.
g. lnjurics:Check applicable_
L All trauma related hospital admits with at least one injury ICD-9
diagnosis code between 800.0-959.9,
_�. Section 3—Emergency Department Disposition
a. Admitted: Check if applicable,enter time, and specify-hospital unit under comments.
b. OR:Check if applicable,enter time,and specify procedure(-.) if known under comments.
C. OR Disposition:Check if applicable,enter time,and specify hospital unit under
comments.
d. Discharged:Check if applicable,and enter time.
e. Transfer to a Trauma Center ED, Check if applicable,enter time,and specify destination
under comments.
f. Interfacility Transfer(Patient transierred to inpatient unit):Check if applicable,enter
time,and speciR destination under comments_
g. Ground Transport: Check if applicable,and enter time.
h. Air Transport: Check if applicable,and enter time.
L Other.Check if applicable.enter titne,and include explanation under comments.
4_ Section 4-Comments:
a. include anything pertinent,explanatory,or interesting information.
b. Include any transfer questions or problems.
ATTACHMENT A
TRAUMA REGISTRY—TRAUMA CENTER SELECTION CRITERA
Reference: Current Version of the National Trauma Data Dank(-.\ITDD)Data Dictionary and the State of California
Data Dictionary,
1. All trauma related hospital admits with at least one injury 1CD-9 diagnosis cod^: between 800.0 959.9
A. Fractures(all)
A, Dislocations(all)
C. lntracranial injuries(all -includes concussion)
D. Internal injuries of chest,abdomen,and pelvis
IJ- Open Hounds
F. Injuries to blood vessels
G. Crushing injuries
H. Burns(burn registry)
1. Injuries to optic nerves
J. Spinal cord injuries
K. Certain traumatic complications
I. Air+fat embolism
2. Secondary and recurrent hemorrhage
3. Post traumatic wound infection
4. 'Traumatic shock
5. Subcutaneous eniphysenia
L. L•'xcludcs:
1. 905-909(late eflects of injury-- del ined as"those things that occur at any time after an acute
injure)
3. 910.924(blisters,contusions,abrasions,insect bites)
3. 930-939(foreign bodies)
4. l;olated spt-ains.-strains,,contusions
2. All injury-related deaths in ED or after admission
3. All trauma transfers from other facilities
A'ITACHMI?NT D
CENTRAL CALIFORNIA EMS AGENCY
NON-'I'RAIIMA HOSPITAL PATIENT REGISTRY FORM
1. IDLYFIFICATION Iniuries: t;,ICD-9-CM 800-959.91
f-b,MS Number Fractures
Skull O Neck:Spine C Limbs G
In:idcnt Location
Ilosnt al Dislocations C. 1nukierauial Injury C, Sprain.�Struiris O
Patient Open WOLIMs 0 Bunts RlHign Body ,y
DOB-, Intcmal Injun tt?: Chest 4 Abdomen o Pelvis
4,Fc Male O Female 0 Inlurics mvolvmg. Blood Vessels O Crushing .O
2. EM ERGENCY DEPARTMENT ADMISSION DATA t),,tic nerves t; Spinal Cord C
UatF ui'A.ri+•al
3. EMERGENCY DEPARTAIENI'DISPOSTION
ime.of Arrw�l-- 'I ilm Time
Method of Arrival: Admit o Transfer to Trauma Center ED C,
Walk-in r: BLS Ambulance
OR J 9tt[ertacility Trutr3fer U
Al S Annbslan:c C. air Ambulant:.O OR Disposition: Gco:,nd Trailsptm O
Other.: If cxhrr,descr hz7
Admit 0 Air—iraatspari O
Meehan4sswt of Iniurt•: ITunsfer 0 Other C
14pttnr Vchiala C'msh 1 V0(L11t:4'CIY C' fi1c.-C'X Cr Discharged 1 Ionic
PedestriFn r> A�satgll 0 Stal)bjng O Gun Shirt =�
Picasc inckade comments canceming difficulties with the itrcrfa.ilirp
Gnsu:d Level Fnll c) Fali rmni Height O Spurts C; transfer arrang4mcnti,ptoccdutes.patient ca.e,etc.
lndtutitr;kt]" Fanning n
4. CC3Ml1F.IVTS
Other O if tither,describe
Vital Sims Upon Arrival:
Eprs. Verbal Motor:— -
GCS:
IIR: RR. OP.
�— tiuhnti;tcd bv:
Procedures:
date alk
Within 30 days of patient discharge,transfer or dctath,email the
Intubadon C' Blood Pioducts C, completed form to Duniel Brown at Ihrown_iko.f2<ro.ta.0
of Units Coven
C'I Scan c Chest Tube 0
Other fforp.cr,describe:
CENTRAL CALIFORNIA
F,mF,RCF,NCV MEDICAL SERVICES
Manual: policy
Emergency Medical Services Number. 703
Administrative Policies and Procedures
Page: 1 of 7
Subject: Continuous Quality Improvement
References: Division 2.5 of the California Health and Safety Code FtTective:
i itle 22, Division 9 of the California Code of Regulations
Section It 57.7 of Evidence Code (l8 07 00
1. POLICY
This policy describe,the roles and responsibilities of all Central California EMS System participants in the provision
of Continuous Quality Improvement(CQi).Alt EMS provider agencies shall meet the requirements of this policy.
H. PURPOSE
"Continuous Quality Improvement"or"C'QI"means methods of evaluation that are composed of structure, process,and
outcome evaluations which focus on improvement ellorts to identify root causes of problems, intervene to reduce or
eliminate these causes,and take steps to correct the process.
11L PROCEDURE
The L MS Agency is responsible for the oversight and supervision of'the entire CQl process and communicating with all
involved participants.
A. FMS Agency CQi Medical Director+`Coordinator responsibilities include:
I. Implement, monitor and evaluate the CQI System, including CQi requirements as described in
Appendix B.
2. Provide oversight of the CQI Committee.
3_ Provide regular CQI reports to Medical Control Committee, Base Hospital Committee, EMSOC.,
CQI Committee and EMS Staff meetings.
4. Review individual Ql Reports and take necessary action.
5. Provide an access point fur lntemal.-Fxternal Customers as identified in Section iiI.F.
6_ Create an investigative Review Panel (IRP), as needed, to provide a grievance process for ENIS
personnel in accordance with State guidelines and requirements(Refer to Section 111.Q.).
7. Monitor quality indicators via database analysis as identified in Appendix A.
8. Review and participate in research generated by the CQl process.
Approved By: rt P Revision:
EMS Division Manager
31312008
HMS Medical Director
Paue 2 of
Subject Continuous Quality Improvement Policy
Number. 703
9. Forward CQI Committee recommendations to EMS Training Division.
10. Manage EMS database to assure quality and completeness of databases.
R. CQI Committee responsibilities include:
NOTE: All proceedings are confidential and protected under Section 1157.7 of Evidence Code: "The
prohibition relating to discovery or testimony provided in Section 1157 shall be applicable to proceedings
and records of any committee established by a local governmental agency to monitor, evaluate, and report
cut the necessity, quality, and level of specialty health services including, but not limited to trauma care
services, provided by a general acute care hospital which has been designated or organized by that
governmental agency as qualified to render specialty health care services."
i. Review.Monitor Data frorn EMS System(III.C).
2. Select quality indicators, items for review and monitoring, create action plans, and monitor
perfonnance (i,e., time, patient satisfaction, workforce satisfaction, protocol compliance, outcome
data). (See Appendix A.)
3. A13er review by EMS Agency,serve as a forum to discuss issuesfconcems brought to the attention of
the EMS Agency by internal and external customers(Ill.P.).
4. Propose,review,and participate in EMS research.
5. Promote CQI training throughout the EMS System,
6. Policy/Protocol Review—SeIected policies reviewed with prenotification sent out to allow participant
fcxdback. Initial review by CQI Coordinaton'Medical Director and proposed revisions discussed at
CQI Committee.
7. Provide recommendations to Training Division,including:
a. Orientation
Paramedic eight-hour introduction to Central California EMS policies,procedures and local
scope of'practice.
b. Primary Training
1) Local EMS Paramedic Training Course
2) Local EMT Courses(Fire LXparuncmt!Schoots'Provider Agencies)
3) AL.D(AED Provider Agencies)
4) Emergency Medical Dispatcher Training
5) Mobile Intensive Care Nursing Training
6) Base Hospital Physician Course
c. Contiruiing Education
I) Case Review.-'Tape Review
Page 3 of 7
Subiect: Continuous duality Improvement Policy
Number: 703
?) Provider Agency C.F.
3) ENIS C.E.—Topics Based on CQI identified deficiencies.
8. CQI Conunittee Members
a. CQI Medical Director
b. CQI Coordinator
C. Base Hospital Physician(chosen by Medical Control Committee)
d. PLN—(chosen by Base Hospital Commitiee)
e. PLO- (Three preferably one from each County)
f: EMS Dispatcher
g. Yire First Responder(chosen by Fire Chiefs Association)
9. CQI Committee Ex-Ofiicio Members
a. EMS Medical Director
b. EMS Division Manager
10. CQ1 Committee Guests
CQI Medical Director or CQI Coordinator may approve the attendance of guests.
C. Data-'System Review
Various databases currently exist which contain data relevant to Continuous Quality improvement(CQI) in
FMS(see list below). `t'hese databases must he searched to:
1. Prospectively identify areas of potential improvement.
2. Ans4%v.r questions about the EMS System.
3. Monitor changes once improvement plans are implemented.
4, Provide accurate information enabling data driven decisions.
5. Monitor individual perfonnance within the FMS System.
6. Suppoti research that will improve our system and potentially broaden CMS knowledge through
publication.
7. The involved databases include:
a. Dispatch Database
b, first Responder Database
C. ENIT-D Database
d. PCR Databases
e. Hospital Databases
1: QI Database
e, Traurna Registry
h. County Coroner's Reports
Page 4of7
Subject: Continuous Quality Improvement Policy
Number; ?03
D. Individual Quality improvement Reports
Individual quality improvement reports are generated by anyone in the EMS System and are reviewed at the
Base Ilospital Physician level as well as by the EMS Agency.
E. E.NIS Research
Any parties interested in EMS research may participate. Leadership is expected from EMS Medical
Directors and Senior FMS Specialists .with EMS Division Manager and Medical Control Committee
approval.
F, lnternaL.External Customers
Various entities interact with the LV1S System. In order to allow input from these sources, the CQT process
may be accessed via the EMS Agency who will detennine if the issue raised will be put on the CQl
Committee Agenda.
I. internal Customers
Pararuedics?L:Iv1`I,-1I�,,EM'r-Ix1First Responders
MICNc.Flight Nurses
Dispatch Personnel
EMS Students
Ambulance Providers
EMS Committees
Hospitals
StaterRegional EMS Personnel
UCSI=Residency Personnel
Rase Hospital Physicians
2, Extenk-rl Customers
Patients
Patients' Families
Community!'Public
Third Party Payors(Insurance Companies,HMOs)
Government Agencies(Public health Department,Police,etc.)
Nursing Biomes
Private Physicians
G. Investigative Review Panel
1. Created on an as needed basis as outlined in Title 22, Division 9.
2. Purpose - An impartial advisory body, the members of which are knowledgeable in the provision
of prehospital emergency medical care and local FMS System policies and procedures, which may
be convened to revictir allegations against the holder of an EMS prehospital emergency medical
care certificate, assist in establishing facts of the matter, and provide its findings to the EMS
Medical Director.
Pit-e 5 of
Subject: Continuous Quality Improvement Piilic�
lyumher: 701
APPENDIX A
Quality Indicators
The following quality indicators are monitored an a routine and continuous basis and reported to the appropriate EMS
committees:
Initial System Review Items: Other Review Items:
1. Trauma Scene Times(<10 minutes) 1. ANIA/RAS/RMC*I'Ratios(at each Base Hospital)
2. Medical Scene Times(<20 tninutes) 2. Codes(compliance with times in protocol)
3. Cardiac Arrest Survival Rates 3. Nature of Incident frequency on QA Reports
d. Trauma Survival Rates 4. Pediatric Smival Rates
5. Percentage of Unrecognized F.sophageal Intubation 5. Prelhospital Violence
6. 90'%4ucce55fiil IV after'l'hree Attempts
7. 95%Successful L'l'Placement after Three Attmipts
Data to Detennine Performance Lxcellence:
l. Are EMS services timely?
2. Do providers adhere to prescribed protocols?
3. What is the level of patient.stakeholder satisfaction?
4. How does performance compare with similar systems?
5. Arc data and infonnation used in planning and operation?
6. Do all workforce members understand and use available data'?
?. ]-lave CQI ef7orts been successful at improvu►g performance''
S. Are changes in one critical performance indicator af-ecting other areas?
9. Arc QI resolutions communicated to all involved parties?
Pag; 6 of 7
Subject: COntirtU0U5 Quality improvement Policy
Number: 703
APPENDIX B
CQ1 Skills Retainment Requirements
EMT-fVEMT-PARAMEDIC
A_ Patient Contact Requirement
The Central California EMS Agency maintains a standard of care that provides a high quality,consistent,and dependable
skill level and knowledge base for its Emergency Medical Services personnel.To assure that EMi'-lis or EMT-Paramedics
maintain adequate patient assessment and other ALS skills,the EMS Agency acknowledges the importance of ntinimunn
patient contacts to assure the proficiency of'skills,problem recognition,and knowledge.
Each EMT-II or EMT-Paramedic accredited in the Central California EMS System shall document an average of at least
24 patient contacts per month(240 per year)while working on an approved Central California County ALS unit. A
written statement from the employer shall he submitted to the Central California EMS Agency by March 24th of each
year.
A patient contact is defined as a patient who is completely assessed by an on-duty EMT-I1 or EN$T-Paramedic during the
course of an EMS response and a prehospital care report is completed as a result of the patient assessment. The EMS
Agency shall audit records to verify compliance on a random basis.
In the event that an EMT-11 or EMT-Paramedic does not achieve the 240 patient contacts(or prorated amount authorized
by the Central California EMS Agency)in the twelve month period,the individual shall complete five(5)ALS field
evaluations within a sixty(60)day period beginning March 21st. An E14S Training Officer approved by the Central
California EMS Agency must continuously supervise this field evaluation. An ALS response includes a patient contact
involving the use of one or more ALS skills excluding cardiac monitoring and basic CPR. The EMS Agency-,in the event
of an unsatisfactory evaluation,may prescribe additional education or evaluation.
B. Paramedic Field Evaluation Requirement
Document satisfactory field evaluations perforned by art approved Central California EXIS Training Officer. L.VIT-IIs or
UNT-Paramedics that have been certified,-'accredited less than two(2)years within the Central California EMS Region
must be evaluated by a designated EMS Training Officer,each six(6)tttonths(Deadline-September 20th and March 201h).
F.VT-lls or FMT-Paramedics that have been certified..accredited greater than two(2)years within the Central California
EMS Region will not be required to do a field evaluation.
A field evaluation wi ll consist of an EMS Training Officer observing an FIVIT-1 l or ErN C-Paramedic conducting three(,3)
patient assessments. The RMS Training Officer 101 evaluate the EMT-I1 or EMT-Paramedic based upon criteria utilized
for field internships as developed by the Central California EMS Agency. An evaluation is documented utilizing a field
evaluation form(as utilized for field internships)and shall be submitted to the Central California EMS Agency within
fifteen days of the completion of the field evaluation.
The agency's liaison officer and the EMS Agency will review unsatisfactory evaluations with the ENIT-ll or ENIT-
Paramedic. Possible actions by the Central California EMS Agency'in the case ol'an unsatisfactory evaluation include
reevaluation,additional training,or initiation of the formal investigation,
C:. ACLS Requirement
Within two(2)years of initial accreditation,the FIVIT-Paramedic shall demonstrate proof of current certification and
continued certification as an Advanced Cardiac Life Support(AC..LS)provider according to the standards of the American
Heart Association. Fulfillment of this requirement may be utilized for completing a portion of the on-going;continuing
education requirements_
Page 7 of 7
Subject: Continuous Quality Improvement Policy
Number: 703
D. BTLS PHTLS Requirement
Within two(2)years of initial accreditation,the EMT-Paramedic shall demonstrate proof oi'satisfactory completion of a.
Basic Traurna Life Support(BTLS)course according to the standards of the American College of Emergency Physicians,
or Preltospital Trauma Life Support(PIl'I'LS). fulfillment of this requirement may be utilized for completing a portion of
the on-going continuing education requirements. Refresher training in these courses may be assigned to individuals by Elie
EMS Medical Director for remedial education as a condition of accreditation.
Ahl)SERVICE PROVIDERS
A_ Skills Proficiency
AED service providers shall assure that all AED authorized personnel have proven AED skills proficiency at least anec
every six(6)months. AFD service providers shall maintain documentation of such skill proficiency exams and provide
copies to the AED Base Hospital and FMS Agency upon request.
B. Caw Review
AED service providers shall provide AF-D authorized personnel with no less than four(4)hours of AED case review every
two(2)years,Attendance documentation shall be foiNvarded to the AED Base Hospital.AFD case rrvie+v information and
data shall be provided by the designated AED Base Hospital in each county. The four (4) hours of case review may be
used towards the 24 hours of continuing education required for EMT-I recertification.
C. AED Refresher Course
API)Service provider personnel shall complete a two(2)hour AW refresher course, which can be included in an EMT-1
refresher course and;or required EMT-I continuing education. The refresher course shall include the successful
completion of an AFI) written and skill examination approved by the Central Califiomia FMS Agency. This should be
completed at a minimum every 2 years in conjunction with EMT-I recertification or refresher training for First Aid.
CENTRAL CALIFORNIA
EmERCF.NCV MEDICAL ST:RVICF.S
Manual: Policv
Emergency Medical Services Number: 704
Administrative Policies and Procedures
Page: 1 of 13
Suliiect: Quality Improvement Reporting
References: California Administrative Code,Title 22, Division 9,Chapter 3 Effective:
02;03,8
I. POLICY
Any unusual occurrence involving CMS personnel or operations will be reported according to the following
procedures.
It. PURPOSF.
The Quality improvement policy is designed so that each participant in the EMS system has the opportunity to
provide feedback and provide input into the operation of the EMS system. A QI Report affords the EMS Agency,
and affected providers and hospitals,a process to document and review policies, personnel performance issues,or
other positive,negative,or unusual incidents_ in instituting the Qi Report,the author assists the EMS Agency,
provider agencies,and hospitals, in constantly upgrading the delivery of Emergency Medical Services in the Central
California EMS Region and potentially improving medical care.
Ill. PROCEDURE
The intent of the Q1 process is to learn ham the issue or incident in order to improve future performance. Therefore,
every attempt should be made to discuss the issue(s)first with all parties involved prior to initiating the QI process.
This may provide insight to all parties concemed,as well as an immediate educational benefit to the EMS system.
The author will notify histher supervisor,Prehospital Liaison Nurse(PLN)or Prehospital Liaison Officer(PLO)of
the incident. Ql Reports may also be initiated through customer complaints received by provider agencies,
hospitals,or the EMS Agency. The supervisor or Pi.N.PI.O wil l prioritize the incident as either Emergent
(immediate notification of the EMS Agency)or Non-Emergent. The author will initiate a Quality Improvement
Report and complete both sides of the form. The PINN/PI.O will notify the QI Coordinator at the LMS Agency by
the neat working day to obtain a QI file number.
if the information required on the report is unknown to the author,the liaison of the author's agency?hospital will
assist in providing the information to help complete the form. Once the form has been completed,the author will
follow his:her agency's procedure for transferring the formic)the liaison of their agency. After the liaison has
received and reviewed the QI Report,the liaison will follow the Quality improvement Flow Chart(Attachment D).
W. FORMS--'CHARTS
The documentation for-ins,flow chart,and category definition and example list are designed to facilitate a more
efficient QI process. The Quality Improvement forms,documentation and investigation information is confidential
and protected information in accordance with California Civil Code Section 56,et seq.California Evidence Code
Section 1040 and Section 1157,et seq.and California Code of Regulations, 'Citle 22,Division 9.
Approved By A Revision
F.MS Division Manager $5e
1010112004
EMS Medical Director
Page 2 of 13
Subject Quality Improvement Reporting Policy
Number 704
A. QuaIit _ (Attachment A)
This is an OFFICIAL EMS Agency document;which is used to initiate the QI process anytime an incident
has occurred, negatively or positively impacts the EMS system. In addition, this document serves as the
response document for individuals asked to give their input or statement. if additional documents are
required, FMS personnel may write(ink only)or type their response on a separate piece of paper and attach
it to Lhe original Ql Report. It is important that no copies of this report and tracking form (attachment B)
are made,since copies maintained at agencies may not be protected.
B. Quality Improvement Tracking Farm(Attachment B)
This form is initiated by the Agency PLN'PLO upon receiving a Ql Report. The form is designed to track
the QI Report using the SUCceSSlve available lines in the RoutinglActions 'Taken section. The PUKTLO
will forward this form,along with the QI Report,to involved agencies,until its final destination at the FNIS
Agency_
C, Category Definitions and.-Examrlgs(Attachment C)
The Ql category definitions and example list is to be utilized by the PLN/PLO or designee to categorize the
type of Qi incident as either Emergent or Non-Emergent,as identified in Attachment C.
I. Emergent—Issues that contributed to a negative patient outcome,and!or issues involving grossly
inappropriate behavior by any involved personnel. Also, issues that may potentially be a threat to
public health and safety but did not necessarily contribute to a negative patient outcome. These
incidents require immediate notification of the EMS Agency.
?. Ion-Emergent- Issues that did not contribute to a negative patient outcome and do not require
immediate notification ol'the FMS Agency.
D. Quality Improvement blow Chart(Attachment D)
This form is an overvieaa of the Qi process from the initiation of a QI Report Lu its resolution. Agency
P1.N'PI..Os should follow progressive steps and timelines of the CQl process closely to ensure a resolution.
V. DOCUMENTATION
A_ gality Improvement Report
1. Section A-I
Contains an area to designate the origin for the County involved,as well as a shaded gray box that
is for"Official Use Only."
CENTRAL.CAUFOR-NIA OHICIAL USE ONLY
EMERGENCY NIEDICAL SL RVICFS CQt#' _____.
»ATh IWVU
COUNTV iNVOINFO:
1ikhSNV I,._KLI;GS _ r3nUt t:A ;14LA it )t3mcr�ent ❑iti9a Etnes<�ebt
tYPHRR
CONEIDr,NVAL
'e b'.:Rbr,�•erp:7 a:rn 1".v i i .It 1rr1•w SG./:7n�labu'2u rvwe[•r l"�Ec 1.<iic�IUN
.n.l 1w-'.rl'7 el,r.l aiw:Ci aluwul.a:u.;Malaaw�rw.i91+2,',.ri.i,iMW
QUALITY iMPROWMENT
REPORT
Section A-1
Page 3 of 13
Subject Quality improvement Reporting Policy
Number 704
2. SCctitin A-TI
Included in this area is the Incident Logistic information. This information is one of the most
essential parts of this document. It provides the specific information that allows the individuals
involved to be contacted and the incident or issue to be reviewed more efficiently.
a. All applicable areas must be completed,to the best of your ability,prior to submission.
b_ `Personnel Involved" area should be completed to the best of your ability. First and last
names are preferred, but Agency unit number or title will be accepted.
inrldettt l.uelsltrs
Cull L.,:auo:r, -__ _._..__.__ LA',S 11i�,•.N: _
J;aI uah_
j;1t 1 It.,lMta:l [0tht:-
Aged Rtco—1 4 or0OB:
YC'}tAIMP s I.AiNih C'rpyj1
Perwnnel lmjol_O �1yin-cti 1)ircuswel ivith Individind
Y'e,
_ .. iJ :. :J
N, —
Section A-11
3. Section A-111
This area serves as a mminder that notification of your supervisouPLNtPLO is required. and to
allow for tracking of that process.
a. The first step to initiate the QI process is to notify your On-Duty Supervisor-'PLN.PIA.
This should be done verbally, ,vith the following, information written on the Q1 Repoli
document.
1'rimary Trackine
fl:v Ar Time Clot-ihn� SL.pervisor 1Pl-P!PUJ Notified.
ti:tin.R Tit r(;lndir€dL:,k1 Cons:k`ted:
Section A-I11
4. Section A-I V
This section is reserved for only the author's information and the date the document was actually
submitted to the PLO/PLN. All areas should be completed prior u)submission.
Page 4 of 13
Subject Quality improvement Reporting Policy
Numbcr 704
Special Note: 'rhe date the Ql Report was written and when it was actually submitted should be
no more than 24 hours between the two. All Ql Reports trust be turned in by the
end of your shift,or within 24 hours after the incident.
Author 1 nrurimflun
Sil:r.-OLI:__
Pnet Kama: Ccrl,V:
Agency,Fac lily. Dale 5ubmated to NL YLN:
Section A-IV
5, Section A-V(See Attachment A back)
T1iis is the back of the QI Report with three distinct areas: Key Issue, Account of Incident, and
Proposed Resolution. Each area must be completed, with the author's initials being placed at the
end of the area.
a. Ke,Llssue: This is to be one to two sentences in length and highlight the primary
point concern (i.e., Policy issue - NNW error). It should not be a synopsis of the entire
event or issue.
b. Account of incident. This is the area that the narration of the concern or issue should be
stated. This will constitute the body of your QI Report and should contain factual
statements, 1rcc from subjective insight or politically motivated it►nucndos. Attempt to
stay focused and concise.
c. Pro nc»cjResolutions: This area MUST be completed by the author prior to being
submitted. The purpose of this area is to gain insight into possible solutions from those
individuals directly involved in the issue.
A. Quality Iniprovernent'I'racking_Form
This forth is utilized by the PLN/PLO to track the Q] Report. The Tracking Form is initiated at the time the
PLN.PLO receives the QI Report from the author. "I'he document becomes the record of all activities or
actions. The Tracking Form is divided into four(4)sections.
1. Section I1-1
This section identifies the demographics of the Q] incident. This area should be completed as
soon as possible, vvith the QI number being obtained by the EMS Agency by the next working
day.
Incident Ln>_istic.:
('ot_nIV IM-CIVC& LJI-E-ESNO _]KINGS ,_I MADERA ;JTLI1_-\RF _ cYrHER._`_.
$r_t[JS: Dale Oj) .• _.. 1)1w Chtsed: —_._...
hi,id,w Dotc to:I tun: 1:�15 i
rh•r:riP i;in•
Section B-i
Page S of 13
Subject Quality Iniprovement Reporting Policy
Number 04
2, Section B-11
This section c assities the type of issue in tlic Q] incident to allow for easier categorization.
Isvuc'v
- 1 AiAmay ❑ Hni?:tal Di ctx or. ❑ Poiaril A.esmnrnt
_ AAt R A S n InappTpnutc Lichavla.- U PabentTrLltslcr
(ull t t ❑ ❑P:nient TrWWwrx
F Dcwnation L] Ntanr-c17Rcsource u1ilizulifm ❑ Merl Tun:nr:a
ll;spu-ch ❑ SiCI 1__-i J'hrsicl�n Lssucs
r UtKu_:er,t:n;ur. ❑ MLdical Conlnll ❑ PvhCy f l rii1;:e,.nn
Eipipmcni Fz:urc McdlC.Itton llroacn ❑ Sco11t o`Practirc
Kpilvnenl I;1-1 elw'4111 ❑ Mix5iwlGm t rnr. [ ] G'ther: _
Call-In Atik4111At ---,—
Section B-11
3- Section B-111
This section documents the routine of the CQI process. The PLNtPI.O should dockinio t all
activities on the line provided pertaining to the incident (i.e., received, forwarded,
recommendation,action). The date and initials of the PLNtPLO making the actions should also be
written.
Rogting/Aytigys IArn:
L:u,te K;-),j 1'rwd Rcmd Acttir_n Initirl
i I n n I��
❑ n ] i
u U 0
Section B-111
4, Section B-IV
The resolution area is the responsibility of the EN1S Agency to complete and signifies conclusion
orthe Q1 issue within the CQI process. The EMS Agency will natil'y the involved agencies of tine
final resolution.
1je,0101011,
El C'c i'.+x ❑ No AuJan Vcr'!,X Reprinl:in4
� ) CCI'it1Cxbf:i;A'Ixvi J P,tlicy:Fnxcd:I.c Re%islun � 1'rillc:n Rels-ri
::FAIT-I CEMI-II ] 1'nh:uun WducnRCpI n'.LVd
I Lxcrn [,J-h-r Ir. � Rcncecli:,;tcluc::ricrp l-i Ahir �...,-,
LjSush:n�iar I J:yrmailnxu�:4livn _._,.. .
❑ Frlu a.kc :dFvvdh: J'ullel'lievtcw
L%VIIIte.: I JNtee-ljn'r I'ru[u_rl Rotrim -
Fury ia'by t:%Hl plinn RCtetreG:t?$tale
Section B-TV
Page 6ofli
Subject Quality Improvement Reporting Policy
Number 704
Vi, RESOLUTION OF QUALITY IMPROVEMENT INCIDENT
A. Investigative Process
I. The Central California EMS Agency shall conduct an investigation of any allegation received
from a credible source, including discovery through medical audit,customer complaint.and?or
other medical professionals.
2. The investigative process shall be conducted pursuant to EMS Policy and Title 2.2, Division 9 of
the California Code of Regulations(Emergence Medical Personnel Certification Review Process
Guidelines). PUK5 and PLOs will assist the EMS Agency during the investigative process.
A. Determination of Ap2ropriate Action
1. The LMS Medical Director or designee steal I deterniine what action, if any,should be taken as a
result of the findings of the investigative process.
2. The nature of the action should be proportionate to and related to the severity of the deviation
From EMS Policies and Procedures or treatment protocols. It will also be proportionate to the risk
to the public health and safety caused by the actions of the holder(if,or applicant fill',a prehospital
EMS certificate.
3. Re-solution will be determined by the following steps:
a. Critique--The EMS Agency will review all document,~,the nature of the issue, and
possible resolution outcomes.
If additional information is needed, the EMS Agency will contact involved agencies for
assistance.
If an agency has determined and implemented resolution, it should be included in the
documentation of the Ql Tracking Form- However,an agency resolution is independent
from any resolution prescribed by the EMS Agency.
b. I he EMS Agency will resolve Ql incidents as outlined in the QI Tracking Form.
Resolution may be one or more of the following_
1) No action—After a complete investigation,no action is necessary to resolve
issue.
2) Policy,Procedure Revision—QI issue is resolved with revision to FNIS Policy
and Procedure Manual or treatment protocols_
3) Lducational Instruction—The appropriate EMS Medical Director will give EMS
personnel feedback on the Ql document to be reviewed by involved individuals
and PLN./PLO.
4) Meeting—A tnecting will take place with involved individuals and the F,MS
Medical Director or designee to discuss the issues and additional actions to
resolve.
$) Remedial Education—Prescribed by EMS Medical Director to correct
deficiencies. This may include written report,living a C.E. class, reviewing
Policy,Protocol, attending lectures and"or additional clinical or field evaluations
(up to 40 hours clinical or 240 hours field). This may also include being
partnered with an individual of the same certification level during the first thirty
days ofa fiormal investigation_
Page 7 of 13
Subject Quality Improvement Reporting Policy
Number 704
G) Written.-Verbal Reprimand—This action will be documented and placed in
individual's EMS training.+accreditation file. May also be utilized for
rcoccurrin�,deficiencies that cannot be corrected with remedial education.
7) RO'erred to the State FMS Authority—Any incident which is a serious threat to
public health and safety andior may require disciplinary/licensure action against
EMS personnel as outlined in title 22,Division 9 of the California Code of
Regulations(Emergency Medical Personnel Certification Review Process
Guidelines). This may include:
a) Placement of a I icense holder on probation.
b) Suspension of license.'certification.
c) Revocation of licenselcerdfication.
d) Denial of license'certifieation.
e) Denial of renewal or Iicensejcertitication_
C. Formal Investigation Process
A formal investigation is an official invcstigativc.PTOCCSS,wfiich is specifically outlined in Title 22,
Division 9 oflhe California Code of Regulations.
D. O.Tounds for Disciplinary Action
A determination by the ENIS Wdical director or designee that any of the actions identified in division 2.5.
Section 1798.200 of the Health and Safety code has occurred constitutes evidence of a threat to the public's
health and safety and is cause for initiating disciplinary action.
E. Nwificationof"Resolution
1. Formal Investigation—The EMS Medical Director or designee shall formally notify the
individuals) involved in accordance with Title 22, Division 9 of the California Code of
Regulations.
2. Routine investigations—'lice LAIS QI Coordinator will send a letter identifying Ql incidents that
have been resolved and closed to each provider or hospital agency.
Page 8 of 13
OFFICIAL USEONLY-
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES CQI#
DATE RCVD: .
COUNTYINVOLVED:
❑Emergent ❑Non:-Emergent
❑FRESNO ❑ KINGS ❑ MADERA ❑ TULARE
[—] OTHER
CONFIDENTIAL
(In Accordance with California Civil Code Section 56,et seq,California Evidence Code Section 1040
and Section 1157,et seq,and California Code of Regulations,Title 22,Division 9)
QUALITY IMPROVEMENT
REPORT
(Information for Attorneys representing the Central California EMS Agency)
Incident Logistics
Call Location: EMS Disp. #:
Date: Time: Location: ❑On Scene ❑Enroute
❑At Hospital ❑Other
Patient Name: Med. Record # or DOB:
PCRBHRR# (Attach Copy):
Personnel Involved A2ency Discussed with Individual
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Primary Tracking
Date & Time On-Duty Supervisor/PLN/PLO Notified:
Name & Title of Individual Contacted:
Author Information
Signature: Date:
Print Name: Cert. #:
Agency/Facility: Date Submitted to PLO/PLN:
(Utilize the back of this form to elaborate your concerns&resolution)
Page 9 of 13
Documentation Area
Issue: (Please State in One or Two Sentences)
Initial:
Account of Incident:
Initial:
Proposed Resolution: (Author Must Complete)
Initial:
(Final completed form will be forwarded to County Counsel from the EMS Agency)
Page 10 of 13
CENTRAL CALIFORNIA QI #:
EMERGENCY MEDICAL SERVICES
CONFIDENTIAL
(In Accordance with California Civil Code Section 56,et seq,California Evidence Code Section 1040
and Section 1157,et seq,and California Code of Regulations,Title 22,Division 9)
QUALITY IMPROVEMENT
TRACKING FORM
(Information for Attorneys representing the Central California EMS Agency)
Incident Logistics:
County Involved: ❑ FRESNO ❑KINGS ❑MADERA ❑TULARE ❑ OTHER
Status: Date Open: Date Closed:
Incident Date: Incident Time: EMS #
Incident Location:
Description:
Issues :
❑ Airway ❑ Hospital Diversion ❑ Patient Assessment
❑ AMA/RAS/RMCT ❑ Inappropriate Behavior ❑ Patient Transfer
❑ Call-In ❑ Interpersonal ❑ Patient Treatment
❑ Destination ❑ Manpower/Resource Utilization ❑ Patient Turnover
❑ Dispatch ❑ MCI ❑ Physician Issues
❑ Documentation ❑ Medical Control ❑ Policy Clarification
❑ Equipment Failure ❑ Medication Broken ❑ Scope of Practice
❑ Equipment Utilization ❑ Medication Error ❑ Other:
❑ Call-In ❑ Medication Missing
Routiniz/Actions Taken:
Date Revd Frwd Rcmd Action Initial
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ 7 7 ❑
Page 11 of 13
Routin /Actions Taken:
Date Rcvd Frwd Rcmd Action Initial
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
Comments:
Resolution: (EMS Agency Only)
❑ Critique ❑ No Action ❑ Verbal Reprimand
❑ Certification Action ❑ Policy/Procedure Revision ❑ Written Report
❑EMT-I ❑ EMT-II ❑ Probation ❑ Written Reprimand
❑Intern ❑ Interim ❑ Remedial Education ❑ Other:
❑ Suspension ❑ Formal Instruction
❑ Educational Feedback ❑ Policy Review
❑ Written ❑ Meeting ❑ Protocol Review
❑ Formal Investigation ❑ Referred to State
Page 12 of 13
iSubject Quality Improvement Reporting Policy
I Number 704
Category and definitions are as lollo s:
CAT>I+rGORY I NON-EMERGENT EMERGENT
` TIME FRAME 60 Days 60 bays
DEF INI TIONS Issues that did not contribute to a negative Issues that contributed to a negative
patient outcome and do not require patient outcome, grossly inappropriate
immediate notification. behavior,or issues with potential threat to
public health and safety.
L•'XAMPLLS Attaboys/Acknowledgement Negative Patient Outcome Issues:
Broken,
'Missing'Controlled Medications Equipment and Stocking Issues
Destination Issues Patient AssessmentlPriority Setting
Education Issues Medication Errors
Equipment and Stocking Issues Medical Treatment
Interagency Issues Private Party Complaints
Interdepartmental Issues Policy and Procedure Deviations
Interpersonal Issues Recurrent Problems(Individual and
PCR Documentation System)
Policy Clarification Technical Skills Issues
Policy Deviation
Radio Communications Grossly Inappropriate Behavior Issues
Tracking Purposes Fraud
Unusual Occurrence Gross Negligence
Insubordination
Patient Abuse
Substance Abuse
IJn professionalArrational Behavior
(Attachment C)
Page 13 or 13
Subject Qualiry Improvement Reporting Policy
Number 704
Nao-i:�:rrgnt I•.rncr Iwo l
Acthored
laimcdiately Nmi:y On-Ca'
EMS Aj,._*4y Stc:lt Wd
Author's?Ird'I.N nr Dc.igucr A,uhx's YLCI?LN to Dk-vrnec Desip�ce ofthier
ReOewx Repurt Pnari:4c Repor•.
Ycs Cw,Fss.m ba Addivasrd al this No hvolved Apncy(s)Submit All
l.ctinl' Repairs iluc+turzi,talio:,:u PAS Agency
First 20 Days
L.b75 Afcncy Ro -wa and Itrp:cnienis
AppropnaU Acliatt
AaCwt's PLO:1'LV
Fccdbacl::o Autl_?. Ep frc,m Oh21 lnv4+lved
Agerc :s)PLp l'�N
EMS Agency Novidem Folmw•IJi,w
Invnivad Agencyls; P:.O,'P1.N
Furwm-d Ir f.%,,c Aevicp(y)NXHIL
Report.0oc.t:r.enlsto Rescarchand Discuss First 40 Days
f-_\•1S Ag_n:+• Resolution
s
Yrs I!c:sativd'r Nv
Atiilwr'f?LCr,'PLN y I'LCt'I'1.N CuHrtts Ah
:)iwvirAriIs Kesc:rtion e,nd Fove s"i tc I!rtxutv'Joearnarliitior,and Fonva.ds to
?I C::YLK oc i:rrr:mol4ttt \�ctrc•ts;• Gh•IS Aevcy for Review and
1'I_l7r'I'LN f tr Co,ir,lcr-s;gnatuve 12cwrnw,,-Id gtorl
Summed Doe u we ntc Retained to AG twrink I`Lrp,
Actha-i:rg Agency PLO-TIN Forta:v;Js
Xepensl:pxt:mcns:o L-14S Ag%!rcr
GMS Aeeacy N:,t.,`lr3lnti;lvcd First 60 Days
LNiS Agency Forwards rs Rmotaeneuuati.^ns rir
Iuvotwd Agcacy(s)PLO•'PLN
Op
Agcncy�s)PLO+?LN Ltplcruent
Ycs I.II I CCIC' No Recoinmendahors
hrau'.vcO Agency{s)PLUIIL.It Fomarca
I_MS Apvcy NunrKr:lavaltivc Documentation to EMS Agctitey thm
Ag.:n.:ys)o I•C losu re Na onrm endatio¢ts 1ta�]cnicuted\^.ra:q,l elal
I:.1�1A ggrncy
C:maFags and
Files .4 Aithr,Notified orhna1 Resolution
EXHIBIT B
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual Policy
Emergency Medical Services Number+1 1
Administrative Policies and Procedures
Page 1 of 4
Subject Rase Hospital Criteria
References Title 22, Division 9,Chapter 4,Article 7 Effective
01;o 1/82
I. POLICY
Base Hospitals for the medical control of EMS Personnel shall be selected by the EMS Agency based upon
appropriate criteria and the needs of the EMS System.
It, PROCEDURE
A. BASE IOSPITAL MLSI`:
1. Be licensed by the State Department of Health as a general acute care hospital.
2. Be accredited by the Joint Commission on Accreditation of Hospitals.
3. I lave a special permit for basic or comprehensive emergency medical service pursuant to the
provisions of Title 22,Division 5.
4. Have the approval and support of hospital administration, medical staff and Emergency
Department staff to participate as a Base Hospital,
5. Agree to provide care to all emergency patients regardless of ability to pay.
6 Demonstrate an on-call system that assures a promptly available specialist and admitting physician
and commitment for care ofall critically ill patients regardless of ability to pay.
7. Agree to abide by the letter and intent of the Health and Safety Code,Division 2.5.
8. Comply with all County regulations and policies regarding,Base Hospitals.
B. BASE.HOSPITAL OPERATIONA1.REQUIREMENTS
Base Hospitals designated as such and under contract with the EMS Agency must comply with the
following requirements:
Approved By Revision
LMS Division Manager 04/01/2007
EMS Medical Director
Page 2 of 4
Subject Base Hospital Criteria Police
Number 311
1. Operations
a. Procure operational radio communications equipment meeting specifications established
by the County and install such equipment in the Emergency Department,for the purpose
of communications with prehospital and interfacility transport units operating pursuant to
this agreement. All radios and telephones to be used for communication with prehospital
personnel must be equipped with recording devices_
b. Assure that recordings are made on all prehospital communications concerning patient
care.
C. sNfaintain written records of Base Hospital+'prehospital and interfacility runs for a
minimum of seven years or in accordance with hospital policy. Maintain the tapes of
paramedic calls for a minimum of 180 days.
d. Operate communications equipment as directed by procedures and protocols established
by the County and approved by the.EMS Medical Director. Develop and utilize a
workable maintenance plan and repair policy for communications equipment.
e. I lave a telephone immediately available in the Emergency Department for exclusive use
in contacting a Receiving Hospital to providc medical information on patient's enroute to
the receiving facility.
f: Designate a Mobile Intensive Care Nurse certified by the EMS Agency who is employed
by the Luse Hospital as a Prehospital Liaison Nurse for the hospital.
g. Designate an lmergency Department Physician as a Base Hospital Medical Director.
Responsibilities are identified in the Base Hospital Director role description.
h, Facilitate interfacility transfers in an appropriate manner as described in ENS Policy,
i. Utilize the following which have been approved by the EMS Medical Director;
1. Paramedic Field Treatment Protocols and Guidelines
2. Fuse Hospital Report Fonn
3, Patient Care Report(Field Assessment Form)
j. Cooperate with the FMS Agency in gathering and providing,statistics and information
needed for monitoring and evaluating ENIS programs.
k. Comply with an infection control policy and notification procedure for all prehospital
care providers and first responders developed by the designated County Health Services
Agency.
I. Comply with procedures for decontamination of patients and rescuers exposed to
hazardous materials as outlined in the hazardous materials plan developed by the EMS
Agency.
Ill. Participate in EMS public education programs.
C. NEW BASE HOSP)TALS
Newly designated Base Hospitals must establish a Base Hospital C ommitiee within the hospital
composed of,at a minimum, U-ic Basc Hospital Medical Director,the Prehospital Liaison Nurse
Pa e 3 of 4
Subject Base Hospital Criteria Policy
Numbcr 311
and a representative of hospital administration to meet and confer regarding operations of die Base
Hospiuil and maintain liaison with members of the Prehospital Care Team and the EMS Agency.
This committee will nieet regularly for one year,or until Base Hospital operations are running
smoothly, whichever is longer.
D. 13ASL-' HOSPITAL STAFFING AND PFRSONNFL
The Base-Hospital shall have:
1. A currently certified Mobile Intensive Care Nurse or Base Iospital Physician in the
Emergency Department immediately available at all times to give radio direction to
prehospital personnel or interfacility transfer personnel according to the standards and
protocols developed by the EMS Agency.
3. A Certified Base Hospital Physician available at all times to provide immediate medical
direction to the Mobile Intensive tare Nurses and/or prehospital personnel or
interfacilirv.
E. BASE HOSPITAL EDUCATION PROGRAMS,EVALUATION,AND QUALITY
IMPROVEMENT
The Base Hospital will:
I. Provide for the continuing education of certified prehospital personnel and Mobile
intensive tare Nurses in accordance with criteria established by the EMS Medical
Director including supervised clinical exposure for paramedics in the Emergency
Department and other patient care divisions which would expand the paramedic's
understanding of medical management.
?. Encourage prehospital personnel to attend in-house lectures,classes,demonstrations,and
seminars which have been approved in advariee by the EMS Agency for continuin4
education credits.
3. Provide patient follow-up information for purposes of education to paramedics.
4. Recommend Mobile intensive Care Nurses for certification and recertification.
G. Advise the EMS Agency of any change in employment status of Mobile Intensive Care
Nurses employed in the hospital.
7. Provide quality improvement of care provided by EMS personnel in accordance with
Policy.
F, BASE IOSPITAL INTERFACE WITH EViS SYSTEM
The Base Hospital will:
1. See that the Base Hospital Medical Director and the Prehospital Liaison Nurse are
scheduled to attend the Emergency Medical Services Operations Committee meetings and
other EMS System meetings where their expertise would be valuable,e.g.,Medical
Control Committee,Base Hospital Committee,Tape Reviews, Fmergency Medical Care
Committee,and Continuous Quality Improvement.
Page 4 of 4
Subject Base Hospital Criteria Policy
Number 31]
2, Rase Hospitals will be authorized through agreements between the approved hospital and
the. PAS Agency.
Exhibit C
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest."
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member's name,job title (if applicable), and date this disclosure is being made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the Corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation's transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Page 1 of 2
Exhibit C
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3) Disclosure(Please describe the nature of the self-dealing transaction you are a party to):
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233(a):
(5)Authorized Signature
Signature: Date:
Page 2 of 2