HomeMy WebLinkAboutCommunity Regional Medical Center-Designation as a Level I Trauma Center_A-15-030.pdfAGREEMENT NO. 15-030
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 13TH day of January '2015,
3 by and between the COUNTY OF FRESNO, a Political Subdivision ofthe State of California,
4 hereinafter referred to as "COUNTY ," and FRESNO COMMUNITY HOSPITAL AND MEDICAL
5 CENTER, doing business as COMMUNITY REGIONAL MEDICAL CENTER, a California non-
6 profit public benefit corporation, whose address is 2823 Fresno Street, Fresno, CA 93721, hereinafter
7 referred to as "CONTRACTOR" (collectively, "the Parties").
8 WIT N E S S E T H:
9 WHEREAS, COUNTY's Departm ent of Public Health's Emergency Medical Services (EMS)
10 Division, is the designated Local EMS Agency (hereinafter referred to as the "EMS Agency") for the
11 Counties of Fresno, Kings, Madera and Tulare , as provided in Health & Safety Code section 1797 .200;
12 and
13 WHEREAS, COUNTY and EMS Agency recognize a continuous need for a Level I Trauma
14 Center to serve trauma victims in Fresno , Kings, Madera and Tulare Counties; and
15 WHEREAS, CONTRACTOR was originally designated by EMS Agency as a Level I Trauma
16 Center on June 19, 1984 and CONTRACTOR has continuously maintained that designation, without
17 interruption, since that time; and
18 WHEREAS, COUNTY and CONTRACTOR entered into an indigent and inmate medical
19 services contract (i.e., "Operating and Funding Agreement") on October 7, 1996 whereby the Parties
2 0 agreed CONTRACTOR would maintain appropriate facilities for a Level I Trauma Center and bum
21 unit, and such Operating and Funding Agreement will terminate at 11 :59 p.m. on November 30, 2014;
22 and
2 3 WHEREAS, CONTRACTOR desires that the local EMS Agency continue its designation of
24 CONTRACTOR as a Level I Trauma Center after termination of the Operating and Funding
25 Agreement, in accordance with Title 22 , Division 9, Chapter 7 of the California Code ofRegulations,
26 entitled "Trauma Care Systems"(§§ 100236 et seq.; hereinafter referred to as the "Trauma Care
2 7 Regulations"), and the Emergency Medical Services System and the Prehospital Emergency Medical
2 8 Care Personnel Act (Health & Safety Code, §§ 1797 et seq .; hereinafter referred to as the "EMS Act");
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1 and
2 WHEREAS, in order for CONTRACTOR to be designated by the EMS Agency as a Level I
3 Trauma Center, CONTRACTOR is required to have a written agreement with the EMS Agency for the
4 provision of such services , as provided by Trauma Care Regulation, section 1 00255(g); and
5 WHEREAS, COUNTY is the entity through which the EMS Agency enters into agreements
6 concerning emergency medical services , including trauma care services; and
7 WHEREAS, the EMS Agency 's Regional Trauma Plan for Fresno, Kings , Madera, and Tulare
8 Counties, implemented on June 19, 1984 , and updated effective August 1, 2013 (hereinafter referred to
9 as the "Regional Trauma Plan") provides that the EMS Agency continues to designate CONTRACTOR
10 as a Level I Trauma Center subject to the CONTRACTOR entering into and maintaining an agreement
11 with the COUNTY for the provision of such services; and
12 WHEREAS , CONTRACTOR represents that it maintains and operates a qualifying trauma
13 center, in accordance with the Trauma Care Regulations and the EMS Act, and is agreeable to such
14 designation by the EMS Agency subject to the terms and conditions provided herein ; and
15 NOW, THEREFORE, in consideration oftheir mutual covenants and conditions , and other
16 valuable consideration, the receipt and adequacy of which is hereby acknowledged, the parties hereto
17 agree as follows :
18 1. THE EMS SYSTEM/DESIGNATION OF CONTRACTOR
19 A. The parties acknowledge and agree that the EMS Agency has the authority to
2 0 plan, implement and evaluate an emergency medical services system in Fresno, Kings, Madera, and
21 Tulare Counties pursuant to Health and Safety Code sections 1797.200 and 1797.204.
22 B. The parties acknowledge and agree that the EMS Agency has the authorit y to
2 3 implement and update a trauma care system for the EMS System, including the authority to designate a
2 4 Level I Trauma Center for the EMS System, pursuant to Health & Safety Code sections 1798.160 et
2 5 seq. of the EMS Act, and the Trauma Care Regulations.
26 C . The parties acknowledge and agree that the EMS Agency Medical Director
2 7 (including his or her Assistant Medical Directors) of the EMS Agency has the authority of medical
2 8 control of the EMS System, including the trauma care system, and the authority to assure medical
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1 accountability through the planning , implementation and evaluation of the EMS System, including the
2 trauma care system, set forth in Health and Safety Code section 1797.202.
3 D. The parties acknowledge and agree that the service area for the CONTRACTOR 's
4 Level I Trauma Center is Fresno, Kings, Madera, and Tulare Counties.
5 E. CONTRACTOR acknowledges and agrees that neither the COUNTY nor the
6 EMS Agency makes any representation, warranty or guarantee, and cannot and do not assure
7 CONTRACTOR that any minimum number of trauma patients will be delivered or referred to
8 CONTRACTOR's facilities.
9 F. CONTRACTOR acknowledges and agrees that the EMS Agency's designation of
10 CONTRACTOR as a Level I Trauma Center for the EMS System is made on a non-exclusive basis ,
11 and that the EMS Agency reserves the right to designate any other qualifying hospitals , at any time , as
12 a Level I, II, III or IV Trauma Center or Level I or II Pediatric Trauma Center for the EMS System.
13 CONTRACTOR acknowledges that the EMS Agency designated Kaweah Delta Medical Center, in
14 Visalia, as a Level III Trauma Center for the EMS System, as provided in the Regional Trauma Plan.
15 2. RESPONSIBILITIES OF CONTRACTOR
16 CONTRACTOR shall , at its own expense, at all times during the term of this Agreement:
17 A. Operate and function as a Level I Trauma Center for all patients presenting at
18 CONTRACTOR's facilities, regardless of their ability to pay.
19 B. Provide and maintain the following as it requires to provide trauma center
2 0 services as a Level I Trauma Center under this Agreement:
21 1. All facilities and resources, including, but not limited to, all necessary
2 2 utilities, supplies, equipment and furniture ; and
2 3 2. All physician, nurse and other professional personnel, and such technical ,
2 4 administrative , allied and supportive paramedical personnel and such other personnel.
2 5 In this regard, CONTRACTOR specifically covenants that it will at all times comply
2 6 with, Trauma Care Regulations sections 100259 (entitled, "Level I and Level II Trauma Centers") and
2 7 100260 (entitled, "Additional Level I Criteria") for Level I Trauma Centers, both of which are
2 8 incorporated herein by reference.
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1 C. Take all necessary action to maintain the designation as a Level I Trauma Center
2 in accordance with the EMS Act, the Trauma Care Regulations, and the EMS Agency Policies and
3 Procedures now in effect, or which may hereafter come into effect, all of which are incorporated herein
4 by reference.
5 D. Provide trauma center services as a Level I Trauma Center in accordance with all
6 Federal , State , and local laws , and regulations now in effect, or which may hereafter come into effect
7 (including, but not limited to , the EMS Act and Trauma Center Regulations), all of which are
8 incorporated herein by reference .
9 E. Comply with all EMS Agency Policies and Procedures now in effect, or which
10 may hereafter come into effect, including, but not limited to , those policies and procedures related to
11 trauma care (EMS Agency Policies #330-Trauma System Overview, #331 -Trauma Facility
12 Designation, #332-Trauma System Monitoring, #333-Trauma Center Criteria, and #33 4 -Trauma
13 Registry Data Collection) and with the EMS System 's continuous quality improvement process
14 requirements now in effect, or which may hereafter come into effect (EMS Agency Policies #703 and
15 #704 adopted pursuant Trauma Care Regulation, sec. 100265 , entitled "Quality Improvement"), all of
16 which are attached hereto as Exhibit A and incorporated herein by reference .
17 F . Continuously maintain, without interruption, American College of Surgeons
18 (ACS) verification as a Level I Trauma Center.
19 G . Actively and cooperatively participate as a member of the Regional Trauma Audit
2 0 Committee and the Central Region Trauma Coordinating Committee.
21 H . Develop and/or conduct periodic instructional and educational programs for th e
2 2 benefit of the hospitals and pre-hospital care personnel throughout the EMS System that are related to
2 3 pre-hospital and in-hospital trauma care for patients.
24 I. Provide and maintain radio and communications equipment in CONTRACTOR's
25 facilities for communications with pre-hospital ambulance providers and hospitals throughout the EMS
26 reg10n .
27 J. Maintain all licenses , permits and certificates necessary to operate as an acute
2 8 care hospital , which, at minimum, includes basic or comprehensive emergency services available,
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1 pursuant to the Trauma Care Regulation, section 1 00259( c), and to maintain accreditation by the Joint
2 Commission on Accreditation of Healthcare Organizations, pursuant to Trauma Care Regulation ,
3 section 100248, entitled, "Trauma Care Regulation."
4 K. Provide all appropriate medical direction and control as a Base Hospital and
5 Disaster Control Facility, when necessary, to emergency medical services personnel in the field in
6 accordance with EMS Agency Policies and Procedures, now in effect, or which may hereafter come
7 into effect, including but not limited to EMS Policy #311 -Base Hospital Criteria, attached hereto as
8 Exhibit Band incorporated herein by this reference.
9 L. Take corrective action where there is a failure of CONTRACTOR to comply with
10 the Trauma Center Standards set forth in EMS Policy #333 (See Exhibit A). The minimum acceptable
11 period of time to correct a deviation from or deficiency in complying with the standard or standards
12 shall be determined by the EMS Agency's Director on a case-by-case basis applicable to the situation .
13 CONTRACTOR's failure to take such corrective action within the time specified by the EMS Agency
14 may, upon declaration thereof by COUNTY, result in breach ofthis Agreement.
15 L. Perform all other obligations of CONTRACTOR under this Agreement.
16 3. RESP ONSIBILITIES OF COUNTY
17 COUNTY shall, at its own expense, at all times during the term of this Agreement cause
18 and/or request the EMS Agency to:
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Develop, implement and monitor trauma care system policies and procedures .
Develop and implement triage procedures, which include injury severity
21 assessment and the determination of patient destination.
22 C. Provide appropriate information and data to CONTRACTOR on the Trauma Care
23 System.
24 D. Perform periodic announced or unannounced site visits to CONTRACTOR's
2 5 facilities for the purpose of monitoring CONTRACTOR's performance under and compliance with this
2 6 Agreement. Site visits shall not unnecessarily interrupt CONTRACTOR or CONTRACTOR's
2 7 personnel.
28 E. Develop and implement, with input from CONTRACTOR, a Trauma Registry
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1 Program and Trauma Registry database for the purpose of data collection, monitoring of trauma
2 centers' compliance with the Trauma Center Standards in the Regional Trauma Plan and evaluation of
3 the trauma care system.
4 F. Perform all other obligations of COUNTY under this Agreement.
5 4. TERM
6 This Agreement shall become effective at 12:00 a.m. on December 1, 2014 and shall
7 terminate on the 30th day of June, 2018.
8 This Agreement shall automatically be extended for an unlimited number of one (1) year
9 extensions upon the same terms and conditions herein set forth, unless written notice of non-renewal is
10 given by either of the parties to the other party no later than thirty (30) days prior to the expiration of
11 the then-current term of this Agreement.
12 5. TERMINATION
13 A. Non-Allocation of Funds -The terms of this Agreement, and the services to be
14 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
15 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
16 terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
17 Notwithstanding anything stated to the contrary in this Agreement, the provisions of this Section 5 .A.
18 shall not be construed as imposing any obligations on COUNTY or the EMS Agency to compensate
19 CONTRACTOR for any service it may provide, or function or activity that it may perform or undertake
2 0 in connection with this Agreement.
21 B. Breach of Contract -The COUNTY may immediately suspend or terminate this
22 Agreement in whole or in part, where in the determination of the COUNTY there is:
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A failure to comply with any term of this Agreement;
A substantially incorrect or incomplete report submitted to the COUNTY;
Improperly performed service.
Without Cause -Under circumstances other than those set forth above, this
2 8 Agreement may be terminated by either party upon the giving of thirty (30) days advance written notice
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1 of an intention to terminate.
2 6. NO MONETARY COMPENSATION
3 CONTRACTOR's Level I Trauma Center functions, services and activities conducted
4 pursuant to the terms and conditions of this Agreement shall be performed without the payment of any
5 monetary compensation by COUNTY to CONTRACTOR. COUNTY shall not be liable for any costs
6 or expenses incurred by CONTRACTOR to satisfy its obligations under this Agreement.
7 The parties acknowledge and agree that their respective covenants made to the other
8 party and benefits received from the other party under this Agreement shall form the basis of the
9 consideration exchanged between them under this Agreement.
10 7. INDEPENDENT CONTRACTOR
11 A. In order to establish that COUNTY is not a co-employer of CONTRACTOR 's
12 officers, agents or employees, the parties agree to the provisions of this Section 7.
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B. In performance of the work, duties , and obligations assumed by CONTRACTOR
under this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all
of CONTRACTOR's officers , agents , and employees , will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of COUNTY. COUNTY shall retain the right to
administer this Agreement so as to verify that CONTRACTOR is performing its obligations in
accordance with the terms and conditions thereof. CONTRACTOR and COUNTY shall comply with
all applicable provisions of law and the rules and regulations, if any, of governmental authorities
having jurisdiction over matters which are directly or indirectly the subject of this Agreement.
C. Because of its status as an independent contractor, CONTRACTOR shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CONTRACTOR shall be solely liable and responsible for providing to , or on behalf of, its employees
all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and
save COUNTY harmless from all matters relating to payment of CONTRACTOR's employees ,
including compliance with Social Security, withholding , and all other regulations governing such
matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be providing
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1 services to others unrelated to the COUNTY or to this Agreement.
2 8 . M ODIFICATION
3 Any matters of this Agreement may be modified from time to time by the written cons ent
4 of all the parties without, in any way , affecting the remainder.
5 9. N ON-ASSIGNMENT
6 Neither party shall assign , transfer or sub-contract this Agreement nor their rights or
7 duties under this Agreement without the prior written consent of the other party .
8 10 . H O LD HARMLESS
9 A. CONTRACTOR agrees to protect, defend, indemnify and hold harmless
10 COUNTY, its elective and appointive boards, officers, agents, employees, EMS Agency, and EMS
11 Agency Medical Director(s), from any and all claims , suits, liabilities, expenses , costs , damages , or
12 judgments of any nature , including attorney fees, for injury to , or death of, any person, and for injury to
13 any property, including consequential damages of any nature resulting therefrom, arising out of, or in
14 any way connected with any negligent or wrongful acts or omissions by, or on behalf of
15 CONTRACTOR, its officers , employees , agents or contractors in performing or failing to perform any
16 services or functions provided for or referred to or in any way connected with any work, services , or
17 functions to be performed by CONTRACTOR, its officers, employees, agents , or contractors under this
18 Agreement. The foregoing clause shall in no way obligate CONTRACTOR to provide such protection,
19 indemnification, or defense to the extent of acts or omissions by COUNTY, its officers , employees ,
2 0 agents , or contractors.
21 B. COUNTY agrees to protect, defend, indemnify and hold harmless
2 2 CONTRACTOR, its elective and appointive boards, officers, agents and employees from any and all
2 3 claims, suits, liabilities , expenses, costs , damages, or judgments of any nature , including attorney 's
24 fees , for injury to, or death of, any persons , or for injury to any property , including consequential
2 5 damages of any nature resulting therefrom , arising out of, or in any way connected with the negligent
2 6 or wrongful acts or omissions by, or on behalf of COUNTY, its officers, employees, agents or
2 7 contractors in performing or failing to perform any services or functions provided for or referred to or
2 8 in any way connected with any work, services , or functions to be performed by COUNTY, its officers ,
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1 employees, agents or contractors under this Agreement. The foregoing clause shall in no way obligate
2 COUNTY to provide such protection, indemnification, or defense to the extent of acts or omissions by
3 CONTRACTOR, its officers, employees, agents, or contractors.
4 C. The aforesaid indemnity and hold harmless clauses by CONTRACTOR and
5 COUNTY shall apply to all damages and claims for damages of every kind suffered, or alleged to have
6 been suffered by the party to be indemnified, including but not limited to attorney fees, by reason of the
7 aforesaid operations ofthe indemnifying party, regardless of whether or not the insurance policies of
8 the indemnifying party shall have been determined to be applicable to any such damages or claims for
9 damages.
10 In addition, each party agrees to indemnify the other party for Federal, State of California
11 and/or local audit exceptions resulting from non-compliance herein on the part of the indemnifying
12 party .
13 11. INSURANCE
14 Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or
15 any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the
16 following insurance policies throughout the term of this Agreement:
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Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
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
policy shall include coverage for bodily injury, broad form property damage ,
personal injury, products and completed operations, and blanket contractual
coverage including, but not limited to, liability assumed under the Indemnification
provisions of this Agreement.
Automobile Liability
Comprehensive Automobile Liability Insurance with a combined single limit of
not less than One Million Dollars ($1 ,000,000) per accident. Coverage should
include owned and non-owned vehicles used in connection with this Agreement.
Worker's Compensation
A policy of worker's compensation insurance as may be required by the California
Labor Code.
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D. Professional Liability
If CONTRACTOR employs licensed professional staff(e.g., Ph.D., R.N .,
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 , Fi ve
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
following the termination of this Agreement, one or more policies of profession al
liability insurance with limits of coverage as specified therein.
Such insurance policy for Commercial General Liability insurance shall name the County
of Fresno , its officers , agents , and employees , individually and collectively, as additional insured , but
only insofar as the operations under this Agreement are concerned. Such coverage for additional
insured shall apply as primary insurance and any other insurance , or self-insurance , maintained by
COUNTY , its officers, agents and employees shall be excess only and not contributing with insurance
provided under CONTRACTOR's policies herein . This insurance shall not be cancelled or chan ged
without a minimum of thirty (30) days advance written notice given to COUNTY. CONTRACTOR
shall obtain endorsements to the Commercial General Liability insurance policy naming COUNTY as
an additional insured and providing for an unrestricted thirty (30) day prior written notice of
cancellation or change in terms or coverage.
Prior to the commencement of performing its obligations under this Agreement,
CONTRACTOR shall provide certificates of insurance and upon request from COUNTY, formal
endorsements, for the foregoing policies , as required herein , to the County of Fresno, 4969 E.
McKinley Avenue, Suite 108 , Fresno , California, 93727 , Attention: Contracts Section, stating that such
insurance coverages have been obtained and are in full force; that the County of Fresno , its officers ,
agents and employees will not be responsible for any premiums on the policies; that such Commercial
General Liability insurance names the County of Fresno , its officers, agents and employees ,
individually and collectively, as additional insured , but only insofar as the operations under this
Agreement are concerned; that such coverage for additional insured shall apply as primary insurance
and any other insurance, or self-insurance, maintained by COUNTY, its officers , agents and emplo yees,
shall be excess only and not contributing with insurance provided under CONTRACTOR's policies
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1 herein ; and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days
2 advance , written notice given to COUNTY.
3 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
4 herein provided, COUNTY may , in addition to other remedies it may have , suspend or terminate this
5 Agreement upon the occurrence of such event.
6 All policies shall be with admitted insurers licensed to do business in the State of
7 California. Insurance purchased shall be purchased from companies possessing a current A.M. Best,
8 Inc. rating of A FSC VII or better.
9 12. CONFIDENTIALITY
10 All services performed by CONTRACTOR under this Agreement shall be in strict
11 conformance with all applicable Federal , State of California and/or local laws and regulations relatin g
12 to confidentiality, now in effect, or which may hereafter come into effect.
13 13. NON-DISCRIMINATION
14 During the performance of this Agreement, CONTRACTOR shall not unlawfully discriminate against
15 any employee or applicant for employment, or recipient of services , because of race , religious creed ,
16 color, national origin, ancestry , physical disability , mental disability, medical condition, genetic
17 information, marital status , sex, gender, gender identity , gender expression, age , sexual orientation, or
18 military and veteran status , pursuant to all applicable State of California and Federal statutes and
19 regulations.
20 14. DISCLOSURE OF SELF-DEALING TRANSACTIONS
21 This provision is only applicable if the CONTRACTOR is operating as a corporation (a
2 2 for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
2 3 changes its status to operate as a corporation.
24 Members ofthe CONTRACTOR 's Board ofDirectors shall disclose any self-dealing
2 5 transactions that they are a party to while CONTRACTOR is providing goods or performing serv ices
2 6 under this agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR
2 7 is a party and in which one or more of its directors has a material financial interest. Members of the
2 8 Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
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1 and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit C and
2 incorporated herein by reference , and submitting it to the COUNTY prior to commencing with the sel f-
3 dealing transaction or immediately thereafter.
4 15. RECORDS/REPORTS
5 CONTRACTOR shall develop and maintain a Trauma Registry Program which is
6 approved by the EMS Agency . The Trauma Registry Program shall include all appropriate trauma
7 patient information and "hospital data" (as that term is defined in Trauma Regulation, section
8 100257(c)) concerning such patients as set forth in EMS Policy #332-Trauma System Monitoring
9 and the Regional Trauma Plan (See Exhibit A). All such records shall be complete and accurate . The
10 EMS Agency shall have access to all such records upon request. CONTRACTOR shall provide traum a
11 registry data and/or reports to the EMS Agency upon request and/or on a regularly scheduled timetabl e
12 such as monthly, quarterly, or annually , which will be agreed upon between the EMS Agency and
13 CONTRACTOR. In the event that the EMS Agency develops the capability to directly access and
14 retrieve trauma registry records through computer technology , CONTRACTOR shall , at no cost to the
15 EMS Agency, assist the EMS Agency in achieving such access and retrieval of CONTRACTOR 's
16 Trauma Registry Program through such means.
17 16. LICENSES/CERTIFICATES
18 CONTRACTOR shall , at its own cost, throughout the term of this Agreement, maintain
19 all necessary licenses, permits and certificates necessary for the provision of services hereunder and
2 0 now or hereafter required by Federal , State and local laws and regulations, the EMS Agency and any
21 other applicable government agencies. This shall include, but not be limited to: 1) being licensed as a
2 2 general acute care hospital , and 2) holding a special permit for basic or comprehensive emergency
2 3 serv1ces .
24 17. AUDITS AND INSPECTIONS
2 5 CONTRACTOR shall at any time during business hours, and as often as COUNTY and
2 6 the EMS Agency may deem necessary , make available to COUNTY and the EMS Agency for
2 7 examination all of its records and data with respect to the matters covered by this Agreement.
2 8 CONTRACTOR shall, upon request by COUNTY and the EMS Agency , permit COUNTY to audit and
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1 inspect all such records and data necessary to ensure CONTRACTOR's compliance with the terms of
2 this Agreement.
3 18. NOTICES
4 The persons having authority to give and receive notices under this Agreement and their
5 addresses include the following:
6 COUNTY CONTRACTOR
7 President and CEO
8
Director, Fresno County
Department of Public
Health
Community Regional Medical Center
2823 Fresno Street
9 P. 0. Box 11867 Fresno, CA 93 721
Fresno, CA 93775
10 Any and all notices between the COUNTY and the CONTRACTOR provided for or
11 permitted under this Agreement, or by law, shall be in writing and shall be deemed duly served when
12 personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
13 United States Mail, postage prepaid, addressed to such party.
14 19. GOVERNING LAW
15 The parties agree that for the purposes of venue, performance under this Agreement is to
16 be in Fresno County, California.
17 The rights and obligations of the parties and all interpretation and performance of this
18 Agreement shall be governed in all respects by the laws of the State of California.
19 20. THIRD PARTY BENEFICIARIES
2 0 The parties hereto agree that the covenants made and benefits received between them
21 (and for the benefit of the EMS Agency under this Agreement) are only between them (and for the
22 benefit of the EMS Agency), and that there are no intended third party beneficiaries ofthis Agreement,
23 provided however, for purposes of this Section 19 , the EMS Agency shall be deemed to be an intended
2 4 beneficiary of this Agreement.
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1 21. ENTIRE AGREEMENT
2 This Agreement constitutes the entire agreement between the CONTRACTOR and
3 COUNTY with respect to the subject matter hereof and supersedes all previous agreement ne gotiation s,
4 proposals, commitments , writings , advertisements , publications , and understandings of any nature
5 whatsoever unless expressly included in this Agreement.
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1 IN WI1NESS WHEREOF, the parties hereto have executed this Agreement as of the day
2 . and year first hereinabove written.
3 ATfEST:
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CONTRACTOR:
COMMUNITY REGIONAL MEDICAL
CENTER
PrintNam
Title: President and Chief Executive Officer
Title: Sr. VP /Chief Financial Officer
Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Date:
Mailing Address:
2823 Fresno Street
Fresno, CA 93721
Phone#: (559) 459-6000
26 Contact: Lynn Bennink, R.N., Trauma Manager
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COUNTY OF FRESNO:
Date: ~~ 13 1 d-Ol'S
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By ~~~~Of?-~~
Date:~~ /.3 1 ;)015
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
COUNTY OF FRESNO
Fresno, CA
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APPROVED AS TO LEGAL FORM:
DANIEL C . CEDERBORG, COUNTY COUNSEL
(~1 J By _____________ ~~~t ~----------
APPROVED AS 0 ACCOUNTING FORM:
VICKI CROW, C.P. AUDITOR-CONTROLLER/
TREASURER-TAX C ECTOR
REVIEWED AND RECOMMENDED FOR APPROVAL:
By_lfl~~~--'--'--/JJt-! _
David Pomaville
Director
Department of Public Health
Fund/Subclass:
Organization :
JW
0001/10000
56201695
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EXHIBIT A
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual Policy
Emergency Medical Services Number330
Administrative Policies and Procedures
Page 1 of4
Subj ec t Trauma System Overview
Effective
R eferenc es California Code of Regulations 11/01/2002
Title 22 . Social Security
Division 9. Prehospital Emergency Medical Services
Chapter 7. Trauma Care Systems
I. POLICY
The Central California Emergency Medical Services Trauma 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.
The Central California Emergency Medical Services Trauma 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 manner
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 . System Organization and Management
Approved By
The EMS Division of the Fresno County Department of Community Health is designated by the Board of
Supervisors from Fresno, Kings, Madera and Tulare Counties as the 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 EMS committees, including the Regional Trauma Audit
Committee. The EMS staff supervises the collection and analysis of trauma data, including ongoing
development of the trauma patient registry.
A Level I Trauma Center, Community Regional Medical Center (RMC), is located in Fresno and directly
receives prehospital trauma patients from within the region often bypassing other receiving hospitals . The
trauma nurse coordinators provide trauma registry data, which is used by the Trauma Audit Committee and
EMS Agency.
A Level III Trauma Center, Kaweah Delta Medical Center (KDMC), is located in Visalia and receives
ground ambulance trauma patients from within Tulare County and adjacent counties.
Revision
EMS Division Manager ~q~ 06/01/2010
EMS Medical Director ~~~
Page 2 of4
Subject Trauma System Overview Policy
Number330
B. Trauma Care Coordination Within the Trauma System
The prehospital care and treatment of trauma patients shall be in accordance with EMS policy and
procequres to insure consistent application of trauma services through-out the EMS region. These policies
include EMS Policy# 332-Trauma System Monitoring, EMS Policy #51 0 -Basic Life Support Protocols,
EMS Policy #530 .23-Paramedic Treatment Protocols, EMS Policy #547-Patient Destination, and other
EMS policies and procedures.
C. Trauma Care Coordination with Neighboring Jurisdictions
Coordination of Trauma Care with neighboring jurisdictions is addressed in the prehospital setting and also
the hospital setting. EMS Policy # 406 -EMS Dispatch Policy Out of County Responses, and EMS Policy
#408 -Helicopter 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 #341 -Patient Transfers Between Acute
Care Facilities, EMS Policy #342-Transfer Agreements Between Acute Care Hospitals, and EMS Policy
#354-Pediatric Trauma and Critical Care Consultation and Transfer Guidelines.
D . Collection and Management of Data
The designated trauma centers and all other receiving hospitals 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 defmed in the State Trauma Regulation Section 100257, is required by all participating trauma hospitals.
Collection and management of data for the Central California Emergency Medical Services Trauma System
is outlined in EMS Policy #332 .
E. Trauma Center Fees for Designation!Redesignation!Evaluation
There are currently no fees for trauma center designation, redesignation, or trauma center evaluation in the
Central California Emergency Medical Services region.
F. Establishment 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 specific
circumstances, such as extended transport time, a trauma patient may be transported to a receiving hospital
for stabilization before proceeding to the trauma center. Kaweah Delta Medical Center is a designated
Level ill Trauma Center and is the primary trauma destination for trauma patients in Tulare County.
G. Designation andRe-designation of a Trauma Center/including Agreements
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.
H . Triage to the Appropriate Facility
The prehospital triage and transport destination of trauma patients is determined by a trauma score, which is
a measurement of both Glasgow Coma Scale and vital signs . In addition, destination is also determined by
mechanism of injury in limited cases. 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. EMS Policy #813 -Prehospital Trauma Score Calculation
and Documentation describes the trauma score measurement used by prehospital personnel in Central
California EMS Region.
Subject Trauma System Overview
I. Repatriation of Stable Trauma Service Health Plan Members
Policy
Number330
Page 3 of4
EMS Policy #54 7 -Patient Destination requires prehospital personnel to attempt to transport stable patients
to the patient's health plan's participating facility
J. Inter-trauma Center & Inter-facility Transfer of the Trauma Patient
The EMS policies and procedures strictly address the coordination and management of Inter-trauma center
and inter-facility transfers of the trauma patient and are addressed in EMS Policy #341 -Patient Transfers
Between Acute Care Facilities, EMS Policy #342-Transfer Agreements Between Acute Care Hospitals,
EMS Policy #354-Pediatric Trauma and Critical Care Consultation and Transfer Guidelines, and EMS
Policy #553 -ALS Interfacility Transfers.
K . Role of the Pediatric Trauma Center
Community Regional Medical Center is the Level I Trauma Center and is the designated destination for all
pediatric trauma.
L. Resources for Trauma Team Response-Equipment & Staff
Trauma Centers are required by EMS Policy #333 -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 Trauma Team
Trauma Centers are required by EMS Policy #333 -Trauma Center Criteria, to have internal hospital
policies and procedures outlining the specific criteria for trauma team activation.
N. Availability of Trauma Specialists
Trauma Centers are required by EMS Policy #333 -Trauma Center Criteria to have internal hospital
policies and procedures outlining the availability of trauma team personnel and specialists.
0. Quality Improvement and System Evaluation/ include Multidisciplinary Peer Review Committee
Quality Improvement is a combined effort of hospitals, providers, and the EMS Agency. EMS Policies
#703-~esolution of 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 EMS policy #332 -Trauma System Monitoring.
The trauma system is also monitored by a peer review committee, which is outlined in EMS Policy #703 -
Continuous Quality Improvement.
P . Identification and Transportation of the Adult and Pediatric Trauma Center Candidate
Trauma center patients are identified by a specific trauma score, which is determined by the patients
Glascow Coma Scale and vital signs and is outlined in EMS Policy #813 -Prehospital Trauma Score
Calculation and Documentation. Once the patient is identified as a trauma center patient, the prehospital
personnel transport the patient to the trauma center in accordance with EMS Policy #547-Patient
Destination.
Page 4 of4
Subject Trauma System Overview Policy
Number330
Q. Trauma Triage Training ofPrehospital Personnel
Prehospital Personnel and MICN's are trained in trauma triage through continuing education courses
available throughout the EMS System Continuing education courses must be in accordance with EMS
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 of the trauma system will be coordinated through the EMS 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 and/or medical
community. Additional requirements will include:
1. A commitment to the establishment of a trauma system that supports the promotion of injury 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 professional groups in the development and dissemination of
education to the public on such topics as injury prevention, safety education programs and access to the
trauma care system.
4 . Each designated facility must participate in the development of public awareness and education
campaigns for their service area.
S. Provider Marketing and Advertising
California Health and Safety Code, Division 2.5, states in part, "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 Injury Prevention Efforts with the Public/Private Sector
Trauma Centers shall participate in injury prevention programs with public and private agencies. Trauma
Centers may produce their own Injury 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
communities.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual Policy
Emergency Medical Services Number 331
Administrative Policies and Procedures
Page 1 of2
Subject Trauma Facility Designation
References California Code ofRegulations, Title 22. Social Security Effective
Division 9. Prehospital Emergency Medical Services 11/01/86
Chapter 7. Trauma Care Systems
I. POLICY
Trauma Centers for the Central California EMS Region are designated by Local EMS Agency based upon the need
for local and regional EMS trauma care services .
II. DESIGNATED TRAUMA CENTERS
The following hospitals have been designated as Trauma Centers:
Date of Original
Trauma Center · Level of Designation Designation
Community Regional Medical Center Level I Trauma Center June 19, 1984
Kaweah Delta Medical Center Level III Trauma Center January 26, 2010
III. PROCEDURE
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 number and type of trauma hospitals needed for local and/or regional trauma care needs,
and the evaluation process for the trauma system.
B. The Regional Trauma Audit Committee will formalize recommendations to the EMS Agency concerning all
aspects of the trauma system, 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 EMS 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.
D. Applications shall be reviewed for their compliance with State and local regulations and their impact on
medical trauma needs. The Regional Trauma Audit Committee, Regional Medical Control Committee, and
each Emergency Medical Care Committee from each county in the region will be consulted for its
recommendation.
Approved By Revision
EMS Division Manager
06/01/2010
EMS Medical Director
Page 2 of2
Subject Trauma Facility Designation Policy
Number331
E . If more than one hospital competes for a role in the local system that is deemed necessary by the regional
Trauma Audit Committee and the EMS Agency, a Request for Proposal procedure may be necessary to
determine the successful applicant.
F . The EMS Agency shall determine a plan for Trauma Care Services.
G. Any change in designation will become part of the revised trauma plan and will be approved by the Local
EMS Agency prior to submission to the State EMS Authority.
H. Failure by a hospital to comply with applicable local and State trauma requirements or applicable
recommendations by site survey teams approved by the EMS Agency, may result in forfeiture of their
trauma designation.
I. Failure by a hospital to provide an adequate quality of care, as identified through medical audit and quality
audit procedures, may result in forfeiture of their trauma designation.
FRESNOnuNGS~DERA
EMERGENCY MEDICAL SERVICES
Manual
Subject
References
DEPARTMENT OF COMMUNITY HEALTH
POLICIES AND PROCEDURES
Emergency Medical Services
Administrative Policies and Procedures
Trauma System Monitoring
California Code of Regulations, Title 22. Social Security
Division 9. Prehospital Emergency Medical Services
Chapter 7. Trauma Care Systems
Policy
Number 332
Page 1 of3
Effective
11/01188
I. POLICY
The trauma care administered to patients of the local trauma care system will be reviewed for appropriateness and
patient outcome. This review will be conducted through the use of the Regional Trauma Audit Committee composed
of health care and trauma care specialists .
II . PROCEDURE
A. TRAUMAREGISTRY
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.
2 . Selection Criteria
Selection criteria are used to determine the specific patients that will be included in the Trauma
Registry. The current registry criterion are included as Attachment A.
3 . Documentation
A Trauma Registry Form will be completed by all trauma centers and receiving hospitals for all
patients who meet registry criteria. Trauma Nurse Coordinators at trauma centers and receiving
hospitals will be responsible for completing the documentation of registry patients. The completed
registry data will be forwarded to the EMS Agency according to established procedures.
B. INTERNAL HOSPITAL REVIEW
Approved By
The medical records (including prehospital) of each registry patient at trauma centers and trauma receiving
hospitals will be reviewed by the Trauma Nurse Coordinator for completeness, accuracy and presence of
any delays in evaluation and treatment. The hospital's Trauma Surgery Director will review the registry
Revision
EMS Division Manager
11/01/2002
EMS Medical Director
Subject Trauma System Monitoring Policy
Number 332
Page 2 of3
records for appropriateness of diagnostic procedures relative to the admitting diagnosis, timeliness of care,
appropriateness of operative therapy relative to diagnosis, complications, morbidity, and length of stay
relative to diagnosis.
The Trauma Surgery Director and Trauma Nurse Coordinator/Manager will present each registry case to the
hospital's appropriate reviewing committee. Trauma receiving hospitals may utilize an existing standing
medical committee, such as a surgical committee. Trauma centers will utilize a specific Trauma Review
Committee whose membership shall minimally include:
TRAUMA CENTER TRAUMA REVIEW COMMITTEE
Trauma Surgery Director Neurosurgeon
Emergency Medicine Representative Orthopedic Surgeon
Trauma Nurse Manager/Coordinator Hospital Administration
Emergency Department Manager/Supervisor Prehospital Liaison Nurse
In addition to the members listed above, the Trauma Center should also consider the following
representatives:
Anesthesiology
Nurse Manager -OR
Nurse Manager -ICU
Radiology Representative
Blood Bank Representative
Medical Records will be available to allow the committee to review all aspects of the patient's care and course
of hospital stay. The hospital Trauma Review Committee 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 non-preventable,
possibly preventable or preventable. The committee shall forward unusual or problem cases to the Regional
Trauma Audit Committee and formulate recommendations on Trauma Care System and EMS System
operation. The definitions for the classifications of death are in accordance with the American College of
Surgeons criteria and are as follows:
1. Non-preventable -An event of complication sequela of a procedure, disease, illness, or injury for
which reasonable and appropriate preventable steps had been taken.
2 . Potentially Preventable-An event of complication that is a sequela of a procedure, disease, illness, or
injury that has the potential to be prevented or substantially ameliorated.
3 . Preventable -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 ameliorated.
C. REGIONAL TRAUMA AUDIT COMMITTEE
1. Membership
The Regional Trauma Audit Committee is an advisory committee to the EMS Agency on issues
related to trauma 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 :
Subject Trauma System Monitoring Policy
Number 332
Page 3 of3
MEMBERSHIP OF THE REGIONAL TRAUMA AUDIT COMMITTEE (T AC)
Trauma Centers Receivin~ Hospitals
Trauma Surgery Director Trauma Surgery Director
Emergency Department Physician Emergency Department Physician
Trauma Nurse Coordinator/Manager Trauma Nurse Coordinator/ PLN
EMSA~ency Local Medical Communitv
EMS Medical Director Neurosurgeon (from Neurosurgical Society)
EMS Division Manager 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 of
the person designated to represent the agency and exercise Committee voting privileges. There will
be one vote per facility .
2. Chairperson/Vice Chairperson
The Committee shall elect a Chairman 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 . The
EMS Agency will provide staff support for the Regional Trauma Audit Committee.
3 . Committee Responsibilities
The Regional Trauma Audit Committee is responsible for reviewing all aspects of the Trauma
Care System and developing recommendations on system operation for the EMS Agency. 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 items 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 .
Case presentations will occur each month with trauma centers generally presenting cases each
month and other facilities (including Madera and Kings Counties) presenting cases on a semi-
monthly or quarterly basis . Criteria for case presentation to the Regional Trauma Audit Committee
are included in Attachment B. 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 EMS Agency will provide monthly reports to the
committee on the regional trauma system . The Committee may provide feedback on system
operation or quality improvement issues directly to the EMS Agency, health care facility or
provider, and other trauma/EMS advisory groups.
D. EMS AGENCY
The local EMS Agency is responsible for monitoring the operation of the Trauma Care System. The EMS
Agency may request an onsite review of any designated trauma hospital with repetitive problems to ensure
that the problems are being resolved . Additional agency involvement (e.g. State Department of Health
Services) may. be requested as appropriate .
ATTACHMENT A
TRAUMA REGISTRY-SELECTION CRITERA
Reference: Definition of a Trauma Patient-Adopted By National Trauma Data Bank (NTDB)
1. All trauma related hospital admits with at least one injury ICD-9 diagnosis code between 800.0-959.9
A. Fractures (all)
B. Dislocations (all)
C. Intracranial injuries (all-includes concussion)
D. Internal injuries of chest, abdomen, and pelvis
E. Open wounds
F. Injuries to blood vessels
G. Crushing injuries
H. Bums (bum registry)
I. Injuries to optic nerves
J. Spinal cord injuries
K. Certain traumatic complications
1. Air/fat embolism
2. Secondary and recurrent hemorrhage
3. Post traumatic wound infection
4. Traumatic shock
5. Subcutaneous emphysema
L. Excludes:
1. 905-909 (late effects of injury-defined as "those things that occur at any time after an acute injury)
2. 910-924 (blisters, contusions, abrasions, insect bites)
3. 930-939 (foreign bodies)
4 . Isolated sprains/strains/contusions
2. All injury-related deaths in ED or after admission
3. All trauma transfers from other facilities
ATTACHMENT B
CASE PRESENTATION CRITERIA
1. Case Presentations shall occur each month at the regi onal Trauma Audit Committee. The criteria for case
presentation shall include:
A. Any death classified as preventable or possibly preventable by the hospital Trauma Review Committee,
including:
1. All deaths with initial surgery (required for stabilization) > 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.
5 . 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 hematoma receiving craniotomy more than 4 hours from arrival at
emergency department to surgical start time , excluding those performed for intracranial pressure (ICP)
monitoring.
E . Delay to surgery for laparotomy:
1. Surgery start time > 1 hour if hypotensive (systolic blood pressure <90mm Hg)
2 . Surgery start time >4 hours if stable
F. Problem Transfers -Any trauma patient transfer of greater than 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 than 15 minutes.
H. Any trauma case where the trauma consultant does not respond in the specified time period.
I. Any case which demonstrates system operational problems.
J. Interesting or educational cases .
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual Policy
Emergency Medical Services Number333
Administrative Policies and Procedures
Page 1 of2
Subject Trauma Center Criteria
References California Code ofRegulations Effective
Title 22 . Social Security 11/08/88
Division 9. Prehospital Emergency Medical Services
Chapter 7. Trauma Care Systems
I. POLICY
A trauma center is a licensed hospital, which has been designated as a Level I, II, III, IV, or Pediatric Level I or II
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 ofRegulations, Title 22., Division 9., Chapter 7.
Trauma Care Services and EMS Agency policy and procedure.
II. PROCEDURE
A. Trauma centers shall maintain, at all times, the standards required of its designation as a Level I, II, III, IV,
or Pediatric Level I or II trauma center in accordance the California Code of Regulations and the Central
California EMS Policies and Procedures. The Trauma Center Standards are included as Attachment A.
B. In addition to the requirements listed in the Trauma Center Standards, a designated trauma center for the
CCEMSA EMS Region shall meet and maintain the following additional requirements:
Approved By
1. Designated trauma centers shall designate a Trauma Program Medical Director, Trauma Nurse
Coordinator/Manager, 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 meetings each calendar year. The emergency department
physician representative shall be a board certified in emergency medicine or maintain current
certification in Advanced Trauma Life Support (ATLS) and be a certified base hospital physician.
2 . Trauma centers shall be designated Base Hospitals and shall meet all requirements outlined in
EMS Policy and Procedure.
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 flle at the EMS Agency.
Revision
EMS Division Manager
06/01/2010
EMS Medical Director
Subject Trawna Center Criteria Level I and Level II Policy
Number333
Page 2 of6
4. Designated trawna centers shall implement and maintain an EMS Agency approved trawna
registry data collection program and provide registry data to the EMS agency on a monthly or
quarterly basis.
5. Designated trawna centers shall have a written agreement with the Local EMS Agency
6. Designated trawna centers shall have a written transfer agreement with all affiliated trawna care
hospitals and appropriate specialty care facilities. A copy of the written agreements shall be on file
with the EMS Agency.
C. Immediately Available
Immediately available implies the physical presence of the health professional in a stated location at the
time of need by the trawna patient within 15 minutes 80% of the time otherwise upon patient arrival with
sufficient advanced notice. (ACS Guidelines)
D . Promptly Available
Promptly available is defined in this policy as the return of a notification call within 20 minutes and
available to the Trawna Center within 30 minutes 80% of the time when requested by the trawna team
leader.
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
~~~~~~-.l!~bi!Jfi',,, .. 'I;.'<MA!c \\ ]te'Rl'FERI~~~\t~:!tt~.~ el' A'"~'~'t!1 ' · • · · · · S.!;ll"'~ k··• ' • · · • . 'Jiiit'iL4.'1 :•: -CmflU :~1~:§1] 1!~1 ;·~re.~·e·f ·ik.evel ~
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
Institutions/Organization E E E E E
JACAHO Accreditation
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
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
A minimum of 1200 trauma program hospital admissions or
A minimum of 240 trauma patients per year whose Injury
Severity Score (ISS) is >15, or
An average of 35 trauma patients (ISS >15) per trauma program
surqeon per year
~trauma research program E
~n ACGME approved surgical residency program 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*
A qualified surgical specialist E
lA qualified non-surgical specialist E
Responsibilities include but not limited to:
Recommending trauma team physician privileges E E E E E
Working with nursing & administration to support needs of E E E E E
trauma patients
Developing trauma treatment protocol E E E E E
1
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
l:,'tl;;·~;<.! .. , ~!t~L.~~·IT~~;,::.C'F{IJERINi!>,:"~~t,~tc-::f;:.&:fU,'t~:ii1i?!%:~r u~:Y~f . lf "".:';~l;.; ~ evel ~eve~ t::fl~er · l!e~~~
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
Determining appropriate equipment and supplies E E E E* E*
Ensuring development of policies/procedures for domestic
violence, elder/child abuse/neQiect E E E E* E*
Having authority & accountability for Ql 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*
!Assisting 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
coordinating day-to-day clinical process & performance E E E E E
improvement of nursing personnel
collaborating with trauma program medical director to carry E E E E E
out trauma proQram activities
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
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
trauma patient
Ability to provide treatment or arrange for transportation to a E E
higher level trauma center
2
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
II &{IL til<ITE~I~-:,,~,~~ l'o"l!hl.SI ~~.:.It !i!P~~;;t~i ~lle.v:el l ~t :'g{,~l
I II PEDS Ill IV
(E = essential E*= CCEMSA D = d~si!able )
[Trauma Team E E E E E
~ multidisciplinary team responsible for the initial resusci tation E E E E E
land 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 proqram medical director and
!Remainder of team shall include physician , nursing and support E
!personnel in sufficient numbers to evaluate , treat, stabilize
[pediatric patients
[SURGICAL DEPARTMENT (S), DIVISION(S), SERVICE(S),
ISt:CTION(S):
[Which includes at least the following surgical specialties &
1:>uti'i't:d by qualified specialists:
Pediatric TC must provide Pediatric Specialist
[General/ (Pediatric General for Pediat ri c Trauma Cente r) E E E E
Neurosurgery E E E
May be provided through a written transfe r ag reement for E
Level Il l
[Obstet ri c/Gynecologic
May be provided through written transfer agreement for E E E
Pediatric TC
Ophtha illluJuyic E E E
Oral/maxillufa{.;Jc:il or head and neck E E E
IO•uiUJJI::jd ic E E E E
Plas t ic E E E
IUroloqic E E E
!Ped iatrics D D E
[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
Anestnesiology E E E E
Internal MediCine E E
Cardiology E
Critical Care -Pediatric trauma centers , in-house, immediately E
available, fulfilled by:
Qualified specialist in pediatric critical care medicine, Q[ E
3
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
r-~~,;:., .'"':'!: ~-ftt\1':,..,, ' '' . . ' , """~"""' .~:i'~'''"~:f: 't~~7'.1~~~GRITitHIA.''' ·~m:;:~"-. '}j,'\,bt l:e'Vet 11:tevei lfevel. l!ei'el r~r&vet~
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
Qualified specialist in anesthesiology with experience in E
!pediatric critical care ;
Qualified surgeon with expertise in pediatric critical care, or E
A physician who has completed at least 2 yea rs of residency in E
pediatrics, supervised by qualified specialist in pedia tric critical
care or pediatric anesthesiology who is on-call and promptly
available, who is advised of all patients requiring admiss ion to
the PICU and part icipate in all major decisions and interventions
Emergency Department w ith qualified specialist in emergency E E E
medicine, immedia tely available
Emergency Department staffed , trauma patients are assured of E E
immediate and appropriate initial care
Gastroenterology E
General Pediatrics E
Hematology/Oncology E
Infectious Disease E
Neonatology E
Nephrology E
Neurology E
Pathology E E E
Psychiatry E E E
Pulmonology E
Rehabilitation/physical medicine, can be provided by written E
agreement
Radiology E E E
QUALIFIED SURGICAL SPECIALIST(S):
General Surgeon capable of evaluating & treat ing adult and E E E D
pediatric trauma patients , Board Certified , Immediately available
In-house* at all times for trauma team activation and promp tly
available for consultation
Pediatric TC must have Pediatric specialists in all areas E
Pediatric TC may be fu lfilled by:
A staff pediatric surgeon with experience in pediat ric trauma, or
A staff trauma surgeon with experience in pediatric trauma
General Surgeon capable of evaluating & treating adult and E
pediatric trauma patients, promptly available at all times
Published on-call schedule E* E* E* E*
4
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
l!tl~'iH~ l"lf t~.fl · ... -GRiffi!iR-1~~ ''*M
~;J:?XQ~:~. ::'>€.Vi -~ .... ~-.. 1-h.h\i~l 2.1
.• ~i:;t:.Y E:.HVHI:
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
Publishe,d back up schedule E* E* E* E*
!Surgical specialists' requirements may be fulfilled by supervised E E E
!senior residents as defined in Section 1 00245 of T itle 22 at the
Level I, II , or pediatric trauma center.
Residency coverage
Senior resident must be capable of assessing emergent E E E
situations in their respective ~nAri~l~y and
Shall be able to provide overall control and surgical E E E
leadership includinq surgical care if needed. and
A supervising, staff trauma surgeon/surgeon with experience E E E
in trauma care shall be on-call and prorrmth' available
lA supervising, staff trauma surgeon shall be advised of all E E E
!trauma patient admissions, participate in majo r therapeutic
!decisions, and be present in the ED for all major resuscitations
land in the OR for a all trauma operative procedures
!On-Call and promptly available
Pediatric TC must have Pediatric ~no,-i~lists in all areas
Neurosurgeon, Board Certified or qualified by Section 100242 E E E
!Title 22. Dedicated to one hospital or back up call *
ILevellll mav be provided throuQh a written transfer aqreement E
Obstetric/Gynecologic E E E D
Pediatric TC available by Transfer aqreement
IOphtha lrrrurugic E E E D
!Oral/maxillofacial or head and neck E E E D
!Orthopedic, Board Certified or qualified by Section 100242 Title E E E E
122. Dedicated to one hu-=>!Jnal or back up call *
!Plastic E E E D
!Urologic E E E D
ICardiothoracic E E D
Pediatrics E E
!Surgical service-available for consultation or by transfer
iaH• ~~:::em~::nts
!Burns E E-E E
ICardiothoracic E E D
!Pediatrics E E
IReimplantauun/Microsurgery E E E
!Spinal cord injury E E E D
5
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
1 ~::!t~,~~~;~?P.!>;·': '>t·l~,;~~,CBJIERIAt:~""~.~~l: ::-f~,~-~.v~~,~~~ii~···: 1~te.'ieJ1 ;!:.~111 l '~~el ~j)( t::e~el~·
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
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
medicine shall not be required to complete ATLS .
Current ATLS is required for all emergency medicine physicians E E E D
and 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
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
experience ; or
A subspecialty resident in pediatric emergency medicine who E
has completed at least one year of subspecialty residency in
pediatric emergency medicine.
A supervising qualified specialist in pediatric emergency E
medicine, or emergency medicine with pediatric experience shall
be promptly available
A supervising qualified specialist on-call shall be notified of all E
patients requiring resuscitation, operative surgical intervention or
ICU admission
!Anesthesiology
Immediately available at all times, may be fulfilled by senior E D D D
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.
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
6
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
~1~"'~'·"",.."J;'1'·¥'\:~~~~I ¢RITE~I~ ~ • .,?.oo.m'n·;i:;J!A;;,.~tlrlllk :ft;r~!:;-~ll!E!Y:eJ r t~t~e l' !Jl!ev~t: ~i!~P"fl ' l!£6vel -• , '"-' " , h C. · t ' ' ;,,..,;_ eve
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
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 sen ior 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 E E E
Qualified non-surgical specialists available for
consultation .
Pediatric trauma centers must have qualified specialists
with pediatric experience, may be provided through transfer
agreement
Cardiology E E
Gastroenterology E E
Hematology E E D
Infectious Diseases E E D
Internal medicine E E D
Nephrology E E D
Neurology E E D
Pathology E E D
Pulmonary Medicine E 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
Rehabilitation/physical medicine E
Pediatric trauma centers -qualified specialists with
pediatric experience shall be on hospital staff and available
for consultation
General pediatrics E
Mental health E
Neonatology E
7
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
-~\~"'¥'~:-..-t-:~-~4~~-CRITERIA~:-~~~~ '}~1~ii.<7?."'·: :!~12£1\~~~~~ 'l:e vtd -.revel l"eviil ·t eJeJ FJi 'e"Vef
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
Nephrololgy E
Pathology E
Pediatric cardiology E
Pediatric gastroenterology E
Pediatric hematology/oncology E
Pediatric infectious disease E
Pediatric neurology E
Ped iatric radiology E
SERVICE CAPABILITIES:
Radiological Service
Radiologist techn ician immediately available in-house, capable E E E D
of performing plain film and computed tomography imaging .
Promptly available -angiography and ultrasound E E E
Radio logical techn ician Qromptly available E E
Clinical laboratory Service
Immediately availab le at all times, and E E E D
Comprehensive blood bank or access to a commun ity cen t ral
blood bank
Type & cross, coagulation studies , micro-sampling E* E* E*
Clinical laboratory Service Promptly Available , and E E
Comprehensive blood bank or access to a community cen t ral
blood bank
Surgical Service
Operating suite ava il able for trauma patient or being utilized E E E E
Operating staff-with trauma education *, Immediately available E
unless operating on trauma patients and backup personnel
[promptly available
Operating staff promptly available unless operating on t rauma E E
[patients and backup staff who are promptly ava ilable
Operating staff who are promptly available E
Appropriate surgical equipment/supplies as dete rmined by E E E E
trauma program med ical director or EMS Agency for Level Ill
Card iopulmonary bypass E
Operating microscope E
Basic Emergency Services
Physician in-house , immediately at all times E E E E
Designate emergency physician to be member of t rauma team , E E E E *
and
Provide emergency medical services to adult and pediatric E E E E
[pat ients, and
8
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL liONS, TITLE 22, CHAPTER 7
-'wl\_'~"f· ~~1~~~i~t~?\·"*·~RI;fERI!4\-~~"1~"-'"'l~.4~~ ii:Eltf!.r 'I.~"\,. I eve lttfvlt Eevt!t P"t ""eY:e.l
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable}
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 service E E E
Appropriate equipment and supplies determined by physician E E E
responsible for intensive care service and the trauma program
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 24/7 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
for acute care of the critically injured patient
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*
equipped for acute care of the critically injured patient
~cute Hemodialysis Capability E E E
9
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
1:"!~""-'<ll "\~,\\~~~~A. ~RilERIJ\'~t~~~!l:;t!:i_,··. >...d..:iD·~."~:.l.!~l 'level; ,rge~el tev@l tWei¥ I ~E£evel ~
I II PEDS Ill IV
(E = essential E*= CCEMSA D = desirable )
Occupational Therapy Service
To 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 for E E E
acute care of the critically injured patient
Social Service E E E D
Services or Programs (Special license or permit not
required)
Pediatric Intensive Care Unit (PICU), E E E
Provided In-house, shall be approved by California State
Department of Health Services' California Children Services
tCCS), or
May be provided by written transfer agreement with an approved E E
PICU, and have established written criteria for consultation and
transfer
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 availability with pharmacist on call E* E* E* D
Shall be in-house within 30 minutes of call E*
Acute 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 community and outlying areas, and
Trauma prevention to the general public E* E* E E*
Public education and illness/injury prevention education
Continuing Education
Continuing education in trauma care shall be provided for: E E E E E
Staff physicians
Staff nurses
10
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
'·' ~t£;~t&~ , .. ' ~ (&l'f'>';j~!r€RJit~RI)t~~:~~lt4~~1;·1:r~~.l>O' ;~6,~~~-.i ~12e~E!l! wtEMJI ltEi!lWt ~tt'e~li!lr *l!eviW CJ;···
I II PEDS .Ill IV
(E = essential E*= CCEMSA D = desirable ·)
Staff aUied health personnel
EMS personnel
Community physicians and health care personnel E E E E E
Trauma physicians ( 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*
Neurosurgeons E* E* E* E*
Emergency Medicine E* 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 and injury prevention;
A suspected child abuse and neglect team (SCAN) E
An aeromedical transport plan with designated landing site; and E
Child Life program
Written lnterfacility Transfer Agreements E E E
Transfer agreements with referring and specialty hospitals
Written transfer agreements with Level or II trauma centers, E
Level I or II pediatric trauma centers or specialty care centers for
the immediate transfer of those patients whose medical care
need additional resources
Written transfer agreements with Levell, II, or Ill 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
am>ropriate 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 interfacility transfers);
lA multidisciplinary trauma peer review committee that includes E E E E E
all members of the trauma team; (CCEMSA * 50% attendance by
reps of Surg, 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;
11
CCEMSA TRAUMA CENTER STANDARDS
SUMMARY OF CALIFORNIA CODE OF REGUAL TIONS, TITLE 22, CHAPTER 7
E = essential E*= CCEMSA D = desirable
Have a written system in place for patient, parents of minor E E E E E
ildren who are patients, legal guardian(s) of children who are
and/or primary caretaker(s) of children who are
to provide input and feedback to hospital staff regarding
to the child·
E E E E E
lnterfacility Transfer of Trauma Patients
atients 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 interfacility transfer
es.
Hospitals shall have written transfer agreements with trauma E E E E E
nters and develop written criteria for consultation and transfer
need in ah her level of care.
ospitals which have repatriated trauma patients from a E E E E E
gnated trauma center shall provide the information required
the system trauma registry, as specified by local EMS agen
icies.
itals receiving trauma patients shall participate in system E E E E E
nd trauma center quality improvement activities for those
ents who have been transferred.
12
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual Policy
Em ergency Medical Services Number 334
Administrative Policies and Procedures
Page 1of3
Subject Trauma Registry Data Collection
References California Code ofRegu1ations, Title 22. Social Security Effective
Division 9. Prehospital Emergency Medical Services
Chapter 7. Trauma Care Systems 12/15/2014
I. 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 defmes the means of collection of data for Quality
Improvement ofthe Trauma System.
II . PROCEDURE
A . EMS AGENCY
I . The EMS Agency shall maintain a Trauma Registry and Trauma Information System . The data
submitted by the hosp itals shall be utilized for trauma system monitoring, evaluation, and research.
Data will be used for periodic reports to the Regional Trauma Audit Committee .
2 . The Trauma Registry will be utilized for quality improvement purposes and will be protected from
disclosure per the California Evidence Code, Section 1157.7. The data base is not subject to the
mandated patient authorization procedures ofHIPPA.
3. Data from the Trauma Registry shall be integrated into the State EMS Authority data management
system as required .
B. TRAUMA CENTERS
Approved By
EMS Director
1. 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 meet the
inclusion criteria for the trauma registry as outlined in Attachment A. Trauma Nurse Coordinators
/Managers or Trauma Registrars at the trauma centers will be responsible for completing the
documentation of registry patients.
3 . Trauma registries should be concurrent . At a minimum, 80 percent of cases must be entered within
60 days of discharge .
Revision
EMS Medical Director
Subject Trauma Registry Data Collection Policy
Number
Page 2 of3
334
4. The completed registry data will 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 Form (Attachment
B) on the following critical trauma patients who present at a non-trauma hospital :
a . Trauma patients meeting any of the trauma triage criteria/destination criteria to a
designated trauma center.
b. Trauma patients with a final disposition to a Trauma Center.
c. Trauma transfers from other facilities .
d . All traumatic arrests , trauma related deaths in the ED or after hospital admission.
2. Completed registry forms will be emailed to the EMS Agency within 60 days of patient discharge ,
transfer or death.
3. The registry form is to be completed by designated personnel from the non-trauma hospital. The
names of designated personnel will be forwarded to the EMS Agency .
D. INSTRUCTIONS FOR COMPLETION OF THE NON-TRAUMA HOSPITAL PATIENT REGISTRY
FORM
1. Section 1 -Identification
a . EMS Number
b. Incident 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 patient.
e . Date of birth
f. Age: Enter 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 ED.
b. Time of Arrival: Enter time of arrival to the ED .
c . Method of Arrival : Check applicable; if "Other'', describe .
d. Mechanism of Injury: Check one ; if"Other'', describe .
Subject Trauma Registry Data Collection Policy
Number
e. Vital Signs Upon Arrival: Enter initial GCS and vital signs taken in the ED.
Page 3 of3
334
f. Procedures: Check any applicable procedure and enter time; if"Other", describe.
1. Blood products: Enter time of first unit and the total number ofunits
given, if any products were given .
g . Injuries : Check applicable .
1. All trauma related hospital admits with at least one injury ICD-9
diagnosis code between 800 .0-959.9.
3 . 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(s) 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 transferred to inpatient unit): Check if applicable, enter
time, and specify destination under comments.
g. Ground Transport: Check if applicable, and enter time.
h . Air Transport: Check if applicable, and enter time.
i. Other: Check if applicable, enter time, 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 Bank (NTDB) Data Dictionary and the State of California
Data Dictionary.
I. All trauma related hospital admits with at least one injury ICD-9 diagnosis code between 800.0-959.9
A. Fractures (all)
B . Dislocations (all)
C. Intracranial injuries (all-includes concussion)
D. Internal injuries of chest, abdomen, and pelvis
E . Open wounds
F . Injuries to blood vessels
G . Crushing injuries
H . Bums (bum registry)
I. Injuries to optic nerves
J. Spinal cord injuries
K. Certain traumatic complications
1. Air/fat embolism
2 . Secondary and recurrent hemorrhage
3 . Post traumatic wound infection
4. Traumatic shock
5. Subcutaneous emphysema
L. Excludes :
1. 905-909 (late effects of injury-defmed as "those things that occur at any time after an acute
injury)
2 . 910-924 (blisters , contusions, abrasions , ins ect bites)
3. 930-939 (foreign bodies)
4 . Isolated sprains/strains/contusions
2 . All injury-related deaths in ED or after admission
3. All trauma transfers from other facilities
ATTACHMENT B
CENTRAL CALIFORNIA EMS AGENCY
NON-TRAUMA HOSPITAL PATIENT REGISTRY FORM
1. IDENTIFICATION
EMS Number -----------
Incident Location----------
Hospital -------------
Patient--------------
DOB ________________________ _
Age _______ _ Male 0 Female 0
2. EMERGENCY DEPARTMENT ADMISSION DATA
Date of Arrival -----'--------------
Time of Arrival ---------------
Method of Arrival:
Walk-in 0 BLS Ambulance 0
ALS Ambulance 0 Air Ambulance 0
Other 0 If other, describe:
Mechanism oflnjury:
Motor Vehicle Crash 0 Motorcycle 0 Bicycle 0
Pedestrian 0 Assault 0 Stabbing 0 Gun Shot o
Ground Level Fall 0 Fall from Height 0 Sports 0
Industrial 0 Farming 0
Other 0 If other, describe :
Vital Signs Upon Arrival:
Eyes :___ Verbal: ____ Motor: __ __
GCS :
HR:
Procedures:
Intubation 0
CT Scan o
Other 0
RR : BP:
Blood Products 0
#of Units Given
Chest Tube o
If other, describe :
Injuries: (lCD -9-CM 800-959.9)
Fractures:
Skull 0 Neck/Spine 0 Limbs 0
Dislocations 0 Intracranial Injury 0 Sprains/Strains 0
Open wounds 0 Bums 0 Foreign Body 0
Internal Injury to: Chest 0 Abdomen 0 Pelvis 0
Injuries involving: Blood Vessels 0 Crushing 0
Optic nerves 0 Spinal Cord 0
3. EMERGENCY DEPARTMENT DISPOSTION
AdmitO Transfer to Tr~uma Center ED 0
OR 0 Interfacility Transfer 0
OR Disposition : Ground Transport 0
Admit o Air Transport 0
Transfer 0 Other o
Discharged Home 0 __ _
Please include comments concerning difficulties with the interfacility
transfer arrangements, procedures, patient care, etc.
4. COMMENTS
Submitted by: ___________________________ __
Within 30 days of patient discharge, transfer or death, email the
completed form to Daniel Brown at dbrown!7i)co.frcsno.ca.us
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual:
Emergency Medical Services
Administrative Policies and Procedures
Subject: Continuous Quality Improvement
References: Division 2.5 of the California Health and Safety Code
Title 22, Division 9 of the California Code ofRegulations
Section 1157 .7 ofEvidence Code
I. POLICY
Policy
Number: 703
Page: 1 of7
Effective:
08/07/00
This policy describes the roles and responsibilities of all Central California EMS System participants in the provision
of Continuous Quality Improvement (CQI). All EMS provider agencies shall meet the requirements of this policy.
II . PURPOSE
"Continuous Quality Improvement" or "CQI" means methods of evaluation that are composed of structure , process, and
outcome evaluations which focus on improvement efforts to identify root causes of problems , intervene to reduce or
eliminate these causes, and take steps to correct the process .
III . PROCEDURE
The EMS Agency is responsible for the oversight and supervision of the entire CQI process and communicating with all
involved participants.
A. EMS Agency CQI Medical Director/Coordinator responsibilities include :
Approved By:
1. 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 QI Reports and take necessary action .
5. Provide an access point for Internal/External Customers as identified in Section III.F.
6. Create an Investigative Review Panel (IRP), as needed, to provide a grievance process for EMS
personnel in accordance with State guidelines and requirements (Refer to Section III.G .).
7 . Monitor quality indicators via database analysis as identified in Appendix A .
8 . Review and participate in research generated by the CQI process.
-•I
Revision:
EMS Division Manager I~CJ ~
3/3/2008
EMS Medical Director
Subject: Continuous Quality Improvement
9. Forward CQI Committee recommendations to EMS Training Division.
10. Manage EMS database to assure quality and completeness of databases.
Page 2 of7
Policy
Number: 703
B. 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
on 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."
1. Review/Monitor Data from EMS System (Ill. C).
2 . Select quality indicators , items for review and monitoring, create action plans, and monitor
performance (i .e., time , patient satisfaction, workforce satisfaction, protocol compliance, outcome
data). (See Appendix A.)
3. After review by EMS Agency, serve as a forum to discuss issues/concerns brought to the attention of
the EMS Agency by internal and external customers (ill. F .).
4 . Propose, review, and participate in EMS research.
5. Promote CQI training throughout the EMS System
6. Policy/Protocol Review-Selected policies reviewed with prenotification sent out to allow participant
feedback. Initial review by CQI Coordinator/Medical Director and proposed revisions discussed at
CQI Committee .
7 . Provide recominendations 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 Department/Schools/Provider Agencies)
3) AED (AED Provider Agencies)
4) Emergency Medical Dispatcher Training
5) Mobile Intensive Care Nursing Training
6) Base Hospital Physician Course
c. Continuing Education
1) Case Review!Tape Review
Subject:
Page 3 of7
Continuous Quality Improvement Policy
Number: 703
2) Provider Agency C.E .
3) EMS C.E. -Topics Based on CQI identified deficiencies.
8. CQI Committee Members
a. CQI Medical Director
b. CQI Coordinator
c. Base Hospital Physician (chosen by Medical Control Committee)
d. PLN -(chosen by Base Hospital Committee)
e. PLO -(Three -preferably one from each County)
f. EMS Dispatcher
g. Fire First Responder (chosen by Fire Chiefs Association)
9. CQI Committee Ex-Officio Members
a . EMS Medical Director
b. EMS Division Manager
10. CQI 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
EMS (see list below). These databases must be searched to :
1. Prospectively identify areas of potential improvement.
2. Answer questions about the EMS System.
3. Monitor changes once improvement plans are implemented.
4. Provide accurate information enabling data driven decisions.
5. Monitor individual performance within the EMS System.
6. Support research that will improve our system and potentially broaden EMS knowledge through
publication.
7. The involved databases include:
a. Dispatch Database
b . First Responder Database
c . EMT-D Database
d. PCR Databases
e. Hospital Databases
f. QI Database
g . Trauma Registry
h. County Coroner's Reports
Subject: Continuous Quality Improvement
Page 4 of7
Policy
Number: 703
D . Individual Quality Improvement Reports
Individual quality improvement reports are generated by anyone in the EMS System and are reviewed at the
Base Hospital Physician level as well as by the EMS Agency.
E. EMS Research
Any parties interested in EMS research may participate. Leadership is expected from EMS Medical
Directors and Senior EMS Specialists with EMS Division Manager and Medical Control Committee
approval.
F. Internal/External Customers
Various entities interact with the EMS System In order to allow input from these sources, the CQI process
may be accessed via the EMS Agency who will determine if the issue raised will be put on the CQI
Committee Agenda .
I . Internal Customers
Paramedics/EMT-Ils/EMT-Is/First Responders
MICNs/Flight Nurses
Dispatch Personnel
EMS Students
Ambulance Providers
EMS Committees
Hospitals
State/Regional EMS Personnel
UCSF Residency Personnel
Base Hospital Physicians
2. External Customers
Patients
Patients' Families
Community/Public
Third Party Payors (Insurance Companies , HMOs)
Government Agencies (Public Health Department, Police, etc.)
Nursing Homes
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 EMS System policies and procedures, which may
be convened to review 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.
Subject: Continuous Quality Improvement
APPENDIX A
Page 5 of7
Policy
Number: 703
Quality Indicators
The following quality indicators are monitored on 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. AMAIRASIRMCT Ratios (at each Base Hospital)
2 . Medical Scene Times (<20 minutes) 2. Codes (compliance with times in protocol)
3 . Cardiac Arrest Survival Rates 3. Nature of Incident Frequency on QA Reports
4 . Trauma Survival Rates 4 . Pediatric Survival Rates
5 . Percentage of Unrecognized Esophageal Intubation 5. Prehospital Violence
6. 90% Successful IV after Three Attempts
7 . 95% Successful ET Placement after Three Attempts
Data to Determine Performance Excellence:
1. 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. Are data and information used in planning and operation?
6. Do all workforce members understand and use available data?
7 . Have CQI efforts been successful at improving performance?
8. Are changes in one critical performance indicator affecting other areas?
9. Are QI resolutions communicated to all involved parties?
Subject: Continuous Quality Improvement
APPENDIXB
CQI Skills Retainment Requirements
EMT -IIIEMT -PARAMEDIC
A. Patient Contact Requirement
Page 6 of7
Policy
Number: 703
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 EMT-Ils or EMT-Paramedics
maintain adequate patient assessment and other ALS skills, the EMS Agency acknowledges the importance of minimum
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
20 patient contacts per month (240 per year) while working on an approved Central California County ALS unit. A
written statement from the employer shall be submitted to the Central California EMS Agency by March 20th of each
year.
A patient contact is defined as a patient who is completely assessed by an on-duty EMT-II or EMT-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-II or EMT-Paramedic does not achieve the 240 patient contacts (or prorated amount authori z ed
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 EMS 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 performed by an approved Central California EMS Training Officer. EMT-Ils or
EMT-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) months (Deadline-September 20th and March 20th).
EMT-Ils or EMT-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 will consist of an EMS Training Officer observing an EMT-II or EMT-Paramedic conducting three (3)
patient assessments. The EMS Training Officer will evaluate the EMT-II 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 EMT-II or EMT-
Paramedic. Possible actions by the Central California EMS Agency in the case of an unsatisfactory evaluation include
reevaluation, additional training, or initiation of the formal investigation.
C. ACLS Requirement
Within two (2) years of initial accreditation, the EMT-Paramedic shall demonstrate proof of current certification and
continued certification as an Advanced Cardiac Life Support (ACLS) 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 .
Subject: Continuous Quality Improvement
D. BTLS/PHTLS Requirement
Page 7 of7
Policy
Number: 703
Within two (2) years of initial accreditation, the EMT-Paramedic shall demonstrate proof of satisfactory completion of a
Basic Trauma Life Support (BTLS) course according to the standards of the American College of Emergency Physicians,
or Prehospital Trauma Life Support (PHTLS). 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 the
EMS Medical Director for remedial education as a condition of accreditation.
AED SERVICE PROVIDERS
A . Skills Proficiency
AED service providers shall assure that all AED authorized personnel have proven AED skills proficiency at least once
every six (6) months. AED service providers shall maintain documentation of such skill proficiency exams and provide
copies to the AED Base Hospital and EMS Agency upon request.
B. Case Review
AED service providers shall provide AED authorized personnel with no less than four (4) hours of AED case review every
two (2) years. Attendance documentation shall be forwarded to the AED Base Hospital. AED case review 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-1 recertification.
C . AED Refresher Course
AED Service provider personnel shall complete a two (2) hour AED refresher course, which can be included in an EMT-1
refresher course and/or required EMT-1 continuing education. The refresher course shall include the successful
completion of an AED written and skill examination approved by the Central California EMS Agency. This should be
completed at a minimum every 2 years in conjunction with EMT-1 recertification or refresher training for First Aid.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual:
Emergency Medical Services
Administrative Policies and Procedures
Subject: Quality Improvement Reporting
References: California Administrative Code , Title 22, Division 9, Chapter 3
I. POLICY
Policy
Number: 704
Page: I of 13
Effective:
02/03/86
Any unusual occurrence involving EMS personnel or operations will be reported according to the following
procedures.
II. PURPOSE
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.
III. PROCEDURE
The intent of the QI process is to learn from the issue or incident in order to improve future performance. Therefore,
every attempt should be made to discuss the issue(s) frrst with all parties involved prior to initiating the QI process.
This may provide insight to all parties concerned, as well as an immediate educational benefit to the EMS system.
The author will notify his/her supervisor, Prehospital Liaison Nurse (PLN) or Prehospital Liaison Officer (PLO) of
the incident. QI Reports may also be initiated through customer complaints received by provider agencies,
hospitals, or the EMS Agency. The supervisor or PLN/PLO will 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 PLN/PLO will notify the QI Coordinator at the EMS Agency by
the next 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 form to 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).
IV . FORMS/CHARTS
The documentation forms, 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 ofRegulations, Title 22, Division 9 .
Approved By Revision
EMS Division Manager
10/01/2004
EMS Medical Director
Page 2 of 13
Subject Quality Improvement Reporting Policy
Number 704
A . Quality Improvement Report Form (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, EMS personnel may write (ink only) or type their response on a separate piece of paper and attach
it to the original QI 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 Form (Attachment B)
This form is initiated by the Agency PLN/PLO upon receiving a QI Report. The form is designed to track
the QI Report using the successive available lines in the Routing/ Actions Taken section. The PLN/PLO
will forward this form, along with the QI Report, to involved agencies, until its final destination at the EMS .
Agency.
C. Category Definitions and Examples (Attachment C)
The QI 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.
1. Emergent-Issues that contributed to a ne gative 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 neces sarily contribute to a negative patient outcome . These
incidents require immediate notifi cation of the EMS Agency.
2. Non-Emergent-Issues that did not contribute to a negative patient outcome and do not require
immediate notification of the EMS Agency.
D . Quality Improvement Flow Chart (Attachment D)
This form is an overview of the QI process from the initiation of a QI Report to its resolution. Agency
PLN/PLOs should follow progressive steps and timelines of the CQI process closely to ensure a resolution .
V . DOCUMENTATION
A . Quality Improvement Report
I. 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 CALIFOR,~]A
EMERGE.~CY 1\'lEDICAL SERVICES
COUNTY INVOLVED:
~FRESNO 0KINGS 0MADERA QTCLARE 0 OTHER _______ _
CONFJOE.'ITIA L
{In o\l'CIIrtbTIC'l' ~tb l)lhrmm, l "'~J ~ Ser.mm ~6. et s.rq. Ca.titr.nua J:hidt>n:e.Code: Stcri~ l t>:Kl
aodS«liu:t 11!7. d t:b:~,. .. l ~~flrntJ t \-.taeo! K ~1bl lm~ "1\lk 7.:!,.Ui "-kit "' 'I ]
QUALITY IMPROVEMENT
REPORT
Section A-I
Page 3 of 13
Subject Quality Improvement Reporting
2. Section A-II
Policy
Number 704
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.
Incident Logisdcs
Call Location: _________________ _
Date: ______ -'-------Ti me: _____ _
EtvlS Disp . It:. ______ _
Locntion: 0 On Scene 0 Enroutc
0 At Hospital 0 Other
Pati en t Name : _____________ _ Mcd. Record# o r DOB :. _______________ ------
PCRJBHRR # (Att:lch Copy}:---------
Persound Involved
·····--------···------·---------------
Section A-ll
3 . Section A-III
))ismsRed with Individual
0 Yell 0 No
0 Yes 0 No
0 Yes 0No
0 Yes 0 No
0 Yes 0No
0 Yes 0 No
0 Yes 0 No
This area serves as a reminder that notification of your supervisor/PLN/PLO is required, and to
allow for tracking of that process .
a. The frrst step to initiate the QI process is to notify your On-Duty Supervisor/PLN/PLO.
This should be done ve rbally, with the following information written on the QI Report
document.
l'rimarv Traeking
Dme & Time On -Duty Supervisor /PLN/PLO Notified:-----------------
Name & Title of I ndividua l Contacted:-----------------------
Section A-III
4 . Section A-IV
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 to submission .
Page 4 ofl3
Subject Quality Improvement Reporting Policy
Number 704
Special Note: The date the QI Report was written and when it was actually submitted should be
no more than 24 hours between the two . All QI Reports must be turned in by the
end of your shift, or within 24 hours after the incident .
Author Information
Signature:---------------Date :----·---·-------
Print Name:---------------C~.#: ---------------
Agency/Facility :--------··· ... ·····--Date Submitted co PLOIPLN: -------
Section A-N
5. Section A-V (See Attachment A back)
This 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. Key Issue: This is to be one to two sentences in length and highlight the primary
point/concern (i.e ., Policy issue -Med 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 Ql Report and should contain factual
statements, free from subjective insight or politically motivated innuendos. Attempt to
stay focused and concise .
c. Proposed Resolutions : 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 .
B. Quality Improvement Tracking Form
This form is utilized by the PLN/PLO to track the QI Report. The Tracking Form is initiated at the time the
PLN/PLO receives the Ql Report from the author. The document becomes the record of all activities or
actions. The Tracking Form is divided into four (4) sections .
1. Section B-1
This section identifies the demographics of the Ql incident. This area should be completed as
soon as possible, with the QI number being obtained by the EMS Agency by the next working
day.
Incident Logistics:
Countyllwolved: QFRESNO Q KJNGS O .rvtADERA 0TULARE OOTHER. ___________ _
Status : Date Open :------------Date Clos.ed: -------------
lncillonl Date and Time:-------------&~$# ______________ __
lncidentLocation: ----------------------------------
Description :----------------------------------
Section B-1
Page 5 of 13
Subject Quality Improvement Reporting
2. Section B-II
Policy
Number 704
Tiris section classifies the type of issue in the QI incident to allow for easier categorization.
h'sue(s ):
0 Airway
0 Alvf,.VRAS
0 Olcll-ln
D Destination
0 Dispatch
0 DOc.umenmtion
0 Equipment Failure
0 Equipment Utilizution
0 Call -In
3. Section B-Ill
0 Hospital P.i'fc rsi on
0 Iri~pproptiate Behavior
0 Tn!c~"TSOll!JI . D Mappow er!Re~ource Utlli_iaiion
D .f\1C.I
0 Me<;li<:AI 4 ont:roJ. D M.ediciiUon Broken
0 Mc<lie<ationError
0 MediCt)Uml Mi ssi ng
Section B-II
0 Pa.ti cnt A~~Sessmcnl
D Patient Tronsfer
D Parient~t!J')e!lt'
0 Patient Th(novcr
D Physician lssues
D Policy Clarification
D Scope of ?ta~ticc
D Other:-----
This section documents the routing of the CQI process . The PLN/PLO should document all
activities on the line provided pertaining to the incident (i.e., received, forwarded,
recommendation, action). The date and initials of the PLN/PLO making the actions should also be
written .
RoutinglActious 'fnkcn:
~ ~ Fn vd Rcmd Ac tion
0 D 0 0
0 0 0 D
0 0 0 0
D 0 0 0
0 0 0 0
0 0 0 D
0 D D 0
Section B-Ill
4 . Section B-IV
The resolution area is the responsibility of the EMS Agency to complete and signifies conclusion
of the QI issue within the CQI process. The EMS Agency will notify the involved agencies of the
final resolution.
Resolution: (EMS Agency Only)
0 C ri ti que
0 Certification .Action
OEMT-1 OEMT-ll
0 lntem 0 lnre1im
0 Suspen si on
0 EducntiOJ'IOl Feedback
0 Written 0 Meeting
0 Forrn.al Investigation
0 NoAction
0 Policy/Procedure Rel"ision
0 Probttti.on
0 Remed ia l Rducatio n
0 Fonnal l ns trac ti on
0 Policy Review
0 Protocol Review
0 Refe;red m Srate
Section B-IV
0 Ve rbal Reprimand
0 WriUt:J\ Rr.pon
0 Wriuen Reprimand
OOthcr: ____ _
-----------
Page 6 of 13
Subject Quality Improvement Reporting Policy
Number 704
VI. RESOLUTION OF QUALITY IMPROVEMENT INCIDENT
A. Investigative Process
1. 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 22, Division 9 of
the California Code of Regulations (Emergency Medical Personnel Certification Review Process
Guidelines). PLNs and PLOs will assist the EMS Agency during the investigative process.
B. Determination of Appropriate Action
1. The EMS Medical Director or designee shall determine what action, if any, should be taken as a
result of the fmdings 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 of, or applicant for, a prehospital
EMS certificate .
3 . Resolution will be determined by the following steps :
a. Critique -The EMS Agency will review all documents, 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 QI Tracking Form. However, an agency resolution is independent
from any resolution prescribed by the EMS Agency.
b . The EMS Agency will resolve QI 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
lSSUe.
2) Policy/Procedure Revision-QI issue is resolved with revision to EMS Policy
and Procedure Manual or treatment protocols.
3) Educational Instruction -The appropriate EMS Medical Director will give EMS
personnel feedback on the QI document to be reviewed by involved individuals
and PLN/PLO .
4) Meeting-A meeting will take place with involved individuals and the EMS
Medical Director or designee to discuss the issues and additional actions to
resolve .
5) Remedial Education-Prescribed by EMS Medical Director to correct
deficiencies. This may include written report, giving 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 of a formal investigation.
Page 7 of 13
Subject Quality Improvement Reporting Policy
Number 704
6) Written/Verbal Reprimand-This action will be documented and placed in
individual's EMS training/accreditation file . May also be utilized for
reoccurring deficiencies that cannot be corrected with remedial education.
7) Referred to the State EMS Authority -Any incident which is a serious threat to
public health and safety and/or 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 license holder on probation.
b) Suspension oflicense/certification.
c) Revocation oflicense/certification.
d) Denial of license/certification.
e) Denial of renewal or license/certification.
C. Formal Investigation Process
A formal investigation is an official investigative process, which is specifically outlined in Title 22,
Division 9 ofthe California Code of Regulations.
D. Grounds for Disciplinary Action
A determination by the EMS Medical 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. Notification of Resolution
1. Formal Investigation-The EMS Medical Director or designee shall formally notify the
individual(s) involved in accordance with Title 22, Division 9 of the California Code of
Regulations .
2. Routine Investigations-The EMS QI Coordinator will send a letter identifying QI incidents that
have been resolved and closed to each provider or hospital agency.
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
:OUNTY INVOLVED:
D FRESNO D KINGS D MADERA D TULARE
OOTHER ______________ __
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. #: _______ _
Time: DMe: ______________________________ __ -------------Location: 0 On Scene D Enroute
0 At Hospital D Other
Patient Name: ---------------------------------Med. Record# or DOB: __________ _
PCR/BHRR #(Attach Copy): ________ _
Personnel Involved Agency Discussed with Individual
0 Yes 0No
0 Yes 0No
0 Yes 0No
0 Yes 0No
0 Yes 0No
0 Yes 0No
0 Yes 0No
Primary Tracking
Date & Time On-Duty Supervisor /PLN/PLO Notified :---------------------
Name & Title oflndividual Contacted: ----------------------------
Author Information
Signature: ________________________________ __ DMe: _____________ __
Print Name: ------------------------------Cert .#: ___________ _
Agency/Facility: ----------------------------Date Submitted to PLO/PLN: ------
(Utilize the back o f this fo rm to elab orate your concerns & re solution)
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)
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
QI#: _____ _
CONFIDENTIAL
(In Accord ance with Californi a Civil Cod e Sec ti on 56 , et seq, Cali fornia Evidence Code Section 1040
and Section 1157 , et se q , an d Ca liforni a Code of Regulations , Title 22, Division 9)
QUALITY IMPROVEMENT
TRACKING FORM
(Information for Attorneys representing the Central California EMS Agency)
Incident Logistics:
County Involved: D FRESNO D KINGS D MADERA D TULARE D OTHER ______ _
Status: Date Open: Date Closed: ----------------------------------------------------
Incident Date: ---------------Incident Time: ---------------EMS# _______ _
Incident Location: ------------------------------------------------------------------
Description: ---------------------------------------------------------------------
ssue(s):
D Airway
D AMA/RASIRMCT
D Call-In
D Destination
D Dispatch
D Documentation
0 Equipment Failure
0 Equipment Utilization
D Call-In
Routing/ Actions Taken:
Date Rcvd Frwd
D D
D D
D D
D D
D D
D D
D D
Rcmd
D
D
D
D
D
D
D
D Hospital Diversion
D Inappropriate Behavior
D Interpersonal
D Manpower/Resource Utilization
D MCI
D Medical Control
D Medication Broken
D Medication Error
D Medication Missing
Action
D
D
D
D
D
D
D
D Patient Assessment
D Patient Transfer
D Patient Treatment
0 Patient Turnover
D Physician Issues
D Policy Clarification
D Scope of Practice
D Other: _____ _
Initial
Routing/Actions Taken:
Date Rcvd Frwd Rcmd
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
D D D
Comments:
Resolution: (EMS Agency Only)
D Critique
0 Certification Action
DEMT-1 DEMT-11
D Intern 0 Interim
0 Suspension
0 Educational Feedback
D Written D Meeting
D Formal Investigation
Action
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
0 No Action
0 Policy/Procedure Revision
0 Probation
0 Remedial Education
0 Formal Instruction
0 Policy Review
0 Protocol Review
0 Referred to State
Initial
0 Verbal Reprimand
0 Written Report
0 Written Reprimand
0 Other: ____ _
Page 12 of 13
Subj ect Quality Improvement Reporting
Category and definitions are as follows:
CATEGORY NON-EMERGENT
TIME FRAME 60 Days
DEFINITIONS Issues that did not contribute to a negative
patient outcome and do not require
immediate notification.
EXAMPLES Attaboys/ Acknowledgement
Broken/Missing/Controlled Medications
Destination Issues
Education Issues
Equipment and Stocking Issues
Interagency Issues
Interdepartmental Issues
Interpersonal Issu es
PCR Documentation
Policy Clarification
Policy Deviation
Radio Communications
Tracking Purpose s
Unusual Occurrence
(Attachment C)
Policy
Number 704
EMERGENT
60 Days
Issues that contributed to a negative
patient outcome, grossly inappropriate
behavior, or issues with potential threat to
public health and safety.
Negative Patient Outcome Issues:
Equipment and Stocking Issues
Patient Assessment/Priority Setting
Medication Errors
Medical Treatment
Private Party Complaints
Policy and Procedure Deviations
R ecurrent Problems (Individual and
System)
T echnical Skills Issues
Grossly Ina:m2ro.Qriate Behavior Issues
Fraud
Gross Negligence
Insubordination
Patient Abuse
Substance Abuse
Unprofessional/Irrational Behavior
Page 13 of 13
Subject Quality Improvement Reporting
Non-Emergent
Policy
Number 704
Author's PLO/PLN or Designee
Reviews Report
Author's PLOIPLN or Designee
Prioritize Report
Immediately Notify On-Call
EMS Agency Staff and
PLO/PLNor
Designee of Other
Can Issue be Addressed at this
Level?
Involved Agency(s) Submit All
Reports/Documentation to EMS Agency
First 20 Days
EMS Agency Reviews and Implements
Appropriate Action
Feedback to Author
Forward
ReporVDocuments to
EMS Agency
Author's PLO/PLN
Up from Other Involved
Agency(s) PLO/PLN
Author's PLO/PLN
Documents Resolution and Forwards to
PLO/PLN of Other Involved Agency(s)
PLOIPLN for Counter-signature
Involved Agency(s) PLO/PLN
Research and Discuss
Resolution
Signed Documents Returned to Authoring PLO/PLN
Authoring Agency PLO/PLN Forwards
Report(s)/Documents to EMS Agency
EMS Agency Notifies Involved
Agency(s) of Closure
EMS Agency Notified Involved
Agency(s) of Closure
EMS Agency
Ca talogs and
Files
EMS Agency Provides Follow-Up to
Involved Agency(s) PLO/PLN
F irst 40 Days
Authoring Agency PLO/PLN Collects All
Reports/Documentation and Forwards to
EMS Agency for Review and
Recommendation
First 60 Davs
EMS Agency Forwards its Recommendations to
Involved Agency(s) PLOIPLN
Agency(s) PLOIPLN Implement
Recommendations
Involved Agency(s) PLO/PLN Forwards
Documentation to EMS Agency that
Recommendations Implemented/Completed
Author Notified of Final Resolution
EXHIBIT B
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Manual Policy
Emergency Medical Services Number 311
Administrative Policies and Procedures
Page 1 of4
Subject Base Hospital Criteria
References Title 22, Division 9, Chapter 4, Article 7 Effective
01/01182
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.
II. PROCEDURE
A. BASE HOSPITAL MUST:
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. Have a special permit for basic or comprehensive emergency medical service pursuant to the
provisions ofTitle 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 of all 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 OPERATIONAL REQUIREMENTS
Base Hospitals designated as such and under contract with the EMS Agency must comply with the
following requirements:
Approved By
J/LJqdL
Revision
EMS Division Manager 04/01/2007 v ,,.....,.
EMS Medical Director ~~
Page 2 of4
Subject Base Hospital Criteria
1. Operations
Policy
Number 311
a. Procure operational radio communications equipment meeting specifications established
by the County and install such equipment in the Emergency Department, for the pmpose
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. Maintain written records of Base Hospitallprehospital 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. Have a telephone immediately available in the Emergency Department for exclusive use
in contacting a Receiving Hospital to provide medical information on patient's emoute to
the receiving facility .
f. Designate a Mobile Intensive Care Nurse certified by the EMS Agency who is employed
by the Base Hospital as a Prehospital Liaison Nurse for the hospital.
g . Designate an Emergency 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 EMS Policy.
1. Utilize the following which have been approved by the EMS Medical Director:
I. Paramedic Field Treatment Protocols and Guidelines
2. Base Hospital Report Form
3. Patient Care Report (Field Assessment Form)
J. Cooperate with the EMS Agency in gathering and providing statistics and information
needed for monitoring and evaluating EMS 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.
1. 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.
m. Participate in EMS public education programs.
C. NEW BASE HOSPITALS
Newly designated Base Hospitals must establish a Base Hospital Committee within the hospital
composed of, at a minimum, the Base Hospital Medical Director, the Prehospital Liaison Nurse
Subject Base Hospital Criteria Policy
Number 311
Page 3 of 4
and a representative ofhospital administration to meet and confer regarding operations of the Base
Hospital and maintain liaison with members of the Prehospital Care Team and the EMS Agency.
This committee will meet regularly for one year, or until Base Hospital operations are running
smoothly, whichever is longer.
D. BASE HOSPITAL STAFFING AND PERSONNEL
The Base-Hospital shall have:
1. A currently certified Mobile Intensive Care Nurse or Base Hospital 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.
2. A Certified Base Hospital Physician available at all times to provide immediate medical
direction to the Mobile Intensive Care Nurses and/or prehospital personnel or
interfacility.
E. BASE HOSPITAL EDUCATION PROGRAMS, EVALUATION, AND QUALITY
IMPROVEMENT
The Base Hospital will:
1. Provide for the continuing education of certified prehospital personnel and Mobile
Intensive Care 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.
2. Encourage prehospital personnel to attend in-house lectures, classes, demonstrations, and
seminars which have been approved in advance by the EMS Agency for continuing
education credits .
3. Provide patient follow-up information for purposes of education to paramedics.
4. Recommend Mobile Intensive Care Nurses for certification and recertification .
6. 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 HOSPITAL INTERFACE WITH EMS 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, Emergency Medical Care
Committee, and Continuous Quality Improvement.
Page 4 of4
Subject Base Hospital Criteria Policy
Number 311
2. Base Hospitals will be authorized through agreements between the approved hospital and
the EMS Agency.