San Francisco Ems Agency Policy Manual
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SAN FRANCISCO EMS AGENCY POLICY MANUAL TABLE OF CONTENTS November 1, 2015 POLICY POLICY TITLE EFFECTIVE NUMBER DATE Section 1: EMS System Organization and Management 1000 Policy Development Process 09/09/13 1010 Advisory Committees 09/09/13 1020 Glossary 01/01/11 Section 2: Personnel & Training 2000 Prehospital Personnel Standards and Scope of Practice 05/15/10 2001 Use of Standard and Special Circumstance Treatment 01/01/11 Protocols 2010 Public Safety First Aid Training and Approval 08/01/08 2020 EMT-1 Program Approval 01/01/11 2030 Paramedic Program Approval 01/07/13 2040 EMT-1 Certification 09/09/13 2050 Paramedic Accreditation 02/01/15 2051 Preceptors for Paramedic Student Interns 09/09/13 (formerly called Paramedic Preceptor and Evaluator) 2052 Paramedic Field Supervisor 09/09/13 2060 Continuing Education Approval 12/01/04 2070 Certificate/License Discipline Process for Prehospital 11/01/10 Personnel Section 3: Communications 3000 Medical Dispatch Center Standards 09/09/13 3000.1 Medical Dispatcher Standards 09/09/13 3010 EMS System Communications Standards 08/01/07 3011 Communication Drills 09/01/09 3020 Field to Hospital Communications 08/01/07 Section 4: Response and Transportation 4000 Prehospital Provider Standards 09/01/11 4000.1 Ambulance Turnaround Time Standard 11/01/15 4001 Vehicle Equipment and Supply List 07/01/14 4002 Controlled Substances 09/09/13 Page 1 of 2 4010 Integrated Response Plan 08/01/08 4020 EMS Aircraft Utilization 02/01/15 4030 Intercounty and Bridge Response 08/01/08 4040 Documentation Evaluation and Non Transport 02/01/09 4041 Scene Management, Physician on Scene, Mass Gatherings 02/01/09 4043 Use of Physical Restraints 01/01/11 4050 Death in the Field 02/01/09 4051 Do Not Resuscitate (DNR) Policy 01/01/11 4070 Critical Care Transport-Paramedic Program Approval 08/01//08 4071 CCT-P Optional Scope of Practice 08/01//08 4072 Bariatric Patient Transports 10/01/11 Section 5: Hospitals and Critical Care Centers 5000 Destination Policy 02/01/15 5000.1 Destination Chart 02/01/15 5001 Critical Trauma Patient Destination 01/07/13 5010 Receiving Hospital Standards 09/01/09 5011 Base Hospital Standards 08/01/08 5012 Pediatric Critical Care Standards 08/01/07 5013 Trauma Center Designation 02/01/04 5014 Level 1 Trauma Care Standards 09/01/05 5015 Stroke Center Standards 08/01/07 5016 STAR Center Standards 01/07/13 5020 Diversion Policy 08/01/12 5021 Emergency Trauma Center Bypass Policy 02/01/09 5030 Interfacility Transports 08/01/08 5040 Emergency Department Downgrade 08/01/07 Section 6: Quality Improvement 6000 Quality Improvement Program 08/01/08 6010 Local EMS Information System (LEMSIS) 08/01/08 6020 Incident Reporting 08/01/07 6030 Research Studies 08/01/08 6040 Pilot Programs 08/01/08 Section 7: Community Programs 7010 Emergency Medical Services at Mass Gatherings and 05/23/12 Special Events Section 8: Disaster 8000 EMS MCI Policy 09/02/14 8050 Hazardous Materials Incident Field Policy 09/01/09 Page 2 of 2 Policy Revision Policy Action Number Title Taken Details 4000.1 Ambulance New Policy Issue: Delays in ambulance patient off-loads at hospitals may affect EMS Turnaround ambulance availability and response times. Standard Recommendation: Improving ambulance patient offload times is one part of an overall comprehensive effort to improve SF EMS response times. Background: This policy defines standards for the ambulance turnaround and patient offload times. The time intervals were adapted from the California Hospital Association August 2014 guide entitled, “Toolkit to Reduce Ambulance Patient Off-Load Delays.” Page 1 of 1 Section 1: EMS System Organization and Management SAN FRANCISCO EMERGENCY MEDICAL SERVICES AGENCY Policy Reference No.: 1000 Effective Date: September 9, 2013 Supersedes: January 1, 2011 POLICY & PROTOCOL PUBLIC COMMENT PROCESS I. PURPOSE To define the San Francisco Emergency Medical Services (EMS) Agency public comment and approval process for policies and patient treatment protocols. II. POLICY A. The EMS Agency is responsible for developing and updating policies and protocols for the administration and operations of the EMS system. By state statute, the EMS Agency Medical Director retains the final decision through his/her medical authority in matters pertaining to the planning, implementation and evaluation of the EMS system including all EMS policies and protocols. The EMS Agency shall follow the procedures outlined in this policy for public comment and approval of new or revised policies or patient treatment protocols. For brevity, the term “policy” is used to mean either policy or protocol in this policy. III. PUBLIC COMMENT PROCESS A. All new or significantly revised current policies are released via email and posted on the EMS Agency website for public review and comment prior to becoming effective. Written comments are due at the EMS Agency by the date listed on the public comment notice and webpage. The EMS Agency allows a minimum of 14 days for public comment. B. All comments received during the comment period will be reviewed by the EMS Agency Medical Director for either inclusion or exclusion in the policy. A summary of the comments received, their disposition and final policy drafts will be reviewed at the next EMS Advisory Committee meeting following the close of the public comment period. C. The EMS Advisory Committee shall vote on a recommendation to the Medical Director to accept or reject the draft version of the policies. The Medical Director may accept or reject the EMS Advisory Committee recommendation when determining the final policy content. D. The EMS Agency Medical Director shall forward the final policy to the Director of Health at the Department of Public - for his/her signature as the Chief Executive Officer of the Health Commission - the governing body for emergency medical services. Page 1 Policy Reference No.: 1000 Effective Date: September 9, 2013 IV. POLICY RELEASE WITHOUT PUBLIC COMMENT A. The Medical Director reserves the right to make minor revisions to policies without public comment for administrative continuity of the EMS System. Minor revisions include grammatical, format editing, and /or minor corrections of outdated information. B. The Medical Director may immediately and without prior notice implement a new or significantly revised EMS Agency policy to protect public health and safety. Policies released under these circumstances shall be valid for 90 days from the initial effective date. Within 60 days of the initial effective date, the policy shall be released for the public comment following the procedures in Section IV. The Medical Director may extend a policy without public comment for one time for a total of 180 days from the initial effective date. V. POLICY EXEMPTION PROCESS A. Requests for a policy exemption by an EMS provider must be submitted in writing to the EMS Medical Director. All requests must identify the reasons for the requested exemption and include substantive supporting documentation justifying the request. B. Upon request of the EMS Medical Director, the EMS Advisory Committee will review the exemption request at their next scheduled meeting to recommend either an approval or denial of the request. C. The Medical Director will review the exemption request, supporting documentation and recommendations in making a determination to approve or deny the request. The Medical Director will notify the submitting agency of a decision within 60 days of the date of the EMS Advisory Committee review. The decision of the Medical Director is final. VI. POLICY DISTRIBUTION A. The EMS Agency is responsible for distribution of the final policy to EMS System stakeholders via email and EMS Agency website posting. B. All EMS system providers are responsible for: 1. Distributing new or revised policies to employees prior to the implementation date and providing training on all relevant policies. 2. Making available an EMS Agency Policy Manual to employees (either paper or electronic versions). Page 2 Policy Reference No.: 1000 Effective Date: September 9, 2013 VII. AUTHORITY California Health and Safety Code, Section 1797 et seq. California Code of Regulations, Title 22, Division 9 San Francisco City Charter, Section 4.110 San Francisco Health Code, Article 3, Section 112 Health Commission Rules and Regulations, January 17, 2012 Page 3 SAN FRANCISCO EMERGENCY MEDICAL SERVICES AGENCY Policy Reference No.: 1010 Effective Date: September 9, 2013 Supersedes: August 1, 2012 ADVISORY COMMITTEES I. PURPOSE To define the roles, structure, membership and procedural standards for advisory committees to the EMS Agency Medical Director. II. POLICY A. Advisory committees, composed of EMS system constituents, shall convene to review EMS system issues relevant to their scope of responsibility and recommend actions to the EMS Agency Medical Director concerning matters of policy, procedure, and protocol. B. The EMS Agency Medical Director, as mandated by state statute, provides medical control and assures medical accountability throughout the planning, implementation and evaluation of the EMS System. The EMS Agency Medical Director retains the final decision through his/her medical authority for the EMS system. III. OPEN PUBLIC MEETINGS A. All committee and sub-committee meetings are open to members of the public. Meeting agendas, minutes, and other documents pertaining to these committees, except quality improvement documents, are public records and subject to public review. The EMS Agency shall distribute and post on its website an annual meeting schedule. B. The quality improvement portions of the EMS Advisory Committee and its sub- committees are closed meetings because of confidential patient information reviewed during case discussions. IV. PARLIAMENTARY AUTHORITY / QUORUM A. Proceedings of the advisory committee and subcommittees are conducted under the “Robert’s Rules of Order” when they do not conflict with this policy. This policy shall take precedence if any procedures are in conflict with “Robert’s Rules of Order.” B.