Exhibit_2_Monterey_County_Emergency_Services.pdf

Monterey County Emergency Medical Services Agency

EMERGENCY MEDICAL

SERVICES MANUAL

(POLICIES, PROTOCOLS & PROCEDURES)

July 2014

Solicitation W91YU0-16-R-0001 Exhibit 2

Monterey County EMS Agency i

Update Log

Log Number Action(s) 200909-01 Update Log and Index; Remove old Destination Policy –

Replace with new; Remove old Spinal Immobilization Policy and Algorithm – Replace with new; Remove MAP Triage Criteria and replace with new; and Insert new MHOAC Policy.

201001-01 Update Log and Index; Remove old ALS Base Hospital Policy – Replace with new; Remove old Prehospital Consent AMA Policy – Replace with new (includes a checklist); and Insert new Minimum ASL Transport Stock Policy.

201003-01 Update Log and Index; Remove old 12-Lead EKG Guidelines – Replace with new; and Remove old 12-Lead EKG Training and Quality Improvement Program – Replace with new policy.

201107-01 Update Log and Index; Remove EMT Investigation and Discipline, EMT Certification (Initial), EMT Certification (Renewal) policies – Replace with revised policies; Remove Field Care Communications Failure, Early Ring-Down, AED Guidelines, Physician On-Scene polices – Replace with revised policies; Add new Field Care Pleural Decompression and Minimum Stock Non-Transport Paramedic Service Provider policies; Add new Adult and Pediatrics Nausea and Vomiting Management policies; Remove the Field Care Interfacility Transfer policy; Remove Emergency Medical Facilities Transfer of Patients in the EMS System policy;

Remove Patient Care Reporting Guidelines (PCR) policy – Replace with revised policy; and Removing the Critical Care Transport policies and retaining them in abeyance of future employment.

201201-01 Update Title Page, Log and Index.

Remove EMS Aircraft Operations and MAP/Triage policies

– Replace with revised policies.

Remove all Adult Cardiac protocols: Cardiac Arrest- Asystole/PEA; Cardiac Arrest – Ventricular Fibrillation;

Chest Pain – Suspected Cardiac Origin; Narrow Complex Tachycardia; Symptomatic Bradycardia; Wide Complex Tachycardia w/Pulse - Replace with revised protocols.

ii

Remove all Adult Environmental protocols: Acute Venomous Snakebite; Allergic Reaction/Anaphylaxis; Heat Emergencies; Hypothermia; Overdose and Poisoning - Replace with revised protocols.

Remove all Adult Neurological protocols: Altered Level of Consciousness; Combative Patient; Non-Traumatic Neuro Impairment Suspected CVA; Seizure - Replace with revised protocols.

Remove Adult Obstetric protocol - Replace with revised protocol.

Remove all Adult Respiratory protocols: Airway Obstruction; Pulmonary Edema; Respiratory Distress w/Wheezes - Replace with revised protocols.

Remove all Adult Medical Care protocols: Routine Medical Care; Nausea and Vomiting Management - Replace with revised protocols.

Remove all Adult Trauma Care protocols: Burn Care;

Isolated Extremity Injury – Replace with revised protocols.

Remove Pediatric Cardiac protocols: Cardiac Arrest- Asystole/PEA; Cardiac Arrest – Ventricular Fibrillation;

Chest Pain – Suspected Cardiac Origin; Narrow Complex Tachycardia; Symptomatic Bradycardia – Replace with revised protocols.

Remove Pediatric Respiratory protocol: Respiratory Distress

– Replace with revised protocol.

Remove all Field Care – Scope of Practice policies: ALS;

BLS – Replace with revised policies.

Remove Field Care – Patient Care policies: Airway Management; 12-Lead EKG – Replace with revised policies.

Remove Field Care – Minimum Stock policy: ALS Transport Units – Replace with revised policy.

Add new Minimum BLS Non-Transport Stock policy with Field Care Minimum Stock policy.

iii

Add new Base Contact Policy with Field Care - Medical Control Policies.

Add new Stroke Center Designation Policy with Emergency Medical Facility Policies.

201207-01 Update Title Page, Log and Index.

Remove Environmental – Overdose and Poisoning policy - Replace with revised policy.

Remove Neurological – Altered Level of Consciousness policy – Replace with revised policy.

Remove Respiratory – Pulmonary Edema; Distress with Wheezes policies – Replace with revised policies

Remove Pediatric Cardiac – Wide Complex Tachycardia with Pulse protocol – Replace with revised protocol.

Remove Pediatric Environmental – Acute Venomous Snakebite; Allergic Reaction/Anaphylaxis; Heat Emergencies; Hypothermia; Overdose and Poisoning protocols – Replace with revised protocols.

Remove Pediatric Neurological – Altered Level of Consciousness; Seizures protocols – Replace with revised protocols.

Remove Pediatric Respiratory – Airway Obstruction protocol

– Replace with revised protocol.

Remove Pediatric Medical – Nausea and Vomiting Management; Routine Medical Care protocols – Replace with revised protocols.

Remove Pediatric Trauma – Burns; Isolated Extremity Injury protocols – Replace with revised protocols.

Add new Field Care – Continuous Positive Airway Pressure (CPAP) policy.

Remove Field Care – Minimum Stock for ALS Transport;

Minimum Stock for ALS Non Transport policies – Replace with revised policies.

iv

Remove Emergency Medical Facilities – Advanced Life Support Receiving Hospital; Educational Standards for Emergency Department Personnel –Replace with revised policies.

201301-01 Update Title Page, Log and Index.

Insert new Personnel Fireline Paramedic policy.

Remove Adult Cardiac Chest Pain Suspected Cardiac Origin protocol – Replace with revised protocol.

Remove Adult Respiratory Pulmonary Edema protocol – Replace with revised protocol.

Remove Field Care policies:

• Patient Care – CPAP

• Patient Care - Spinal Immobilization

Replace with revised policies

Insert new Field Care Special Events policy.

Remove PCR policies:

• Patient Care Records

• PCR Completion Guidance

Replace with revised policies

Insert new PCR Abbreviation policy

201307-01 Update Title Page, Log and Index.

Remove Adult Cardiac protocols:

• Cardiac Arrest-Asystole/PEA

• Cardiac Arrest-Ventricular Fibrillation Pulseless

Ventricular Tachycardia Replace with revised protocols

Remove Adult Neurological Non-Traumatic Neuro Impairment/Suspected CVA protocol – Replace with revised protocol.

Insert new Adult Trauma Care Crush Injury Syndrome protocol.

Insert new Field Care Patient Management EMT Patient Care During Transport policy.

v

Insert new Field Care Patient Care policies:

• Pain Management

• Ventricular Assist Device (VAD)

Remove Patient Care Approved PCR Abbreviations policy – Replace with revised policy.

201401-01 Update Title Page, Log, and Index

Delete Administration - Medical Advisory Committee policy.

Remove Adult Cardiac Chest Pain Suspected Cardiac Origin protocol – Replace with revised protocol.

Remove Adult Environmental Acute Venomous Snakebite protocol – Replace with revised protocol.

Remove Adult Neurological Non-Traumatic Neuro Impairment/Suspected CVA protocol – Replace with revised protocol.

Remove Adult Trauma – Burn Care protocol – Replace with revised protocol.

Remove Adult Trauma – Isolated Extremity Injury protocol – Replace with revised protocol.

Remove Field Care – MAP Triage Criteria policy – Replace with revised policy.

Remove Field Care – Minimum Stock for ALS Units policy

– Replace with revised policy.

Remove Field Care – Patient Destination policy - Replace with revised policy.

Remove Patient Care Records policy - Replace with revised policy.

vi

201407-01 Update Title Page, Log, and Index

Insert new Administration policy – ALS Service Provider Response and Scene Time Reporting.

Remove Adult Neurological Non-Traumatic Neuro Impairment/Suspected CVA protocol – Replace with revised protocol.

Insert new Adult Medical – Pain Control protocol.

Insert new Field Care – Scope of Practice – Tactical Medicine policy.

Remove Field Care Patient Management – MAP Triage Criteria policy – Replace with revised policy.

Remove Field Care – Patient Care policies: 12-Lead EKG, Pain Management, Spinal Immobilization policies – Replace with revised policies.

Remove Field Care both Minimum Stock policies – Replace with single revised policy.

201501-01 Next Scheduled Revision/Update vii

Update Log ..................................................................................................................................... i

ADMINISTRATIVE POLICIES

Medical and Health Operational Area Coordinator Mobile Intensive Care Agency Authorization of Non-transporting ALS Service Provider Response and Scene Time Reporting Non-transporting for Non-Contract Ambulance and Convalescent Transport Services

PERSONNEL POLICIES

EMT Certification (Initial) EMT Certification (Renewal) EMT Investigation and Discipline Emergency Medical Dispatch Fireline Paramedic Mobile Intensive Care Nurse Authorization and Reauthorization Paramedic Accreditation

ADULT PROTOCOLS

Cardiac Cardiac Arrest-Asystole/PEA Cardiac Arrest-Ventricular Fibrillation Pulseless Ventricular Tachycardia Chest Pain Suspected Cardiac Origin Narrow-Complex Tachycardia Symptomatic Bradycardia Wide Complex Tachycardia with Pulses

Environmental Acute Venomous Snakebite Allergic Reaction/Anaphylaxis Heat Emergencies Hypothermia Overdose and Poisoning

Neurological Altered Level of Consciousness Combative Patient Non-Traumatic Neuro Impairment/Suspected CVA Seizure

Obstetic Childbirth viii

Respiratory Airway Obstruction Pulmonary Edema Respiratory Distress with Wheezes

Medical Care Nausea and Vomiting Management Pain Control Routine Medical Care

Trauma Care Burn Care Crush Injury Syndrome Isolated Extremity Injury

PEDIATRIC PROTOLS

Cardiac Cardiac Arrest-Asystole/PEA Cardiac Arrest-Ventricular Fibrillation Pulseless Ventricular Tachycardia - Pediatric Symptomatic Bradycardia - Pediatric Narrow Complex Tachycardia - Pediatric Wide Complex Tachycardia with Pulses - Pediatric

Environmental Acute Venomous Snakebite - Pediatric Allergic Reaction/Anaphylaxis - Pediatric Heat Emergencies - Pediatric Hypothermia - Pediatric Overdose and Poisoning - Pediatric

Neurological Altered Level of Consciousness - Pediatric Seizure - Pediatric

Respiratory Airway Obstruction - Pediatric Respiratory Distress - Pediatric

Medical Care Nausea and Vomiting Management - Pediatric Routine Medical Care - Pediatric

Trauma Care Burns - Pediatric Isolated Extremity Injury - Pediatric ix

FIELD CARE POLICIES

Scope of Practice ALS Scope of Practice BLS Scope of Practice Tactical Medicine

Scene Management Emergency Medical Scene Management Code Three Operations - Guidelines

Patient Direction Organ Donor Pre-hospital Consent Pre-Hospital Determination of Death Withholding Resuscitation – Patient’s Request

Patient Management MAP Triage Criteria EMS Aircraft Operations EMT Patient Care During Transfer Patient Destination Patient Transport - 5150 Physician of Scene Transfer of Patient Responsibility

Patient Care 12-Lead EKG AED Guidelines Airway Management Continuous Positive Airway Pressure (CPAP) Drowning and Near Drowning Intraosseous Infusion Pain Management Pleural Decompression Restraint Guidelines Spinal Immobilization Ventricular Assist Device Patient Management

Minumum Stock Minimum Stock-ALS Units

Medical Control Base Contact Communication Failure Early Hospital Ring-Down x

Hazardous Materials Hazardous Materials Medical Response Plan Nerve Agent Antidote (MK-1 Kit) Administration

Mutual Aid Medical Mutual Aid

Special Events Special Events

PATIENT CARE POLICIES

Patient Care Records Patient Care Records-Approved Abbreviations Guidelines for Completing the Prehospital Care Record First Responder Record Completion Guidelines

QUALITY IMPROVEMENT PROGRAMS

Collection of Ambulance Data Quality Improvement Quality Improvement - Emergency Medical Dispatch Provider 12-Lead EKG Training and Quality Improvement Program

TRAINING PROGRAMS

ALS Training Program Approval BLS Training Program Approval Continuing Education Providers Emergency Medical Dispatch Training Program Evaluation and Monitoring of Prehospital Care Training Programs

COMMUNICATIONS

EMS Communication System Emergency Medical Dispatch Provider

EMERGENCY MEDICAL FACILITY POLICIES

Advanced Life Support - Base Hospital Advanced Life Support – Receiving Hospital Educational Standards for Emergency Department Personnel STEMI Receiving Center Stroke Center Designation xi

TRAUMA CARE POLICIES

Trauma Care - Data Collection and Management Trauma Care - Interfacility Transfer and Transportation Trauma Care - Quality Improvement and System Evaluation Trauma Care - Service Area Trauma Care - System Organization and Management

Effective Date: September 1, 2009 (EMS Manual Revision 001)

Approved: Approved:

EMS Medical Director EMS Agency Director

Policy: Administrative

Medical and Health Operational Area Coordinator

I. PURPOSE

The purpose of this policy is to describe a process for the initial notification and activation of the Medical and Health Operational Area Coordinator (MHOAC).

II. AUTHORITY

Division 2.5, Health and Safety Code, Section 1797.150-152.

III. DEFINITIONS

A. Departmental Operations Center (DOC) means the center for coordinating discipline-specific activities outside the city or county Emergency Operations Center (e.g.

Medical/Health DOC).

B. Medical Health Operational Area Coordinator (MHOAC): The Monterey County Health Officer and the Director of Emergency Medical Services (EMS) have designated the EMS Director as Monterey County Medical and Health Operational Area Coordinator (MHOAC). The Health Officer retains the authorities described in Section 101049 of the Government Code; the Health Officer serves as the alternate MHOAC. The primary responsibilities of the MHOAC are to manage disaster medical resources, including personnel, equipment, and supplies; implement the operational area disaster medical and health response plan; request and approve mutual aid; activate hospital notifications and communication systems; survey EMS resources (hospitals and transportation providers);

orchestrate patient distribution; coordinate evacuation and patient tracking; effectively and efficiently process all medical and health information; and facilitate the establishment of priorities through the Operational Area Emergency Operations Center.

C. Mutual aid requests are understood to be for non-reimbursed, voluntary resources unless otherwise indicated.

D. Operational Area means the unincorporated areas and all political subdivisions (cities and special districts) within the boundaries of the county.

E. Operational Area Emergency Operations Center (EOC) means the center for coordinating multi-discipline activities within the county or operational area.

F. Regional Disaster Medical and Health Coordinator (RDMHC): At the regional level, EMS Authority and Department of Public Health jointly appoint the Regional Disaster Medical Health Coordinator/Specialist (RDMHC/S) whose responsibilities include supporting the mutual aid requests of MHOAC’s for disaster response within the region and providing mutual aid support to other areas of the state in support of the state medical response system. The RDMHC/S also serves as an information source to the state medical and health response system.

IV. DESIGNATION

The Monterey County Health Officer and the Director of Emergency Medical Services (EMS) have designated the EMS Director as Monterey County Medical and Health Operational Area Coordinator (MHOAC). The EMS Agency’s Duty Officers provide MHOAC support and may be the initial point of contact if the EMS Director is not immediately available.

V. POLICY

A. The MHOAC is available 24/7 through Monterey County Emergency Communications Center (9-1-1).

B. All requests for Medical/Health mutual aid shall be compliant with guidelines set forth by

SEMS/NIMS.

C. Requests for resources, status reports, and other vital exchanges of information between the following local medical and health providers and services outside of the operational area shall be processed by the MHOAC:

1. Ambulance provider agencies (both public and private).

2. Public Health Department(s).

3. Acute care hospitals.

4. Environmental health agencies.

5. Convalescent Hospitals.

6. Medical clinics.

7. Extended care facilities.

8. Other health related agencies.

D. The MHOAC shall be notified of the occurrence of any of the following:

1. Hospital evacuation, multi-casualty incident, or medical disaster;

2. Activation of the Operational Area Emergency Operations Center (EOC) or Health Department’s Operations Center (DOC);

3. Mutual-aid resources (non auto-aid) have been requested from outside the county (beyond normal response areas);

4. Local resources are depleted or are anticipated to be soon depleted; or

5. Coordination of resources between multiple jurisdictions is needed.

VI. REQUESTS FOR MUTUAL AID

A. Requests for additional resources are normally initiated by local medical/health providers, Incident Commanders, Operational Area Coordinators of other disciplines (e.g. Fire, Law), Office of Emergency Services, EOC Directors/Coordinators, or the Regional Disaster Medical/Health Coordinator through the Emergency Communications Center (9- Emergency Communications will forward the request to the MHOAC or EMS Agency Duty Officer for action.

B. Mutual aid request will provide the following information:

1. Person/Agency making the request;

2. Type/number of resources requested;

3. Response location;

4. Contact person; and

5. Applicable safety/security considerations.

C. The MHOAC is responsible for managing disaster medical resources, including personnel, equipment, and supplies. Resource management includes assessing disaster medical response needs, tracking available resources, and requesting or providing mutual aid. The status of local resources (i.e. numbers of available resources) within the operational area is assessed before requesting outside resources or submitting a resource request to the

RDMHC/S.

D. Following an assessment of local resources, the MHOAC may request or provide mutual aid as conditions warrant. The MHOAC or his/her designee (i.e., EMS Agency Duty Officer) acts as the single-ordering authority for operational area (county) medical and health mutual aid requirements.

E. The MHOAC shall provide the following information to the RDMHC/S for mutual aid requests:

1. Local tracking number;

2. Person/agency making request;

3. Type/number of resources requested;

4. Response location:

5. Contact person;

6. Resources support needs (i.e. fuel, water, food, lodging, etc.); and

7. Applicable safety and security considerations.

F. If required, the MHOAC may request the Health Department’s Operations Center (DOC) or Operational Area Emergency Operations Center (EOC) be activated to support the public health or medical event.

G. The MHOAC is responsible for creating and maintaining documentation of all activities and communications.

VII. MUTUAL AID REQUEST PROCEDURES

A. Requests for Medical-Health Mutual Aid from other Operational Areas to Monterey County include the following activities:

1. RDMHC/S either contacts the Monterey County Emergency Communications Center (9-1-1) or the MHOAC directly with the medical-health mutual aid request.

2. If applicable, County Communications shall notify the EMS Agency’s Duty Officer at (831) 235-5403 of the request.

3. The EMS Duty Officer shall notify the MHOAC of the request. If the MHOAC is not available, the duties of the MHOAC shall be assumed by the EMS Duty Officer.

4. The MHOAC or his/her designee shall contact Monterey County medical-providers via EMSystem Emergency Medical Communications Network (800Mhz), MedNet radios, landline or cellular phone service, or Internet to inventory, assess and confirm available resources.

5. The MHOAC shall evaluate the current medical-health resources of the Monterey County operational area and ensure the integrity of the countywide medical/health response system before committing and releasing mutual aid resources to the

RDMHC/S.

6. Monterey County medical-health providers shall not be permitted to respond, provide mutual aid, or “self-dispatch” to any event outside of the county without the authorization and coordination of the Monterey County MHOAC.

7. Ambulance personnel who respond outside of Monterey County shall be authorized to operate according to Monterey County ALS/BLS clinical protocols and shall coordinate patient destinations in accordance with the established Incident Command System.

B. The CDC CHEMPACK Program is intended to provide antidotes to respond to a nerve agent attack or an organophosphate exposure (i.e., pesticides). Each cache treats about 1,000 people. Based upon Monterey County’s population, the operational area has been allocated a total of three caches (potential capable of treating 3,000 people). All three of the CHEMPACK caches are ‘hospital configured.’ The MHOAC is responsible for responding to CHEMPACK requests from the RDMHC/S and resolving distribution of materials within the operational area.

VIII. OPERATIONAL AREA COORDINATION

A. The MHOAC or his/her designee will advise the Health Officer, Director of Health, EMS providers, and Emergency Communications of actions being taken or considered.

B. The MHOAC or his/her designee shall ensure the Fire and Law Operational Area Coordinators and the County Office of Emergency Services are advised of significant medical-health mutual aid requests received and/or requested by the County.

C. The MHOAC shall coordinate all mutual aid resource with the RDMHC/S.

Effective Date: December 1, 2008

Policy: Administrative

Mobile Intensive Care Agency

I. PURPOSE

The purpose of this policy is to establish guidelines for the designation a Monterey County Mobile Intensive Care Agency.

II. DEFINITIONS

A. A Mobile Intensive Care Agency means a public or private corporation, institution or Agency which has demonstrated the capability to meet all criteria for approval and has a written agreement signed by the EMS Medical Director to provide ALS Services to a designated geographic area with a designated number of Mobile Intensive Care Units

(MICN).

B. A Mobile Intensive Care Unit means a Monterey County designated emergency vehicle staffed by and equipped to provide ALS at the scene of an emergency and/or during transport of (a) patient(s) experiencing a medical emergency to a hospital.

III. REQUIREMENTS

A. A designated Mobile Intensive Care Agency shall:

1. Have a written agreement with the local EMS Agency to participate in the ALS program and to comply with all applicable State regulations and local policies and procedures, including a mechanism to assure compliance.

2. Provide emergency medical service response on a continuous twenty-four (24) hours per day.

3. Have and agree to utilize and maintain communications as specified by the EMS Agency.

4. Have and agree to maintain a drug and solution inventory, and BLS and ALS medical equipment and supplies as specified by the EMS Agency.

5. Designate a Quality Improvement Manager who shall be at minimum an EMT-P and the liaison to the County, the ALS Base Hospital, and ALS Receiving Hospital (s).

6. Participate in the Monterey County Approved Quality Improvement Program Guidelines.

7. Establish a mechanism to ensure that all EMT-Ps employed by the agency are current in meeting their continuing education and continuous service requirements as specified in the policies and procedures of the local EMS Agency.

• Agree to permit designated agents of the EMS Agency to observe on MICUs. Agree to accept EMT-Ps and Mobile Intensive Care Nurses (MICU) for field probations and make available paramedic preceptors who meet preceptor standards established by the EMS Agency.

• Agree to permit MICNs and emergency department physicians to observe on MICUs.

• Agree to utilize the assigned Base Hospital for coordination, medical direction and training.

• Agree to provide visible identification of paramedic personnel.

• Agree to notify the EMS Agency of all paramedic operational problems or changes in a timely manner, including changes in number of units, permanent unit locations(s), unresolved Base Hospital complaints, major agency personnel changes, i.e., Chief, Quality Improvement Manager, Supervisors, owner-manager, changes in status of certified personnel, and radio frequency interference.

• Ensure liability insurance necessary for participation in the ALS Program.

• All mobile intensive care units, both public and private, shall be staffed at minimum with one

(1) certified EMT-1 (Ambulance). It is the responsibility of the MICA to ensure the availability of well-trained and rested personnel necessary to provide optimal patient care.

• Any person who drives the ambulance will have in his/her possession a valid California Driver’s License and a current, valid ambulance driver’s certificate. (Ambulance may be driven by individuals who do not possess an Ambulance Driver’s certificate if they are salaried full-time police officers, deputy sheriffs or fire fighters, Title 13, Section 1100.2 California Code of Regulations.

B. All MICUs will be stationed in such a manner as to be available for dispatch within one minute of receipt of call from 7:00a.m. to 10:00p.m., and two minutes from receipt of call from 10:00 p.m. to 7:00a.m. All MICUS will be stationed in such a manner as to permit arrival at the scene of an emergency within the requirements set forth for each Mobile Intensive Care Agency by the EMS Agency

C. The Mobile Intensive Care Agency shall not respond a MICU to any inter-facility request when doing so requires the use of the last or only unit available to serve the Agency’s response zone.

D. No Mobile Intensive Care Agency shall advertise itself or a responding unit as providing ALS services unless it does, in fact, routinely provide ALS services on a continuous twenty-four (24) hour per day basis and is currently designated by the EMS Medical Director to provide such services.

E. The EMS Agency shall review its agreement with each Mobile Intensive Care Agency at least every two (2) years. Such agreements may be changed, renewed, canceled, or otherwise modified at that time.

F. The EMS Agency may deny, suspend or revoke the Agreement/MOU with a Mobile Intensive Care Agency for failure to comply with applicable policies, procedures, and regulations.

Policy: Administrative

Authorization of Non-transporting

I. PURPOSE

To establish standards and procedures for the authorization of fire, law-enforcement, or other public agencies to provide non-transporting EMT-Paramedic services as an authorized part of the Monterey County emergency medical services ("EMS") system

II. POLICY

No person or organization shall provide EMT-Paramedic services unless that person or organization has been authorized by the Monterey County EMS Agency in accordance with the following procedure.

III. DEFINITIONS

"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.

IV. PROCEDURE

A. An agency seeking authorization to provide non-transporting EMT-Paramedic services shall submit to the Monterey County EMS Agency a written proposal, with a resolution of support from the agency's governing board, covering the following mandatory elements:

B. Mandatory Elements - applicants must provide all of the following:

1. The geographic area and population to be served. Include a map showing the proposed basing location(s) of the EMT-Paramedic unit(s).

• The applicant's number of EMT-Paramedics, EMT-Paramedic units, and their hours of availability.

• A minimum medical equipment and supplies list (inventory) carried on each of the applicant's EMT-Paramedic units.

• The applicant's plan for maintaining and replenishing its drug, solution, and equipment inventory.

• The applicant's plan for the capture, analysis, and regular submission of its patient-care data to the Monterey County EMS Agency.

• The applicant's plan for ensuring skill retention of its EMT-Paramedics.

2. A description of the applicant's telecommunications capabilities, including:

a. The telecommunications equipment to be carried on each of applicant's EMT- Paramedic units;

b. The applicant's ability to communicate with local fire, law-enforcement, ambulances, and base hospital(s); and

c. The applicant's communications-failure plan.

d. A description of the applicant's CQI program, including the job description of the person who will oversee the program and the applicant’s plans for participation in the county QA/QI program.

C. Supporting Information - applicants should also provide the following information:

1. The number of applicant's medical responses, by month, for the past calendar year.

2. The applicant's actual medical response times, by month, for the past calendar year.

3. The applicant's experience providing automated external defibrillation ("AED"), including:

a. The number of AED-authorized personnel;

b. The number of AED-equipped vehicles;

c. The number of patients on whom the AED was applied during the previous calendar year; and

d. The number of patients actually defibrillated (i.e., shocked) during the previous calendar year. The anticipated impact, if any, of the proposed EMT-Paramedic services on the agency's provision of AED services.

4. The medical need for non-transporting EMT-Paramedic services within the applicant's service area.

5. The applicant's proposed response-time standards for its non-transporting EMT- Paramedic services.

6. The applicant's plan to synchronize its dispatch center's response-time clock(s) with "universal time" and/or the 9-1-1 PSAP.

7. The applicant's willingness to respond to medical emergencies outside its normal service area whenever it has the closest available EMT-Paramedic unit.

8. The applicant's plan to install "automatic vehicle locators" on its EMT-Paramedic units.

9. The applicant's plan for the capture, analysis, and regular submission of its response-time data to the Monterey County EMS Agency.

10. The applicant's plan for coordination with local law-enforcement agencies.

11. A letter of support from the local EMT-Paramedic base hospital.

12. The applicant's plan to utilize the county-wide hospital-status information system (currently the EMSystem).

13. The applicant's commitment to participate in medical disaster planning and drills.

14. The applicant's commitment to participate in injury-prevention activities.

a. The applicant's commitment to attend and participate in meetings of the Monterey County EMS Medical Advisory Committee and the EMS Operations Committee

b. The applicant's commitment to participate in the development and implementation of a county-wide system of medical call prioritization.

c. The applicant's proposed budget for the first year of EMT-Paramedic services.

d. A description of the method that will be utilized to finance the applicant's

EMT-paramedic services, including any proposed fees and method of fee collection.

e. The applicant's commitment to support and assist local EMS training programs.

f. The applicant's medical record-retention policy.

g. The applicant's proposed liability-insurance coverage.

D. Upon receipt of a written proposal as described above, the EMS Agency will determine whether it is complete as to the mandatory elements.

1. If the proposal is incomplete, the EMS Agency will notify the applicant in writing of the missing or incomplete item(s).

2. As soon as the proposal is complete as to the mandatory elements, the EMS Agency will schedule the matter for discussion and recommendation by the EMS Medical Advisory Committee and the EMS Operations Committee at their next regular public meetings.

a. After these committees have made their recommendations, the matter will be scheduled for discussion and recommendation by the EMS Council.

b. The EMS Medical Director will consider the recommendations of these committees in deciding whether to grant authorization to provide non-transporting EMT-Paramedic services.

Effective Date: July 1, 2014

Policy: Administrative

ALS Service Provider Response and Scene Time Reporting

I. AUTHORITY

Authority for this policy are found in Division 2.5, California Health and Safety Code, Section 1797.204, and California Code of Regulations Sections 100145(a), 100148(b)(d)(2)(e), 100170, 100171

II. PURPOSE

To meet the requirements established in the statutes listed above for EMS system planning, implementation, and evaluation.

III. DEFINITIONS

A. ALS Service Provider: An organization that has an agreement with the Monterey County EMS Agency to provide paramedic level services within their service area.

B. Date of Service: Date that the call was received at the County 911 Communications Center.

C. Time of Call Receipt: This is the time that the call is received by the agency dispatch position either electronically or by phone.

D. Time of Dispatch: Time recorded in the CAD system by the dispatcher to denote the time that the responding unit was requested to respond to the request for service.

E. Time of Arrival at the Scene: The moment the responding crew notifies the communications center that it is fully stopped at the location where the vehicle will be parked while the crew exits to approach the patient. Arrival at a staging location will also be considered the time of arrival at the scene.

F. Time of Departure From the Scene: Time recorded in the CAD system when the unit notified their dispatch center that they are leaving the scene due to patient transport, becoming available, responding to another call, or to pick up a staff member.

G. Time of Arrival at the Receiving Facility: The time that the ambulance comes to a stop at the emergency department when transporting a patient. Ambulance only.

IV. POLICY

C. ALS service providers are to provide a monthly report to the EMS Agency containing specified data elements for every patient response.

D. This report is to be provided to the designated EMS Agency staff person by the 15th of the following month.

E. The following data elements are required

1. Date of service

2. Time of call receipt by the dispatch provider.

3. Time of dispatch to the scene.

4. Time of arrival at the scene.

5. Time of departure from the scene.

6. Time of arrival at the receiving facility if the ALS service provider transports the patient.

7. Unit identifier.

8. Incident location by address, intersection, or nearest location identifier as entered into the CAD.

F. The monthly report shall be in an Excel document format.

Policy: Administrative

Non-transporting for Non-Contract Ambulance and Convalescent Transport Services

I. PURPOSE

To ensure appropriate patient care and transportation by personnel who are duly authorized by Monterey County to provide medical transportation services but are not authorized to respond to emergency calls.

II. DEFINITIONS

A. Ambulance = any vehicle which is specially designed, constructed, modified, or equipped for transporting sick, injured, infirm, or otherwise incapacitated person, capable of supporting BLS or a higher level of care.

B. Convalescent Transport = transport by a Monterey County authorized vehicle which is specially designed, constructed, modified, or equipped for transporting patients who require wheelchairs or who cannot travel in an upright, sitting position, and who in addition do not require medical care, assistance, or monitoring during the transport.

C. Critical Care Transport (CCT) = any transport of a patient by ambulance when the ambulance staff on board includes a physician a registered nurse, or other medical personnel authorized to provide a level of care that exceeds the paramedic scope of practice.

D. EMS-System Ambulance = ambulance operating under Monterey County contract and authorized by Monterey County contract and authorized by Monterey County to respond to 9-1-1 emergency calls.

E. Medical Care, assistance, or monitoring = care, assistance, or monitoring that requires any medical knowledge or skill.

F. Non-contract ambulance = an EMT-I ambulance, an EMT-P ambulance, or a Critical Care Transport unit operating under Monterey County license but not authorized by Monterey County to respond to 9-1-1 emergency calls.

III. PATIENT TRIAGE

A. Policy: No medical transport service shall accept for transport any patient who requires a higher level of care than it is capable of providing. If there is any doubt that the patient’s condition allows safe transport at the available level of care (convalescent transport EMT-I, EMT-P, or CCT), then the patient must be transported at the appropriate higher level of care.

1. Convalescent transport services shall not accept patients:

a. Who requires medical care, assistance, or monitoring during the transport; or

b. Who require restraints; or

c. Who have intravenous (IV) lines, nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes, or indwelling vascular access lines.

2. EMT-I ambulance services shall not accept patients:

a. Who have or appear to have life-threatening conditions; or

b. Who require or may reasonably be expected to require EMT-P assessment, monitoring, or intervention during the transport; or

c. Who would, under Monterey County ALS Field Treatment Protocols, receive cardiac monitoring, prophylactic IV lines, or any other EMT-P intervention.

B. Telephone Triage: Determination as to the appropriate level of transport should be made, if possible, at the time service is requested and before a medical transport unit responds.

1. All callers requesting medical transportation shall be asked to provide enough information to answer the following questions:

a. Is this a perceived emergency? Does anyone involved – patient, caller, or call taker – consider it an emergency?

b. Is this a request for immediate ambulance service?

c. Is this patient experiencing unusual difficulty in breathing?

d. Is there a change in the patient’s usual level of consciousness?

e. Is the patient bleeding significantly?

f. Is the patient experiencing unusual pain, numbness, or tingling.

2. If any of the above questions is answered in the affirmative, or then answer cannot be determined, then the request for medical transportation must immediately be referred to 9-1-1 for emergency response, unless the caller is the patient’s private physician.

If that case, the medical transport service need not refer the request if it can provide medically appropriate care and transport.

3. An appropriate request for immediate convalescent transport need not be referred to 9-1-1 by an authorized provider of such service.

C. On-Scene Triage:

1. Upon initial patient contact, the medical transport crew shall promptly assess the patient to determine whether it can provide medically appropriate care and transport.

See § III.A. above.

2. The ultimate responsibility for assessing and accepting a patient rests with the most medically qualified member of the transport crew; telephone triage is merely the first step in the medical screening process. No one may require the medical transport crew to accept any patient in violation of this policy.

3. Responding EMT-I or convalescent transport personnel should call for a 9-1-1 emergency response whenever it may be necessary – before, during, or after transport.

IV. VEHICLE ACCIDENTS

The primary responsibility for emergency response to, and patient transport from, vehicle accidents rests with the EMS system ambulance provider:

A. Reported Accidents: A non-contract ambulance or convalescent transport service receiving an emergency call from a private person requesting an ambulance at the scene of a motor vehicle accident shall immediately notify the Monterey County Communications Center (or call 9-1-1) to initiate the appropriate emergency response. The non-contract ambulance or convalescent transport service shall not respond to such calls.

B. Witnessed Accidents: If an accident is witnessed by a non-contract ambulance or convalescent transport crew, the crew shall immediately report the accident to the Monterey County Communications Center.

1. If no law enforcement, fire, or EMS-system ambulance personnel are on scene:

a. Stop to assess the situation and ascertain if there are any injuries.

b. Contact County Communications on the radio, via 9-1-1, or through company dispatch to request appropriate emergency response.

c. If there are injuries, render appropriate patient care, in accordance with

Monterey County EMS Policies and Procedures, until patient care can be transferred to EMS-system ambulance personnel.

2. If law-enforcement or fire personnel are on scene without an EMS-system ambulance, stop and ask the Incident Commander if your assistance is required. Make clear that you have happened upon the accident and have not been dispatched. If requested by the Incident Commander, render appropriate patient care, in accordance with Monterey County EMS Policies and Procedures, until patient care can be transferred to EMS-system ambulance personnel.

C. Patient Transport: Non-contract ambulance and convalescent transport patients from accident scenes except as requested by the EMS-system ambulance provider.

V. DOCUMENTATION

A. PCR Completion: Non-contract ambulance and convalescent transport personnel shall complete a Monterey County Prehospital Care Record “PCR” for every patient contact, whether or not a transport results, according to current Monterey County EMS policy.

B. Distribution: Copies of each completed PCR will be distributed and transmitted to the Monterey County EMS Agency according to current Monterey County EMS policy:

1. If the patient was transported to a Monterey County Base Hospital, the “EMS Agency” copy remains at the Base Hospital and is forwarded to the EMS Agency by the Base Hospital Coordinator on a weekly basis.

2. If the patient was not transported to a Monterey County Base Hospital, the “EMS Agency” copy is to remain with the transporting agency and then sent to the EMS Agency on a weekly basis.

3. Copies of any specific PCR will be provided to the Monterey County EMS Agency promptly upon request.

VI. RECORD-KEEPING

A. Tape Recordings:

1. Non-contract ambulance and convalescent transport providers shall tape record all telephone and radio calls for service.

2. Such tape recordings shall be kept for at least ninety days.

B. Written Requests: Copies of any written requests for service shall be kept for at least one year.

C. PCRs: Copies of all completed PCRs shall be kept for at least one year.

D. Inspection: Any of the above records shall be subject to inspection by the Monterey County EMS Medical Director, or his/her designee, upon request with at least one working day’s notice.

VII. QUALITY ASSURANCE/QUALITY IMPROVEMENT

A. Written Plan:

1. Each non-contract ambulance and convalescent transport provider shall have a written quality-improvement plan approved by the Monterey County EMS Agency.

2. The provider shall keep a current copy of its quality-improvement plan on file with the EMS Agency at all times.

3. The EMS Agency will, upon request, assist providers in the development of such plans.

B. Quality Improvement Coordinator: Each non-contract ambulance and convalescent transport provider shall designate a qualified employee to serve as its Quality Improvement Coordinator.

1. The provider shall keep this individual’s name and telephone number on file with the EMS Agency at all times.

2. The designated Quality Improvement Coordinator shall act as liaison with the EMS Agency and other EMS-system participants.

C. Policy Manual: Each non-contract ambulance and convalescent transport provider shall keep a current copy of its policy manual on file with the EMS Agency at all times.

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Effective Date: May 1, 2011

EMS Medical Director EMS Director

Policy: Personnel

EMT Certification (Initial)

I. PURPOSE

To specify the requirements and procedure for initial Emergency Medical Technician (EMT) certification in Monterey County.

II. POLICY

To initially certify as an EMT, an applicant must satisfy all relevant state regulations. If this policy should be superseded by changes in state regulations, then the EMS Agency practice will be adjusted accordingly, until this policy can be revised and disseminated. Note: Completing the National Registry Emergency Medical Technician (NREMT) exam and issuance of the NREMT card still requires the applicant to be independently certified in California to perform EMT level services.

III. REFERENCES

A. Division 2.5, California Health and Safety Code

B. Title 22, California Code of Regulations, Division 9, Chapter 2

IV. PROCEDURE

A. Submit all of the following documents to the Monterey County EMS Agency:

1. Monterey County EMS Application for EMT Certification and Health and Safety Code § 1798.200 Affidavit (completed, signed, and dated). A written explanation (with appropriate documentation) of any affirmative affidavit response is required and needs to accompany the application.

2. A copy of the National Registry Emergency Medical Technician (NREMT) Certificate Card and Exam Certificate. This is to demonstrate that the applicant has passed the written and skills exam approved by the EMS Authority. EMT certification expiration date of the initial certificate will be from two (2) years, or less, from the passing the NREMT exam (not the NREMT card expiration date); effective date of initial certificate is when all requirements have been satisfied. NREMT passing exam certificates greater than two (2) years will not be accepted for initial California EMT certification.

3. Completed Department of Justice (DOJ) and Federal Bureau of Investigation (FBI) LiveScan Background Investigation report. All negative DOJ LiveScan issues need to be adjudicated and resolved prior to certification. LiveScan is only required to be submitted once unless changing certifying entity or certification lapse of one (1) year or more.

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4. Proof of age eighteen (18) or over. A copy of current driver's license will suffice.

5. A money order or cashiers’ check for $75 issued to the EMS Authority.

B. All of the necessary documents must be received by the EMS Agency within the relevant time limits specified above. An application will not be processed until all of the necessary documents are received and accepted. Fax or illegible photocopies will not be accepted.

The EMS Agency may return any incomplete or abandoned application by U.S. Postal Service to the applicant's last known address.

C. The EMS Agency will issue a forty-five (45) day temporary wallet-sized certificate to eligible applicants. The certificate will contain the following information, and is normally valid for two (2) years or less:

1. The name of the individual certified.

2. The assigned EMT California Central Registry certification number.

3. The date the certification is effective

4. The date certification expires.

5. The status of the EMT certification (i.e., active, probation, denied, suspended, expire, etc.).

6. The name and location of the EMT certifying authority (Monterey County EMS Agency).

7. The name and signature of the individual (EMS Medical Director) authorized to certify, or facsimile of same.

8. A statement that the individual named on the card has fulfilled the requirements for certification as an EMT in California.

D. The EMS Authority will issue the permanent (effective for two (2) years or less) EMT certificate (card) and send to the applicant’s mailing address.

E. Under normal circumstances, the certificate will be issued within thirty (30) days after the applicant has satisfied all of the certification requirements and resolved any outstanding LiveScan issues.

F. Certification as an EMT shall be for a maximum of two (2) years except in the following cases:

1. A person who possesses a current and valid out-of-state EMT, EMT-Intermediate, or Paramedic certification, or a current and valid National Registry EMT-Basic, EMT- Intermediate, or Paramedic certification, the expiration date shall be the same expiration date as stated on the out-of-state or National Registry certification. The certification expiration date will be the final day of the final month of the two (2) year period.

2. An individual currently certified as a California AEMT or licensed as a California Paramedic shall have an EMT expiration date that is the same as the current AEMT certificate or Paramedic license.

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V. AFFIDAVIT

California Health and Safety Code § 1798.200(c) states any of the following actions shall be considered evidence of a threat to public health and safety and may result in the denial, suspension, or revocation of a certificate or license issued under Division 2.5 of the Health and Safety Code, or in the placement on probation of a certificate or license holder under this division:

A. Fraud in the procurement of any certificate or license under this division.

B. Gross negligence.

C. Repeated negligent acts.

D. Incompetence.

E. The commission of any fraudulent, dishonest, or corrupt act which is substantially related to the qualifications, functions, and duties of prehospital personnel.

F. Conviction of any crime which is substantially related to the qualifications, functions, and duties of prehospital personnel. The record of conviction or certified copy of the record shall be conclusive evidence of the conviction.

G. Violating or attempting to violate directly or indirectly, or assisting in or abetting the violation of, or conspiring to violate, any provision of this division or the regulations adopted by the authority pertaining to prehospital personnel.

H. Violating or attempting to violate any federal or state statute or regulation which regulates narcotics, dangerous drugs, or controlled substances.

I. Addiction to the excessive use of, or the misuse of, alcoholic beverages, narcotics, dangerous drugs, or controlled substances.

J. Functioning outside the supervision of medical control in the field care system operating at the local level, except as authorized by any other license or certification.

K. Demonstration of irrational behavior or occurrence of a physical disability to the extent that a reasonable and prudent person would have reasonable cause to believe that the ability to perform the duties normally expected may be impaired.

L. Unprofessional conduct exhibited by any of the following:

1. The mistreatment or physical abuse of any patient resulting from force in excess of what a reasonable and prudent person trained and acting in a similar capacity while engaged…