qa/qi plan station 73 / 40

LEHIGH COUNTY STATION 73 SCHUYLKILL COUNTY STATION 40

CONTINUOUS QUALITY IMPROVEMENT

PROGRAM

IN ACCORDANCE WITH THE RULES AND REGULATIONS OF THE EASTERN

PENNSYLVANIA EMS COUNCIL AND THE COMMONWEALTH OF

PENNSYLVANIA DEPARTMENT OF HEALTH

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ST LUKES EMS CQI PLAN

Table of Contents

Executive Summary ................................................................................................ 3 INTRODUCTION TO CONTINUOUS QUALITY IMPROVEMENT ................................. 4 CONTINUOUS QUALITY IMPROVEMENT PLAN .......................................................... 5 EASTERN PA EMS COUNCIL CQI............................................................................... 9 EASTERN PA EMS COUNCIL BLS CQI ................................................................... 12 EASTERN PA EMS COUNCIL ALS CQI ................................................................... 14 MONTHLY MEDICATION INVENTORY FORM ............................................................ 19 ALS QUARTERLY CQI REPORT ................................................................................. 20 ALS CQI FORM .......................................................................................................... 21 BLS QUARTERLY REPORT ........................................................................................... 22 BLS QUARTERLY REPORT ........................................................................................... 22 BLS CQI FORM............................................................................................................. 23 EMS PROVIDER SCOPE OF PRACTICE ..................................................................... 24 ALS APPROVED MEDICATIONS ................................................................................. 37 GLOSSARY....................................................................................................................... 41 INDEX ............................................................................................................................ 44

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Executive Summary

The purpose of this program is to provide a systematic approach for the creation of a continuous quality improvement program. In the Eastern Pennsylvania EMS Council Region, St Lukes Emergency Medical Services is comprised of (2) Two Advanced Life Support EMS stations. Station 73 is located in Lehigh County Region and provides EMS Services to various muncipalities throughout the region Station 40 is located in Schuylkill County and Provides EMS Services to various municipalities throughout the region St Lukes Emergency and Transport Services is committed to providing the highest level of pre-hospital care to all patients in all situations. Enclosed within these pages is the program that will allow us to meet these goals.

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INTRODUCTION TO CONTINUOUS QUALITY IMPROVEMENT

Continuous Quality Improvement (CQI) is an important concept in Emergency Medical Services. It consists of continuous review with the purpose of identifying and correcting aspects of our EMS system that require improvement. Once issues are identified, a plan is developed and implemented to prevent further occurrences. CQI is a system that is designed and performed to assure that patients receive the highest quality of care. There are some obstacles for CQI in EMS. Some EMS providers think that CQI is associated with Bad outcome and Disiplinary procedures. As EMS providers, we have roles in the CQI process. There are several ways we as providers can work toward providing the highest level of pre-hospital care. These are some examples:

• Documenting all aspects of EMS Incidents

• Becoming involved in the CQI process

• Complying with All Eastern PA EMS Council Regional Protocols

• Complying with DOH, And EMS Council Regulations.

• Striving to learn and to improve your self by education and training.

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CONTINUOUS QUALITY IMPROVEMENT PLAN

Purpose: Our Quality and Performance Improvement Plan is Designed to:

1. Ensure that patients receive the quickest, highest quality and most appropriate care.

2. Identify deviations from the Regional Patient Care Protocols.

3. Provide a mechanism for identifying system, service and practitioner deficiencies and ensuring corrective action and remediation are taken as needed.

4. Provide a tool for assessing the quality of training received by practitioners.

Method We utilize the “continuous quality improvement” model for our quality improvement plan. Our driving force is each participant in the organization, whether they are a patient, client, supervisor, board member, EMT or Paramedic, they all have a vested interest in what occurs with this organization and in ensuring that we deliver the highest quality care in the region and state.

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Process Each time that an ambulance is dispatched, a Patient Care Report (PCR) will be generated. PCRs will be completed within 24 hours as outlined in the Rules and Regulations, §1001.41 (d), which states:

d) When an ambulance service transports a patient to a hospital, before its ambulance departs from the hospital, it shall provide to the individual at the hospital assuming responsibility for the patient, either verbally, or in writing or other means by which information is recorded, the patient information designated in the EMS patient care report as essential for immediate transmission for patient care. Within 24 hours following the conclusion of its provision of services to the patient, the ambulance service shall complete the full EMS patient care report and provide a copy or otherwise transmit the data to the receiving facility. The ambulance service may report the data to the receiving facility in any manner acceptable to the receiving facility which ensures the confidentiality of information designated as confidential in the EMS patient care report.

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All PCRs will be reviewed for completeness. They also will be reviewed for the following parameters: Times:

1. Dispatch to enroute (see mobilization and response chart for guidance)

2. Enroute to onscene (see mobilization and response chart for guidance)

3. On scene time (see mobilization and response chart, justification chart for guidance)

Physical Exam

1. Completeness of documented physical examination 2. Documented initial vital and ongoing vitals signs, to include, at a

minimum two sets of vitals (GCS, heart rate, respiratory rate, blood pressure, and SPO2 (if available))

3. Completeness of ongoing reassessment/PE Treatment

1. Appropriate use and choice of protocol. 2. Appropriate notification of medical command (applicable to BLS

also) 3. Appropriate treatment

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Chart Review: Reviewing PCRs is a vital part of the QI process because it allows the service to evaluate its practitioner’s documentation skills, as well as treatment modalities. In order to review the practices that pose the greatest risk to our patients, 100% Of ALL PCRs will be reviewed. Problem Identification Any problems or trends identified will be brought to the attention of the following: Service QI representative/Officer Supervisor/Chief of Operations Service Medical Director Regional

.

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EASTERN PA EMS COUNCIL CQI

Regional Quality Assurance Indicators The Regional Medical Director (or designee) shall objectively and systematically monitor and evaluate the quality and appropriateness of patient care for all BLS and ALS patients that meet the quality assurance indicator criteria. The criteria will be developed and reviewed on a yearly basis by the EMS Council, the Regional Medical Directors, the Regional ALS and BLS Committees and the State Quality Assurance Committee. These criteria will identify the type of patients that will be monitored. These indicators reflect the essential elements of care that should be provided for patients that meet the criteria. PCRs of those patients that meet the criteria will be reviewed. The procedure will be as follows:

1. Each service will submit trip sheets to the EMS Council. ALS service PCRs will be submitted by the eighth (8th) calendar day of the following month. BLS service trip sheets will be submitted by the fifteenth (15th) day of the following month. If electronic transmission of trip sheet data has been utilized, the information will be obtained from the EMSCAN program.

2. The Regional Medical Director or his designee will conduct a medical audit on the trip sheets that meet the indicator criteria. A sample check may also be conducted at this time.

3. Each quarter the Regional Medical Director or his designee will review the reports that have been submitted in compliance with the regional quality assurance plan.

4. Each quarter the Regional Medical Director will forward a copy of the regional quarterly reports to the State Emergency Medical Director.

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Problem Identification Problems may be identified by the following methods:

1. Audits of PCRs 2. Review of quarterly reports 3. Submission of regional confidential quality assurance reports 4. Hospital complaints 5. service complaints 6. citizen complaints

Problems that indicate a system trend will be reviewed be the EMS Council Staff and forwarded to the Regional Quality Assessment and Improvement Committee or other appropriate committee. Problems that involve individual services or providers will be reviewed by EMS Council Staff. If the Service Medical Director or officers of the service have addressed the matter adequately, the documentation of the problem will be added to the appropriate file. If further action is needed the problem will be directed to the DOH or to the QA&I Committee as appropriate.

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Remediation Problems or deficiencies that have not been addressed by the SMD and have been forwarded to the QA&I Committee for review will be dealt with in a suitable manner. The QA&I Committee will recommend actions to be taken to resolve system problems to the EMS Council Staff. Emphasis will be on preventing further occurrences of the problem or correcting deficiencies through additional training, retraining and/or counseling. Corrective actions will be consistent from one occurrence to another. Education Upon approval of this plan, it shall be the Regional EMS Council’s responsibility to educate the services and the SMDs in the use of this plan. The EMS Council will provide support for implementation of service programs and assist the quality assurance officers in maintaining their quality assurance plans.

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EASTERN PA EMS COUNCIL BLS CQI

BLS Quality Indicators

1. Adequate documentation 2. Minimum staffing requirements 3. Equipment availability/failure 4. Utilization of ALS 5. Utilization of aeromedical evacuation 6. Delay in response 7. Delay in patient treatment/transport 8. Appropriate Treatment

a. Airway control b. Appropriate bleeding and wound care c. Fractures splinted d. Appropriate immobilization e. Re-evaluation of patient condition

9. Appropriate handling and documentation of Patient refusals Problem Identification Each quarter, the Service will submit a report that has been reviewed by the SMD. Criteria and format of the quarterly report will be determined by the CQI Officer, with input from the SMDs, hospital personnel, EMS providers, and EMS Council staff. Problems that are identified through the review of the quarterly reports or through monthly audits will be handled at the service level first. Problems that are identified as system problems should be forwarded to the EMS Council office, which may send the problem to an appropriate committee for resolution. Problems identified by other pre-hospital EMS providers, hospital personnel; physicians and/or citizens will be handled with strict confidentiality. If a Quality Improvement Report is completed and the DOH requests an investigation of the complaint, the Services QI contact person will be contacted in writing with a request for assistance in conducting the investigation.

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EASTERN PA EMS COUNCIL BLS CQI

Remediation If the service’s QI contact identifies a problem, they should seek to remediate the situation through counseling of the provider. If the problem continues, the QI officer should forward the documentation of the problem and attempts to at the remediation to the chief operations officer or other appropriate person in the service. If this person cannot resolve the problem, the SMD should be consulted. Any problems that cannot be resolved at a service level must be sent, with appropriate documentation to the EMS Council. If the problem could result in a provider’s certification being suspended or revoked, the documentation will be sent to the DOH for investigation.

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EASTERN PA EMS COUNCIL ALS CQI

General Requirements Each ALS service within the region will be responsible for developing a quality assurance program that will aide in identifying problems affecting patient care. Each service is required to comply with the following:

1. Have a service Medical Director who meets the requirements of that position as stated in Act 82, Rules and Regulations. The Service Medical Director’s duties shall be all of those listed in the Rules and Regulations as well as participating in the development and implementation of quality improvement activities.

2. Appoint an individual to act as the primary point of contact for quality improvement issues and who will insure that all QI requirements are met. The name of the QI contact will be furnished to the EMS Council.

3. Conduct a monthly audit of patient care utilizing the QI indicators established by the QI Committee and other indicators as defined by the Service Medical Director or Service QI rep. All audits will maintain the strictest confidentiality.

4. Submit a Quarterly Report to the EMS Council Director of QI as formulated by the Regional Quality Assessment and Improvement Committee and the ALS ad hoc QA Committee. Prior to transmission, the reports will be reviewed and approved by the Service Medical Director prior to submission. Any deficiencies and corrective actions taken will be included.

5. Ensure that all personnel meet the certification and continuing education requirements for the State and Region.

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ALS Quality Indicators Each month the ALS Service Quality Improvement Designate shall review each patient care record for completion and for compliance with the following quality indicators:

1. Adequate documentation (CC, PMH, HPI, meds, allergies, PE, TX and results, command contact)

2. Minimum staffing compliance 3. Equipment availability and failures 4. Utilization of aero-medical evacuation 5. Appropriate receiving facilities (i.e. trauma for trauma, peds

for peds, burns for burns) 6. Delay in response, extended response times 7. Delay in patient treatment and transport

8. Appropriate treatment:

a. Appropriate airway management b. Bleeding and wound control c. Immobilization d. Reevaluation of patient’s condition

9. Appropriate handling and documentation of patient refusals 10. Appropriate release of patients to BLS care

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ALS Service Reporting Requirements Each Month the ALS Service will submit a report with the following items included (format to be developed at a later date):

1. Staffing – to show which provider staffed each six hour block of each day of the month.

2. Quantity Indicators – Details each successful and unsuccessful skill that an ALS provider performed, as well as the number of hours that each provider worked.

3. Medication inventory- Inventory of all of the medications that are carried on each unit. The SMD or their designee must count these medications and verify the quantities present.

4. Controlled Substance Checklists – The log of each time a provider checked and confirmed the quantity and expiration dates of controlled substances on each unit.

5. Controlled Substance Usage Log – Report of each time that a controlled substance was used, detailing time, date, ordering MCP and disposition of unused substance.

6. If the ALS service performs ALS inter-facility transports, a report must be submitted detailing the following

a. Dates of transports b. EMS form numbers c. Length of transport d. Medications given beyond the scope of practice of a

paramedic e. Name of RN or MD who accompanied the patient (if

applicable) f. What facility provided medical command for the

transport

Each ALS inter-facility transport must be review by the SMD, who must sign the report.

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Each calendar quarter of the year, each ALS service will submit a quarterly report. The quarterly report will contain quality assurance indicators and parameters. The indicators and parameters will be reviewed at least yearly and revised as recommended by the ALS ad hoc QA committee, the Regional Medical Directors, and/or the Regional Quality Assessment and Improvement Committee. Indicators should include, but not be limited to the following:

1. Actual enroute time 2. Response time 3. on scene time (trauma and medical with separate thresholds

for each) 4. Rendezvous time 5. Deviation from regional protocols 6. Reasons for failure to make contact with medical command 7. Appropriateness of care rendered

The quarterly report must be reviewed by the SMD who will document what steps, if any, are being taken to correct deficiencies noted.

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Problem Identification Problems that are identified through the monthly review, the quarterly review, written complaints from other EMS providers or hospital personnel or written citizen complaints will be handled at the service level first. The Quality Assurance Officer will investigate the complaint or document the deficiencies and provide counseling or retraining for the provider. If a specific deficiency continues to occur, the QA Officer may forward documentation of the problem to the chief or other appropriate officer within the organization. This officer may choose to counsel the individual or forward the problem to the SMD. The SMD may order additional retraining of the individual or other actions as provided for in Act 82 (Rules and Regulations). If the SMD feels that there is a system problem, they may forward documentation of the problem to the RMD. Problems that are identified as system problems will be forwarded to the EMS Council Office. Individual deficiencies that may result in disciplinary action will be forwarded to the Department of Health, routed via the EMS Council Office, for investigation. If a Quality Assurance Report is completed and the DOH requests an investigation of the complaint, the ALS Service’s identified contact person (QAO) will be contacted in writing with a request for help in conducting the investigation. Remediation If an ALS service’s QAO identifies a problem, he should first seek to remediate the problem the situation through counseling or retraining of the provider. The emphasis of remediation is placed on retraining rather than punitive actions. Retraining may take the form of repetition of certain portions of the paramedic training program, ACLS, PALS, PHTLS, etc. The provider may be required to write an essay or paper about appropriate care in identified cases.

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MONTHLY MEDICATION INVENTORY FORM

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ALS QUARTERLY CQI REPORT

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ALS CQI FORM

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BLS QUARTERLY REPORT

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BLS CQI FORM

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EMS PROVIDER SCOPE OF PRACTICE

NOTICES

Pre-hospital Practitioner Scope of Practice

[34 Pa.B. 3988]

Under 28 Pa. Code §§ 1003.21(c)(13), 1003.22(e)(3), 1003.23(f), 1003.24(e) and 1003.25b(c), the Department of Health (Department) is publishing the scope of practice for ambulance attendants, first responders, emergency medical technicians (EMT), EMT-paramedics and pre-hospital registered nurses (PHRN) under the Emergency Medical Services Act (35 P. S. §§ 6921--6938).

Skills identified may be performed by a pre-hospital practitioner at the practitioner's level of certification/recognition only if the practitioner has successfully completed training (cognitive, affective and psychomotor) on the specified skill, which includes training to perform the skill on adults, children and infants, as appropriate.

A PHRN with medical command authorization may perform, in addition to those services within an EMT-paramedic's scope of practice, other services authorized by The Professional Nursing Law (63 P. S. §§ 211--225.5), when authorized by a medical command physician through either on-line medical command or standing medical treatment protocols. To administer drugs in addition to those permitted by applicable medical treatment protocols, a PHRN must also have received approval to do so by the advanced life support service medical director of the advanced life support ambulance service under which the PHRN is functioning.

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This list supersedes the list of skills in the scope of practice of pre-hospital personnel published at 33 Pa.B. 2713 (June 7, 2003). Changes made are: (1) clarification related to immunizations. Immunizations may only be done when the practitioner is functioning as a physician extender under the Medical Practice Act of 1985 (act) (63 P. S. §§ 422.1--422.51a) and Osteopathic Medical Practice Act (63 P. S. §§ 271.1--271.18).

Persons with a disability who require an alternate format of this notice (for example, large print, audiotape or Braille) should contact Bob Gaumer, Department of Health, Emergency Medical Services Office, Room 1032, Health and Welfare Building, Harrisburg, PA 17120, (717) 787-8740. Speech or hearing impaired persons should call by using V/TT (717) 783-6154 or the Pennsylvania AT&T Relay Service at (800) 654-5984 (TT).

CALVIN B. JOHNSON, M.D., M.P.H., Secretary

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Yes--The skill is in the scope of practice for the level of certification.

No--The skill is not in the scope of practice for the level of certification.

AA--Ambulance attendant.

FR--First responder.

EMT--Emergency medical technician.

EMT-P--Emergency medical technician paramedic.

1--May assist higher level practitioner only when in the physical presence and under the direct supervision of the ALS practitioner.

2--Additional training and approval by service medical director required.

3--The skill may be performed by BLS personnel in accordance with Statewide BLS protocols or medical command order.

4--The skill is not approved for the level of certification regardless if taught in a course approved for that level of certification.

5--The acronym is explained following the table.

6--Skill may only be used when functioning with a licensed ambulance service or QRS that complies with Department requirements for performing this skill.

7--May only be done as a physician extender under the act.

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Topic Skill AA FR EMT EMT-P

Airway/ventilation/oxygenation

Airway--esophageal tracheal--dual lumen CombiTube®

No No No Yes


Airway--oral and nasal

Yes Yes Yes Yes


Airway--pharyngeal tracheal lumen

No No No No4


Bag-valve-ETT/CombiTube® ventilation

No Yes1

Yes1 Yes


Bag-valve-mask (BVM)--with in-line small-volume nebulizer

No Yes1

Yes1 Yes


BVM ventilation Yes Yes Yes Yes


Chest decompression--needle

No No No Yes


CPAP/BiPAP5--demonstrate application of

No No No Yes


Cricoid pressure (Sellick maneuver)

No Yes Yes Yes


Cricothyrotomy--needle

No No No Yes


Cricothyrotomy--open/surgical

No No No Yes


Cricothyrotomy--overwire (Seldinger) technique

No No No Yes


End tidal CO2 monitoring/capnograp

No Yes1

Yes1 Yes

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Esophageal obturator airway/esophageal gastric tube airway

No No No No4


Extubation No No No Yes


Flow restricted oxygen powered ventilation device (demand valve)

No Yes Yes Yes


Gastric decompression--OG5 and NG5 tube (suction)

No No No Yes


Gastric tube insertion--nasal and oral

No No No Yes


Head-tilt/chin-lift Yes Yes Yes Yes


Intubation--digital and lighted stylet

No No No Yes


Intubation--endotracheal tube

No No No Yes


Intubation--medication paralytics assisted (RSI5)

No No No No4


Intubation--nasotracheal and orotracheal

No No No4 Yes


Intubation--retrograde

No No No No4


Intubation--transillumination/lighted stylet

No No No Yes


Jaw thrust and modified jaw thrust (trauma)

Yes Yes Yes Yes


Laryngeal mask airway

No No No No4


Mouth-to-mouth, nose, stoma, barrier and pocket mask

Yes Yes Yes Yes

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Obstruction--direct laryngoscopy (remove with forceps)

No No No Yes


Obstruction--manual (Heimlich, finger sweep, chest thrusts) upper airway

Yes Yes Yes Yes


Oxygen therapy--blow-by delivery

Yes Yes Yes Yes


Oxygen therapy--humidifiers

No Yes Yes Yes


Oxygen therapy--nasal cannula

Yes Yes Yes Yes


Oxygen therapy--nonrebreather mask

Yes Yes Yes Yes


Oxygen therapy--partial rebreather

No Yes Yes Yes


Oxygen therapy--regulators

Yes Yes Yes Yes


Oxygen therapy--simple face mask

Yes Yes Yes Yes


Oxygen therapy--Venturi mask

No No No Yes


Peak expiratory flow assessment

No No No Yes


Pulse oximetry Yes1

Yes2

Yes2 Yes


Suctioning--meconium aspiration

No No No Yes


Suctioning--stoma No No Yes Yes


Suctioning--tracheobronchial

No No No Yes


Suctioning--upper airway (nasal)

No Yes Yes Yes


Suctioning--upper airway (oral)

Yes Yes Yes Yes


Transtracheal jet ventilation

No No No Yes

Airway/ventilation/oxygen Ventilators-- Yes Yes Yes2 Yes

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ation automated transport (ATV)

1 2

Assessment of Glasgow Coma Scale Yes Yes Yes Yes Assessment of Level of

consciousness Yes Yes Yes Yes

Assessment of Patient assessment skills identified in the NSC5

Yes Yes Yes Yes

Assessment of Vital sign--body temperature

Yes Yes Yes Yes

Assessment of Vital sign--pulse Yes Yes Yes Yes Assessment of Vital sign--pupils Yes Yes Yes Yes Assessment of Vital sign--

respirations Yes Yes Yes Yes

Assessment of Vital sign--skin color/temperature and condition (CTC)

Yes Yes Yes Yes

Cardiovascular/circulation Blood pressure--auscultation

Yes Yes Yes Yes

Cardiovascular/circulation Blood pressure--electronic noninvasive

Yes Yes Yes Yes

Cardiovascular/circulation Blood pressure--palpation

Yes Yes Yes Yes

Cardiovascular/circulation Cardiac monitoring--apply electrodes

No Yes1

Yes1 Yes

Cardiovascular/circulation Cardiac monitoring--multilead

No No No Yes

Cardiovascular/circulation Cardiac monitoring--single lead (interpretive)

No No No Yes

Cardiovascular/circulation Cardiopulmonary resuscitation (CPR) adult, infant, child, one and two person

Yes Yes Yes Yes

Cardiovascular/circulation Cardioversion--synchronized

No No No Yes

Cardiovascular/circulation Carotid massage (vagal maneuvers)

No No No Yes

Cardiovascular/circulation Defibrillation--counter shock--manual

No No No Yes

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Cardiovascular/circulation Defibrillation--automated external defibrillator

Yes2

Yes2

Yes2 Yes

Cardiovascular/circulation Hemodynamic monitoring/assist (Swan Ganz, arterial, central venous lines)

No No No No4

Cardiovascular/circulation Intra-aortic balloon pump monitoring/assist

No No No No4

Cardiovascular/circulation Mechanical CPR device

No No No Yes

Cardiovascular/circulation Military/pneumatic antishock trousers/garment (MAST5)

No No Yes Yes

Cardiovascular/circulation Thrombolytic therapy--initiation

No No No No4

Cardiovascular/circulation Thrombolytic therapy--monitoring

No No No No4

Cardiovascular/circulation Transcutaneous pacing

No No No Yes

Cardiovascular/circulation Use a (cardiac) magnet to alter the mode of an AICD5 or pacemaker

No No No Yes

Communications Verbal patient report to receiving personnel

No Yes Yes Yes

Communications Communications with PSAPs5, hospitals, medical command facilities

Yes Yes Yes Yes

Documentation Out-of-hospital do not resuscitate (DNR) orders (Act 59)

Yes Yes Yes Yes

Documentation Patient Care Report completion

No Yes Yes Yes

Hazardous materials Contaminated equipment disposal (sharps and PPE5)

Yes Yes Yes Yes

Hazardous materials Decontamination Yes Yes Yes Yes

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Hazardous materials Disinfection Yes Yes Yes Yes Hazardous materials PPE5 use Yes Yes Yes Yes Immobilization PASG/MAST5--pelvic

stabilization No No Yes Yes

Immobilization Spinal immobilization--helmet stabilization or removal

No No Yes Yes

Immobilization Spinal immobilization--long board w/pt supine and standing

Yes Yes Yes Yes

Immobilization Spinal immobilization--manual stabilization and cervical collar

Yes Yes Yes Yes

Immobilization Spinal immobilization--rapid extrication

No No Yes Yes

Immobilization Spinal immobilization--seated patient (KED©5, and the like)

No No Yes Yes

Immobilization Splinting--manual, ridged, soft, vacuum

Yes Yes Yes Yes

Immobilization Splinting--traction Yes Yes Yes Yes IV initiation/maintenance/fluids

Central venous cannulation (femoral vein only)

No No No Yes

IV initiation/maintenance/fluids

Central venous line--access of existing catheters

No No No Yes


Clean technique No No No Yes


External jugular vein cannulation

No No No Yes


Heparin/saline lock insertions as no-flow intravenous (IV)

No No No Yes


Indwelling IV catheters as described in 28 Pa. Code § 1003.23(e)(2)

No No Yes Yes

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(relating to EMT) IV initiation/maintenance/fluids

Intraosseous--needle placement and infusion--anterior tibia or distal femur

No No No Yes


Peripheral venous--initiation (cannulation)

No No No Yes


Subcutaneous indwelling catheters--access of existing catheters

No No No Yes


Vascular access devices in home healthcare--access of existing catheters

No No No Yes


Venous (blood sampling)--obtaining

No No No Yes


Venous central line (blood sampling)--obtaining

No No No No4


Arterial line--capped--transport

No No Yes Yes


Arterial line--monitoring/assist

No No No No4


Blood/blood-by products

No No No No4

Lifting and moving Patient lifting, moving and transfers per NSC5

Yes Yes Yes Yes

Lifting and moving Patient restraints on transport devices

Yes Yes Yes Yes

Medication administration routes

Endotracheal tube No No No Yes


Inhalation (aerosolized/nebulized)

No No No Yes

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Intramuscular No No No Yes


Intraosseous--anterior tibia or distal femur

No No No Yes


IV--bolus No No No Yes


IV infusion, including by IV pump

No No No Yes


Nasogastric No No No Yes


Oral No No No Yes


Rectal No No No Yes


Subcutaneous No No No Yes


Sublingual No No No Yes


Topical No No No Yes


Auto-injectors No No Yes3 Yes

Medications Activated charcoal No No Yes3 Yes Medications As published in the

Pennsylvania Bulletin by the Department

No No No Yes

Medications Immunizations No No No Yes7 Medications Oral glucose No No Yes3 Yes Medications Over-the-counter

medications No No No No4

Medications Oxygen Yes Yes Yes Yes Medications Autoinjected

epinephrine--primary use--not patient's prescription

No No Yes2, 3,

6 Yes

Medications--patient assisted

Autoinjected epinephrine

No No Yes3 Yes


Metered dose inhaler--bronchodilator

No No Yes3 Yes

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Nitroglycerin No No Yes3 Yes

Patient assessment/management

Behavioral--restrain violent patient

No No Yes Yes


Blood glucose assessment

No No No Yes


Burns--chemical, electrical, inhalation, radiation, thermal

Yes Yes Yes Yes


Childbirth--umbilical cord cutting

No Yes Yes Yes


Childbirth (abnormal/complications)

No No Yes Yes


Childbirth (normal)--cephalic delivery

Yes Yes Yes Yes


Dislocation reduction (shoulder)

No No No No4


Eye irrigation/care Yes Yes Yes Yes


Hemorrhage control--diffuse, direct, pressure point, tourniquet, bandaging

Yes Yes Yes Yes


Intracranial monitoring/assist

No No No No4


As outlined in Department approved regional and Statewide TX5 and transport protocols

Yes Yes Yes Yes


Multiple casualty incident/incident command system

No Yes Yes Yes


Triage (prioritizing patients)--use of tags

Yes Yes Yes Yes


Urinary catheterization

No No No Yes

Rescue Vehicle access and extrication

Yes Yes Yes Yes

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Acronym Explanation AICD Automatic implantable cardioverter defibrillators CPAP/BiPAP Continuous positive airway pressure/biphasic positive

airway pressure KED Kendrick extrication device NSC United States Department of Transportation National

Standard Curriculum OG and NG Oral gastric and nasal gastric tube PASG/MAST Pneumatic antishock garment/military antishock

trousers PPE Personal protective equipment PSAP Public safety answering point RSI Rapid sequence induction TX Treatment

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ALS APPROVED MEDICATIONS

NOTICES DEPARTMENT OF HEALTH

Approved Drugs for ALS Ambulance Services

[34 Pa.B. 3987]

Under 28 Pa. Code § 1005.11 (relating to drug use, control and security), the following drugs are approved for use by ground advanced life support (ALS) ambulance services and may be administered by emergency medical technician-paramedics, pre-hospital registered nurses and health professional physicians when use of the drugs is permitted by the applicable Department of Health (Department) approved regional medical treatment protocols:

1. Adenosine

2. Albuterol

3. Amiodarone

4. Aspirin

5. Atropine sulfate

6. Benzocaine--for topical use only

7. Bretylium

8. Calcium chloride

9. Dexamethasone sodium phosphate

10. Diazepam

11. Dilaudid--for interfacility transports only

12. Diltiazem

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ALS APPROVED MEDICATIONS

13. Diphenhydramine HCL

14. Dobutamine

15. Dopamine

16. Epinephrine HCL

17. Fentanyl

18. Furosemide

19. Glucagon

20. Heparin by intravenous drip--for interfacility transports only

21. Heparin lock flush

22. Hydrocortisone sodium succinate

23. Glycoprotein IIb/IIIa Inhibitors--for interfacility transports only

a. Abciximab

b. Eptifibatide

c. Tirofiban

24. Intravenous electrolyte solutions

a. Dextrose

b. Lactated Ringer's

c. Sodium chloride

d. Normosol

e. Potassium--for interfacility transports only

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25. Ipratropium bomide

26. Isoproterenol HCL--for interfacility transports only

27. Levalbuterol--for interfacility transports only

28. Lidocaine HCL

29. Lorazepam

30. Magnesium sulfate

31. Metaproterenol

32. Methylprednisolone

33. Midazolam

34. Morphine sulfate

35. Naloxone HCL

36. Nitroglycerin by intravenous drip--for interfacility transports only

37. Nitroglycerin ointment

38. Nitroglycerin spray

39. Nitroglycerin sublingual tablets

40. Nitrous oxide

41. Oxytocin

42. Phenergan

43. Pralidoxime CL

44. Procainamide

45. Sodium bicarbonate

46. Sodium thiosulfate

47. Sterile water for injection

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48. Terbutaline

49. Tetracaine--for topical use only

50. Verapamil

This list supersedes the list of approved drugs published at 33 Pa.B. 2713 (June 7, 2003). Changes made are as follows: (1) addition of Levalbuterol for interfacility transports only; (2) addition of Ipratropium bromide; and (3) change of Benzocaine Tetracaine in combination to separate listings of Benzocaine and Tetracaine for topical use. Ambulance services are not authorized to stock drugs designated ''for interfacility transports only.'' However, paramedics and health professionals may administer a drug so designated if the facility transferring a patient provides the drug, directs that it be administered to the patient during the transfer and the regional transfer and medical treatment protocols permit the administration of the drug by those personnel.

Section 1005.11 of 28 Pa. Code permits a ground ALS ambulance service to exceed, under specified circumstances, the drugs (taken from the master list) that a region's medical treatment protocols authorize for use within the region. In addition, under 28 Pa. Code § 1001.161 (relating to research), the Department may approve an ambulance service to engage in a research project that involves use of a drug not included in a region's medical treatment protocols. Finally, under 28 Pa. Code § 1001.4 (relating to exceptions), a ground ALS ambulance service and its ALS service medical director may apply to the Department for an exception to a region's medical treatment protocols.

The list of drugs in this notice does not apply to air ambulance services. Under 28 Pa. Code § 1007.7(i)(2) (relating to licensure and general operating requirements), each air ambulance service is to develop its own medical treatment protocols which identify drugs that may be used by the air ambulance service. The air ambulance service is to then submit the protocols to the medical advisory committee of the appropriate regional emergency medical services council for the medical advisory committee's review and recommendations. Following its consideration of the recommendations, and after making further revisions if needed, the air ambulance service is to file the protocols with the Department for approval.

Persons with a disability who require an alternate format of this notice (for example, large print, audiotape or Braille) should contact Robert Gaumer, Department of Health, Emergency Medical Services Office, Room 1032, Health and Welfare Building, Harrisburg, PA, 17120, (717) 787-8740, speech or hearing impaired persons may use V/TT: (717) 783-6154 or the Pennsylvania AT&T Relay Service at (800) 654-5984 (TT).

CALVIN B. JOHNSON, M.D., M.P.H., Secretary

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GLOSSARY

Advanced Life Support–The advanced pre-hospital and inter-facility emergency medical care of serious illness, or injury by appropriately trained health professionals and certified EMT-Paramedics. ALS Services – Any service that provides Advanced Life Support care to patients ALS Squad Unit – A vehicle which carries ALS personnel and ALS equipment, but is not capable of patient transport. Usually used to assist BLS units on ALS calls. ALS Service Medical Director –A medical command physician or a physician meeting the equivalent qualifications in section 1003.5(relating to ALS service medical director) who is employed by, contracts with or volunteers with either directly, or through an intermediary, and ALS ambulance service to make medical command authorization decisions, provide medical guidance and advice to the ALS ambulance service and evaluate the quality of patient care provided by the pre-hospital personnel utilized by the ALS ambulance service. Basic Life Support – (BLS) The basic pre-hospital or inter-facility emergency medical care and management of illness and injury performed by trained and/or certified personnel. BLS Services – Any service which is licensed to provide ambulance service at the Basic Life Support level of care. Department – The Department of Health of the Commonwealth of Pennsylvania or its designee. Director of Quality Improvement (DQI) - the individual on the EMS Council Staff that administers the Regional Quality Assurance/Improvement program. Emergency Medical Services Office (EMSO) – An office within the Department of Health which is responsible for the tasks identified under Title 28, section 1001.1.

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Emergency Medical Technician (EMT) – an individual trained to provide pre-hospital emergency medical treatment and certified as such by the DOH in accordance with the current National Standard Curriculum for basic EMTs. Emergency Medical Technician-Paramedic (EMT-P)- An individual who is trained to provide pre-hospital emergency medical treatment at an advanced level and certified as such by the DOH under the current National Standard Curriculum for Paramedics. First Responder – An individual who holds current CPR certification as well as a valid certificate of successful completion of a training program that conforms to the National Standard Curriculum approved by the DOH. Health Professional (HP) – A licensed physician who has education and continuing education in ALS and pre-hospital care, or a professional registered nurse. Medical Advisory Committee (MAC) – An advisory body composed of a majority of physicians, to advise a regional EMS Council or the Council on issues that have potential impact on the delivery of emergency medical care. Medical Command – An order given by a medical command physician to a pre-hospital practitioner in a pre-hospital, inter-facility or emergency care setting in a hospital, to provide immediate medical care to prevent loss of life or aggravation of physiological illness, or to withdraw or withhold treatment. Medical Command Authorization – Permission given by the ALS service medical director, including an air ambulance medical director, to an EMT-Paramedic, or a pre-hospital registered nurse, under section 1003.28 (relating to medical command authorization) to perform, on behalf of an ALS ambulance service, ALS services under medical command or in accordance with the Department approved regional EMS Council transfer and medical treatment protocols, when medical command cannot be secured, is disrupted or is not required under the approved Regional EMS Council transfer and medical treatment protocols.

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Medical Command Facility (MCF) –The distinct unit within a facility that contains the necessary equipment and personnel, as described in section 1009.1 (relating to operational criteria) for providing medical command to and control over pre-hospital personnel when providing medical command. Medical Command Facility Medical Director (MCFMD) –a medical command physician who meets the criteria established by the Department to assume responsibility for the direction and control of the equipment and personnel at a medical command facility. Medical Command Physician (MCP) – A physician licensed by the Commonwealth who meets the criteria set forth by the DOH for a medical command physician; has completed the Regional EMS Council training module; and is approved by the Regional Medical Director to provide medical command to pre and inter-hospital personnel. Mobile Intensive Care Unit (MICU) – An ambulance which carries ALS personnel and equipment and is capable of patient transport. Public Safety Answering Point (PSAP) – A communications center established to serve as the first point at which calls by or on behalf of patients are received requesting emergency medical assistance. Pre-Hospital Registered Nurse (PHRN) – an individual recognized by the Department as having medical command authorization to provide pre-hospital ALS care. Quality Assurance & Improvement Committee(QA&I) – a committee of the Regional EMS Council that is charged with reviewing and recommending changes to the EMS Council, services, providers and facilities within the EMS system as needed for improvements in the delivery of patient care. Quality Assurance Officer (QAO) – the designated responsible party at the BLS or ALS service that is charged with handling the QA/QI duties for the service. Quick Response Service (QRS) – An entity recognized by the Department to respond to an emergency and provide EMS to patients pending the arrival of the pre-hospital personnel of an ambulance service.

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INDEX

A Airway--esophageal tracheal--dual lumen

CombiTube®, 27 Airway--oral and nasal, 27 ALS CQI FORM, 21 ALS inter-facility transp, 16 ALS Quality Indicators, 15 ALS QUARTERLY CQI REPORT, 20 ALS Service Medical Director, 41 Amiodarone, 37 Appropriate treatment, 7

B Basic Life Support, 41 BLS CQI FORM, 23 BLS Quality Indicators, 12 BLS QUARTERLY REPORT, 22 BVM ventilation, 27

C Calcium chloride, 37 Chart Review:, 8 completed within 24 hours, 6 CONTINUOUS QUALITY IMPROVEMENT PLAN, 5 Controlled Substance Checklists, 16 Controlled Substance Usage Log, 16 Cricothyrotomy--needle, 27

D Dispatch to enroute, 7 Documenting all aspects of EMS Incidents,

4

E EASTERN PA EMS COUNCIL ALS CQI, 17 Education, 11 EMS PROVIDER SCOPE OF PRACTICE, 24 Executive Summary, 3 Extubation, 28

F Fentanyl, 38

G GLOSSARY, 41

I INTRODUCTION TO CONTINUOUS QUALITY

IMPROVEMENT, 4 Intubation--retrograde, 28

L Laryngeal mask airway, 28

M Medical Command Facility (MCF), 43 Medical Command Physician (MCP), 43 Medication inventory, 16 Method, 5 MONTHLY MEDICATION INVENTORY FORM, 19

O obstacles for CQI, 4 Oxytocin, 39

P Physical Exam, 7 practitioner's level of certification, 24 Problem Identification, 8

Q Quality Assurance Officer (QAO), 43

R Regional Quality Assurance Indicators,

9 Remediation, 11

S service Medical Director, 14 St Lukes Emergency Medical Services, 3 Staffing, 16 Station 40, 3 Station 73, 3

qa/qi plan station 73 / 40

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