New York State Department of Health Bureau of

New York State Department of Health Bureau of
No.
17 - 01
Date: February 8, 2017
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 93-07, 87-38 and 99-04
Re: Advanced Standing
in EMS Certification
Programs
Page 1 of 3
I. Purpose
The purpose of this Policy Statement is to delineate procedures for granting Advanced Standing in
Emergency Medical Services certification courses (Basic EMT, Advanced EMT, EMT-Critical Care and
EMT-Paramedic), excluding Certified First Responder.
EMS course sponsors may need to recognize the experience and expertise that medical professionals
bring to their courses. This will require tailoring programs to avoid redundancy and repetition and
recognize an individual’s education and experience. When appropriate, course sponsors, in
consultation with their Medical Director and Certified Instructor Coordinator (CIC), are encouraged to
review and evaluate the experience and education of a student and grant "advanced standing." This
should be based on competency based evaluations and take the form of waived attendance of specific
class sessions for the individual or a modified course schedule for the class.
The sponsor, Medical Director and CIC must evaluate a candidate’s prior experience and education
with the understanding of the specific course objectives for each certification level. While some
candidates may be competent in a particular objective, others may need review or may not have
covered the objective at all in their original course. Even a professional license does not guarantee a
candidate's competency in all of the specific objectives of an EMS certification course. As an example,
a Registered Nurse (RN) who is a Certified Emergency Nurse (CEN), and has ACLS and ATLS or
equivalent training with work experience in an emergency department, may not need to complete a
small portion of a paramedic program and a field internship in order to complete all of the objectives.
While an RN with long term care experience may need to attend the majority of the paramedic course
in order to complete all of the objectives.
In order to determine an individual's educational needs it will require a review the student's prior
education and experience, as well as an assessment of current knowledge and skills.
II. Who Can Offer Advanced Standing?
In order to award advanced standing to medical professionals, the course sponsor must first have
completed two (2) or more full-original certification courses at the certification level for which advanced
standing is being sought. Any candidate seeking advanced standing must be registered in an EMS
original certification course.
17-01 Advanced Standing in EMS Certification Programs
1 of 3
III. Candidate Eligibility Requirements
Each candidate must meet the eligibility requirements as set forth in Title 10 NYCRR Part 800.6 as well
as for the course in which they are enrolled. Candidates seeking advanced EMS certification (AEMT,
EMT-CC or EMT-P), must have a NYS EMT certification that remains valid throughout the entire
training program. Further, to be eligible for advanced standing in an EMS certification course, the
candidate must have current certification or license in New York State, in one of the professions listed
below:










Certified First Responder
Emergency Medical Technician
Advanced EMT
EMT-Critical Care
Registered Nurse
Nurse Midwife
Nurse Anesthetist
Nurse Practitioner
Physician Assistant
Physician
Specific class sessions may be waived for Licensed Practical Nurses (LPN), Respiratory Therapist and
other medical and allied health professionals when appropriate and with approval of the Bureau of EMS
(BEMS) Central Office.
IV. Procedures
1.
The candidate must be enrolled in an original EMS certification course.
2.
The Medical Director and CIC must review and verify the candidate's credentials. This includes,
but may not be limited to obtaining copies of the following:
a)
b)
c)
d)
3.
Professional license(s);
Certification(s);
College transcripts;
Course completion records from relevant continuing education programs (e.g., CPR, ACLS,
PALS or equivalent, clinical training and experience).
The candidate's cognitive knowledge, psychomotor skills and clinical proficiency must be
assessed. The level of proficiency required to "waive" session attendance or to modify the class
schedule must be equal to or greater than the entry-level proficiency of a graduate from the
course.
a. Cognitive objectives must be evaluated through a formal written examination, which adequately
reflects each section of the current Educational Standards and curriculum. In many instances, the
exam make-up may be similar to the make-up of a “challenge” written exam that is administered at
the start of a refresher course. A blueprint of this exam must be developed, approved by the course
sponsor Medical Director and CIC, and kept on-file with all other course related paperwork.
b. Psychomotor objectives must be evaluated through a formal practical skills examination, which
adequately reflects the objectives in the current Educational Standards and curriculum. The course
sponsor is encouraged to develop scenario type evaluations that encompass multiple objectives in
lieu of evaluating each objective separately. A blueprint of this exam must be developed, approved
by the course sponsor Medical Director and CIC, and kept on-file with all other course related
paperwork.
17-01 Advanced Standing in EMS Certification Programs
2 of 3
c.
Individuals currently holding a NYS EMS certification (at the start of the first class session), may be
granted advanced standing, up to their current level of certification, without additional cognitive or
psychomotor testing. For example, a currently certified EMT- Critical Care who enrolls in a
Paramedic original course, may be given advanced standing for those components of the Paramedic
curriculum that are contained in the NYS EMT - Critical Care curriculum. Prior to approval, the
Paramedic course sponsor’s Medical Director may decide to conduct a portion, or all of the required
cognitive and psychomotor testing. Advanced standing must be approved by the Paramedic course
sponsor Medical Director.
4.
The course Medical Director may grant advanced standing for some or all of the objectives of the
hospital clinical and Field Internship for a candidate who can document prior hospital or
prehospital care experience relevant to specific objectives. The candidate must also demonstrate
the ability to serve as a team leader in a variety of prehospital emergency situations. These
requirements should not be more, or less than those required of all other students, as approved
by BEMS in the course sponsor’s policies and procedures.
5.
Once the decision is made by the course Medical Director to grant approval for advanced
standing, the candidate and CIC must sign a written agreement outlining the candidate's course
requirements.
6.
Once a candidate has successfully completed all course requirements to the satisfaction of the
course Medical Director, he/she is eligible to take the state certifying practical skills and written
examinations.
7.
If the course is conducted exclusively for students seeking advanced standing (i.e., a paramedic
course exclusively for EMT-CC's or a course exclusively for experienced emergency nurses),
after the assessment and evaluation of all of the candidates has been completed, the sponsor
needs to file a modified course schedule with the Department.
8.
The course sponsor must maintain, individual candidate files (student record) which includes a
copy of the student-sponsor agreement, all of the candidate's credentials, records of
performance on assessment exams (written and practical), field internship evaluation and
documentation of completion of all course requirements. If a Course Sponsor plans to offer
advanced standing they must develop written advanced standing policies and procedures as part
of their sponsorship agreement with BEMS.
V. Resources
For additional information refer to the following:
National EMS Education Guidelines
http://www.health.ny.gov/professionals/ems/national_education_standards_transition/
Educational Standards for each level of EMS certification
http://www.health.ny.gov/professionals/ems/national_education_standards_transition/docs/national_ed
ucation_standards.pdf
EMS Certification Practical Skills Matrix
http://www.health.ny.gov/professionals/ems/national_education_standards_transition/docs/2017_pse_c
hart.pdf
17-01 Advanced Standing in EMS Certification Programs
3 of 3
No. 17-02
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 00-01, 00-02, 11-08 & 14-02
Date: March 13, 2017
Re:
Epinephrine
Auto-Injectors
(EpiPen®)
Page 1 of 3
The purpose of this policy is to assist eligible entities defined by Article 30, section 3000-c
of the Public Health Law (PHL) in understanding the notification process for utilizing
epinephrine auto-injectors (i.e. EpiPen®). An epinephrine auto-injector program is
designed to encourage greater acquisition, deployment and use of epinephrine autoinjectors in an effort to reduce the number of deaths associated with anaphylaxis.
An “epinephrine auto-injector device" is defined as a single-use device used for the
automatic injection of a premeasured dose of epinephrine into the human body, approved
by the U.S. Food and Drug Administration for the purpose of emergency treatment of a
person appearing to experience anaphylactic symptoms.
Eligible entities are defined as:
1. An ambulance service or advanced life support first response service; a certified first
responder, emergency medical technician, advanced emergency medical technician or
paramedic, who is employed by or an enrolled member of any such service;
2. A children's overnight camp as defined in subdivision one of section thirteen hundred
ninety-two PHL, a summer day camp as defined in subdivision two of section thirteen
hundred ninety-two of PHL, a traveling summer day camp as defined in subdivision three of
section thirteen hundred ninety-two of PHL or a person employed by such a camp;
3. School districts, boards of cooperative educational services, county vocational education and
extension boards, charter schools, and non-public elementary and secondary schools in this
state or any person employed by any such entity;
4. A sports, entertainment, amusement, education, government, day care or retail facility; an
educational institution, youth organization or sports league; an establishment that serves
food; or a person employed by such entity; and
5. Any other person or entity designated or approved, or in a category designated or approved
pursuant to regulations of the commissioner in consultation with other appropriate agencies.
New York State EMS agencies with a Department issued agency code; children’s camps as
defined by subpart 7-2 of the New York State Sanitary Code; and schools are strongly
encouraged to participate in the epinephrine auto-injector program.
17-02 Epinephrine Auto-Injectors
Page 1 of 3
Epinephrine Auto-Injector Program
To initiate an epinephrine auto-injector program, the following steps should be
considered:

A health care practitioner or pharmacist authorized to prescribe medications may
prescribe, dispense or provide an epinephrine auto-injector device to or for an eligible
person or entity by a non-patient-specific prescription.

Select and successfully complete a training course in the use of epinephrine autoinjector devices conducted by a nationally recognized organization experienced in
training laypersons in emergency health treatment, by using the Training Guidelines
(https://health.ny.gov/professionals/ems/pdf/epi_auto-inject_training_guidelines.pdf)
or by a program approved by the Commissioner of Health.
Any training program submitted for approval must include, but may not be limited to
the following objectives and competencies:
1.
2.
3.
4.
identify common causes of allergic reactions;
identify the signs and symptoms of a mild and severe allergic reaction (anaphylaxis);
identify how signs and symptoms of anaphylaxis differ from other medical conditions;
demonstrate knowing when epinephrine should be administered and when it should not be
administered;
5. demonstrate determining the correct dose of auto-injector, adult or pediatric, to administer;
6. demonstrate the steps for administering epinephrine by an auto-injector;
7. describe the methods for safely storing and handling epinephrine and appropriately disposing of the
auto-injector after use;
8. demonstrate the steps for providing for on-going care of the patient until Emergency Medical Services
(EMS) arrives;
9. demonstrate knowledge of appropriate documentation and reporting of an event in which an
epinephrine auto-injector was administered; and
10. understand the NYS laws that allow an individual to possess and use an epinephrine auto-injector in a
life-threatening situation.
Prior to initiating the training program, please submit proposed training programs for
approval to:
New York State Department of Health
Bureau of Emergency Medical Services and Trauma Systems
875 Central Avenue
Albany, NY 12206
518-402-0996
518-402-0985 (fax)

Suggested policies and procedures:






Written policies and procedures for the acquisition, storage, accounting, and proper disposal
of used auto-injectors.
Written policies and procedures for the training of authorized users;
Written practice protocols for the use of the epinephrine auto-injector;
A method of making notification of the use of the epinephrine auto-injector;
A method for documentation of the use of the epinephrine auto-injector; and
A process for quality assurance.
17-02 Epinephrine Auto-Injectors
Page 2 of 3
Reporting an Epinephrine Auto-Injector Use
In the event that an epinephrine auto-injector is administered to a patient experiencing
anaphylaxis, the entity should report the incident. At a minimum, the following should be
provided as part of this written notification:







The name of the epinephrine auto-injector entity;
Location of the incident;
The date and time of the incident;
The age and gender of the patient;
The number and dose of epinephrine auto-injectors administered to the patient:
The name of the ambulance service that transported the patient, and
The name of the hospital to which the patient was transported.
In the case of an EMS agency, the report must be written and submitted on a Prehospital
Care Report (PCR/e-PCR) and shared with the agency’s physician medical director.
In addition, Subpart 7-2 of the State Sanitary code requires children's camp operators to
report in writing any epinephrine administration to the permit-issuing official within 24
hours of the administration.
Resources
New York State Public Health Law, Article 30, section 3000-c
http://www.health.ny.gov/professionals/ems/art30.htm#BM3000c
Epinephrine by Auto-Injector Training Guidelines for Unlicensed or Uncertified Personnel
https://health.ny.gov/professionals/ems/pdf/epi_auto-inject_training_guidelines.pdf
EMT original curriculum Lesson 4-5 on Allergies
http://www.health.ny.gov/professionals/ems/national_education_standards_transition/docs/nys_e
mt_education_standards.pdf
American Academy of Pediatrics
http://www.aap.org
American Red Cross - Anaphylaxis and Epinephrine Auto-Injector - Online Course
http://www.redcross.org/take-a-class/course-dowbt000000000011096
American College of Allergy, Asthma & Immunology
http://acaai.org/
Food Allergy Research and Education
https://www.foodallergy.org/treating-an-allergic-reaction/epinephrine
Asthma and Allergy Foundation
http://www.aafa.org/
Regional EMS Council Listing
http://www.health.ny.gov/professionals/ems/regional.htm
Chapter 373 of the Laws of 2016 - effective March 28, 2017
17-02 Epinephrine Auto-Injectors
Page 3 of 3
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates:
10-04
No.
17-03
Date:
March 13, 2017
Re: Ketamine for
Prehospital EMS
Services
Page 1 of 2
This Policy Statement establishes the State Emergency Medical Advisory Committee
(SEMAC) and the Department’s criteria for including ketamine in an EMS agency’s
controlled substance formulary. Please take the time to read and understand this Policy
Statement. Each individual EMS agency, its controlled substances agent and the medical
director are responsible for adhering to all applicable laws, regulations and policies.
History:
In June of 2009, the SEMAC approved ketamine to be added to the State EMS Drug
Formulary. This change required the Department to review and approve the medication,
the process for inventory, security and training. This updated version reflects changes
allowed by the Bureau of Narcotics Enforcement (BNE) and based on SEMAC approved
advanced life support protocols.
Based on the potency of ketamine and the potential for serious issues of diversion and
abuse, the Department remains extremely concerned about its applications in the
prehospital environment.
Conditions for Approval:
In order for the Department to approve the addition of ketamine to an EMS agency with a
current Class 3C controlled substance license, the following conditions must be met and the
Department must review and issue written approvals.
1.
The Regional Medical Advisory Committee (REMAC) must develop protocols for the
administration of ketamine and a quarterly evaluation of its use on the regional level.
2.
The protocols must also be approved by the SEMAC and then by the Department.
3.
The service medical director must approve, in writing, ketamine for use by the EMS
service.
4.
Only those individuals certified at the paramedic level may administer ketamine.
5.
The EMS agency must submit an amendment to their Controlled Substance Operations
Plan to include, but not be limited to the following:



A detailed description of the procurement; inventory process and security of ketamine.
A program for 100% quality assurance by the service medical director for instances
where ketamine has been administered.
A separate Quarterly Report (attached) for ketamine stock and administrations. This
must be received by the Department within 30 days of the end each quarter.
17-03 Ketamine for Prehospital EMS Services
Page 1 of 2
6.
The EMS agency must submit for review and approval by the Department, the training
program developed to in-service personnel. The program must include, but not be
limited to training on the updated controlled substance plan, inventory, security,
patient administration and reporting policies and procedures. The curriculum format
must follow the BEMS required curriculum addition format.
7.
Each substock (the controlled substance medications carried on each vehicle) is limited
to a MAXIMUM of 1,000 mg.
8.
There are two (2) components of the reporting process:
a. The EMS agency must submit a Ketamine Quarterly Report form
(http://www.health.ny.gov/forms/doh-5012.pdf) within 30 days of the end of
each quarter.
b. The EMS agency medical director is required to provide a written report of the
service’s use of ketamine in the prior year no later than January 31st of each
year. It must include, but not be limited to the following items:




9.
The total number of administrations, amount or medication used and dose.
The amount of ketamine wasted.
A summary of the patient presenting problems.
A narrative summary highlighting the Quality Assurance reviews conducted for
each ketamine administration.
All instances where a theft, loss or diversion, are suspected MUST BE REPORTED
TO THE DEPARTMENT IMMEDIATELY. This report must be made to the BEMS
Central Office using the Loss of Controlled Substances Report form (DOH-2094). This
form is available on line at http://www.health.ny.gov/forms/doh-2094.pdf.
10. Prior to including ketamine in the EMS agency’s formulary, the medical director and
the agent must receive written approval from the Department.
11. If the agency makes any changes or updates to the Controlled Substance Operations
Plan, it must provide the specific changes to the Department in writing prior to
implementation.
The Department continues to closely monitor the EMS agencies that maintain a Class 3C
controlled substance license to insure that there is the strictest compliance with all of the
applicable sections of Public Health Law, the Codes, Rules and Regulations – Part 800 and
Section 80.136 of the Part 80 Rules and Regulations on Controlled Substances in New York
State, as well as the EMS service’s approved Controlled Substance Operations Plan.
17-03 Ketamine for Prehospital EMS Services
Page 2 of 2
Drug Formulary
KETAMINE
Class
Anesthetic Induction
Description
Ketamine is a controlled substance medication that is a rapid-acting
general anesthetic producing an anesthetic state characterized by
profound analgesia, normal pharyngeal-laryngeal reflexes, normal or
slightly enhanced skeletal muscle tone, cardiovascular and respiratory
stimulation, and occasionally a transient and minimal respiratory
depression.
Onset & Duration
Onset:
Rapid – IV within 30 seconds half life 10-15 min.; IM
within 3-4 minutes
Duration:
IV 2 mg/kg lasts 5-10 minutes; IM 9 to 13 mg/kg lasts 12-25
minutes
Indications
1. Ketamine is indicated as the sole anesthetic induction agent for
management of trauma patients in extreme pain requiring proper
immobilization and/or extrication.
Contraindications
1. Ketamine is contraindicated in those in whom a significant elevation
of blood pressure would constitute a serious hazard and in those
who have shown hypersensitivity to the drug.
Adverse Reactions
1. Cardiovascular - blood pressure and pulse rate are frequently
elevated following administration of Ketamine alone. However,
hypotension and bradycardia have been observed. Arrhythmia has
also occurred.
2. Respiration - Although respiration is frequently stimulated, severe
depression of respiration or apnea may occur following rapid
intravenous administration of high doses of Ketamine.
3.
4.
5.
6.
Laryngospasms and other forms of airway obstruction have
occurred during Ketamine anesthesia.
Eye - Diplopia and nystagmus have been noted following Ketamine
administration. It also may cause a slight elevation in intraocular
pressure measurement.
Neurological - In some patients, enhanced skeletal muscle tone
may be manifested by tonic and clonic movements sometimes
resembling seizures.
Gastrointestinal - Anorexia, nausea and vomiting have been
observed; however, this is not usually severe and allows the great
majority of patients to take liquids by mouth shortly after regaining
consciousness.
General: Anaphylaxis, local pain and exanthema at the injection site
have infrequently been reported. Transient erythema and/or
morbilliform rash have also been reported.
Ketamine continued...
Drug Interactions
Prolonged recovery time may occur if barbiturates and/or narcotics are used
concurrently with Ketamine.
How Supplied
Injection:
IM or IV 15 mg (15 mg/mL) and 30 mg (30 mg/mL)
Ketamine Hydrochloride Injection, USP is supplied as the hydrochloride in
concentrations equivalent to Ketamine base.
Container Concentration
Fliptop 100 mg/mL
Vial
Fliptop
50 mg/mL
Vial
Fill Quantity
5 Box of
mL
10
10 Box of
mL
10
Color of solution may vary from colorless to very slightly yellowish and
may darken upon prolonged exposure to light. This darkening does not
affect potency. Do not use if a precipitate appears.
Store at 20 to 25°C (68 to 77°F).
Protect from light.
Dosing
Adult IV
Adult IM
1-4.5 mg/kg IV over 1 min.
6.5-13 mg/kg IM one dose
Pediatric IV >3 months 1.5 mg/kg IV over 1 min.
Pediatric IM >3 months 4-5 mg/kg one dose
Protocol
MA XX
MA XX
Adult Pain Management
Pediatric Pain Management
Special Considerations
1. Elevation of blood pressure begins shortly after injection, reaches a
maximum within a few minutes and usually returns to preanesthetic values
within 15 minutes after injection.
2. Because pharyngeal and laryngeal reflexes are usually active, Ketamine
can not be used alone for advanced airway management such as
intubation. Mechanical stimulation of the pharynx should be avoided,
whenever possible, if Ketamine is used alone.
3. The incidence of emergence reactions may be reduced if verbal and
tactile stimulation of the patient is minimized during the recovery period.
This does not preclude the monitoring of vital signs.
4. The intravenous dose should be administered over a period of 60
seconds. More rapid administration may result in respiratory depression or
apnea and enhanced pressor response.
5. Use with caution in the chronic alcoholic and the acutely alcoholintoxicated patient.
6. This medication is a Class III controlled substance medication approved
for prehospital use by the SEMAC and the Department.
No.
17 - 04
Date: March 31, 2017
Bureau of Emergency Medical Services
And Trauma Systems
POLICY STATEMENT
Supersedes/Updates: 07-02, 09-09, 11-04
Re: Fentanyl for
Prehospital EMS Services
Page 1 of 3
This policy is an update regarding fentanyl for prehospital Emergency Medical Services
agencies. Please take the time to read and understand this Policy Statement. Each
individual EMS agency, its controlled substances agent and the medical director are
responsible for adhering to all applicable laws, regulations and policies.
History:
At the request of the State Emergency Medical Advisory Committee (SEMAC) and a
number of air medical service physician medical directors, the Department was
approached requesting that fentanyl be added to the formulary authorized by the Class 3C
controlled substance license. This request was reviewed by the Department’s Division of
Legal Affairs and the Bureau of Narcotic Enforcement (BNE).
Based on the potency of fentanyl and the serious issues of diversion and abuse, the
Department initially approved its use by New York States air medical service providers
under specific conditions. At the May 2007 meeting of the SEMAC, the use of fentanyl
was approved for all advanced life support (ALS) EMS agencies possessing a current
Department of Health EMS Agency Certification and Prehospital Controlled Substance
License.
At present, the SEMAC and the Department approve regional ALS protocols that allow for
the administration of fentanyl on standing orders for specific prehospital conditions in both
adult and pediatric patients. In order for an ALS level EMS agency to possess and
administer fentanyl, all of the following conditions must be met and the agency must
receive Department approval.
This policy addresses the following:



Approval Process
Reporting Process
Required Conditions
17-04 Fentanyl for Prehospital EMS Services
Page 1 of 3
Approval Process:
In order for the Department to approve the addition of fentanyl to an EMS agency with a
current Class 3C controlled substance license, the following conditions must be met and
the Department must review and issue written approval.
1.
The Regional Medical Advisory Committee (REMAC) must provide protocols for the
administration of fentanyl and a periodic evaluation of its use on the regional level.
2.
The protocols must be approved by the SEMAC and the Department.
3.
The service medical director must approve, in writing, fentanyl for use by the EMS
agency.
4.
Only those individuals certified at the EMT - Critical Care or Paramedic level may
participate in the Operational Plan and administer a controlled substance medication
to a prehospital patient.
5.
The EMS agency must submit an amendment to their Controlled Substance Operations
Plan to include, but not be limited to the following:


A detailed description of the procurement; inventory process and security of fentanyl.
A program for routine quality assurance by the service medical director for instances
where fentanyl has been administered.
The training program used to in-service all appropriate staff on the inventory, security
and administration of fentanyl.
Policies for submitting the Quarterly Report (attached) for fentanyl stock and
administrations. This must be received by the Department within 30 days of the end
each quarter.


6.
Prior to including fentanyl in the EMS agency’s controlled substance formulary, the
medical director and the agent must receive written approval from the Department.
7.
Each substock may have a maximum of 400mcg of fentanyl.
Reporting Requirements:
1. A separate Quarterly Report for fentanyl stock and administrations. This form is
available on line at http://www.health.state.ny.us/forms/doh-4352.pdf. This must be
received by the Department within 30 days of the end each quarter.
2. As a part of the reporting process, the agency medical director is required to provide a
written report of the service’s use of fentanyl in the prior year no later than January
31st of each year. The report should include, but not be limited to the following
items:




The total number of administrations, amount or medication used and dose.
The amount of fentanyl wasted.
A summary of the patient presenting problems.
A narrative summary highlighting the Quality Assurance reviews conducted for
each fentanyl administration.
17-04 Fentanyl for Prehospital EMS Services
Page 2 of 3
Please note that failure to submit the quarterly and/or the annual reports may result in
the suspension of the agency’s authority to possess and administer controlled
substance medications.
3. All instances where a theft, loss or diversion, are suspected MUST BE REPORTED TO
THE DEPARTMENT IMMEDIATELY. This report must be made to the BEMS Central
Office using the Loss of Controlled Substances Report form (DOH-2094). This form is
available on line at http://www.health.ny.gov/forms/doh-2094.pdf
4. Prior to including fentanyl in the EMS agency’s formulary, the medical director and the
agent must receive written approval from the Department.
5. If the agency makes any changes or updates to the Controlled Substance Operations
Plan, it must provide the specific changes to the Department in writing prior to
implementation.
Required Conditions:
1. Fentanyl may only be stocked in 2ml vials or ampules containing 50mcg/ml.
2. The Department must approve the sub-stock inventory that exceeds 400mcg of
fentanyl.
3. The agency operation plan and the medical director must insure that the formulary
includes an appropriate antagonist in an amount proportional to the amount of fentanyl
carried, necessary to reverse the effects of a fentanyl administration.
4. Fentanyl may only be administered on standing orders for adult patients as delineated
in the approved regional ALS protocols. Other administrations will require direct
medical control consultation.
The Department continues to closely monitor the EMS agencies that maintain a Class 3C
controlled substance license to insure that there is the strictest compliance with all of the
applicable sections of Public Health Law, the Codes, Rules and Regulations – Part 800 and
Section 80.136 of the Part 80 Rules and Regulations on Controlled Substances in New
York State, as well as the EMS service’s approved Controlled Substance Operations Plan.
Issued and authorized by Bureau of EMS Office of the Director
17-04 Fentanyl for Prehospital EMS Services
Page 3 of 3
No.
Bureau of Emergency Medical Services and
Trauma Systems
POLICY STATEMENT
Supersedes/Updates: New
17 - 05
Date: April 13, 2017
Re: Certified Athletic
Trainers
Page 1 of 2
PURPOSE:
The purpose of this policy statement is to provide EMS providers knowledge and
understanding of the role, responsibility and capabilities of Certified Athletic Trainers so that
when EMS is called to a sporting event, the patient will benefit from positive communication
and consistent prehospital emergency medical care.
BACKGROUND:
EMS often responds to sporting events where Certified Athletic Trainers are employed, such
as public schools, sports leagues and college sporting events. In many instances, a Certified
Athletic Trainer may be the highest trained healthcare provider available when an athlete has
sustained an injury or has become ill. It is important that EMS providers and Certified Athletic
Trainers work together.
Certified Athletic Trainers are certified under NYS Education Law, Article 162. Section 8351
defines an Athletic Trainer as:
“… any person who is duly certified in accordance with this article to perform athletic training under the
supervision of a physician and limits his or her practice to secondary schools, institutions of postsecondary
education, professional athletic organizations, or a person who, under the supervision of a physician, carries out
comparable functions on orthopedic athletic injuries, excluding spinal cord injuries, in a health care organization.
Supervision of an athletic trainer by a physician shall be continuous but shall not be construed as requiring the
physical presence of the supervising physician at the time and place where such services are performed.”
Certified Athletic Trainers manage athletic injuries and illnesses such as sprains, strains,
contusions, and postsurgical reconditioning. Their responsibilities include:
•
•
•
•
•
•
•
Identification of factors that may contribute to athletic injury and eliminate them before an injury occurs;
conduct pre-participation screenings;
develop appropriate fitness and training programs;
apply protective or injury preventative devices, such as tape, bandages, or braces;
maintain CPR and AED training;
recognition and evaluation of potentially serious, life threatening injuries; and
administering appropriate first aid and emergency care to the injured athlete.
17 - 05 NYS Certified Athletic Trainers
Page 1 of 2
At athletic events, Certified Athletic Trainers provide emergency care and first aid to
individuals who have sustained an athletic injury, evaluate the injury(s), and make referrals to
appropriate medical personnel. Through individual consultation and lectures, Certified
Athletic Trainers also instruct coaches, athletes, parents, medical personnel, and the
community in the care and prevention of athletic injuries.
Additional information regarding Certified Athletic Trainers can be found at:
http://www.op.nysed.gov/prof/at/
RECOMMENDATIONS:
EMS agencies should be aware of those facilities, both public and private, that may have
Athletic Trainers working with teams at their sporting events. Meeting with Certified Athletic
Trainers and discussing the EMS agency resources, scope of practice and protocols, will
assist developing an understanding of the roles and responsibilities, improve relationships
and should it become necessary, the prehospital care provided at the scene of a medical
emergency. As a part of the planning process the agency medical director should be
contacted to discuss specific issues and treatment plans.
17 - 05 NYS Certified Athletic Trainers
Page 2 of 2
No.
Bureau of Emergency Medical Services and
Trauma Systems
POLICY STATEMENT
Supersedes/Updates: New
17 - 06
Date: May 24, 2017
Re: Syringe Epinephrine
for Basic EMTs
Page 1 of 2
Based on the results of a State Emergency Medical Advisory Committee (SEMAC) demonstration
project, the New York State Emergency Medical Service Advisory Council (SEMSCO) approved
Syringe Epinephrine for Emergency Medical Technicians (Check & Inject NY) at the September
14, 2016 meeting. The project established that EMTs, with the appropriate training may
administer the proper dose of epinephrine for a patient experiencing a severe anaphylactic
reaction using a specific 1cc syringe. Additionally, the project realized a significant cost saving
over maintaining epinephrine auto-injectors.
The Commissioner of Health has approved the addition of Syringe Epinephrine and at the
request of the SEMAC, this approval includes the intramuscular administration of 1:1000
epinephrine using a 1cc syringe, a 23 gauge, 1 inch intramuscular safety needle and a single
dose 1:1000 epinephrine packaged in a 1mg/ml vial as an addition to the scope of practice for
an EMT.
Policy
 Education:
Every EMT original, refresher and continuing medical education (CME) certification
training program must include the didactic content and psychomotor skills for the
administration of 1:1000 epinephrine using a syringe for treating a patient with severe
anaphylaxis.
The NYS EMS Instructional Guidelines have been updated and an Intramuscular Injection
Psychomotor Evaluation Tool (practical skills sheet) has been developed to assist EMS course
sponsors, Certified Instructor Coordinators (CIC) and EMS agencies in providing initial and
ongoing training. An instructor update can be found at http://vitalsignsconference.com under
“All Courses” in “Instructors” section. The course is entitled “2017 Instructor Update – Epi for
EMTs”. The education resources are available at:
http://www.health.ny.gov/professionals/ems/national_education_standards_transition/index.ht
m on pages 2 through 4.

BLS EMS Agencies
EMS Agencies intending to implement a Syringe Epinephrine program, in consultation with their
medical director, should develop written policies and procedures for the use of Syringe
Epinephrine that are consistent with regional policies and protocols. This should include, but not
be limited to the following:
17-06 Syringe Epinephrine for EMTs
Page 1 of 2






Written policies and procedures requiring an approved training program, requirements for continuing
education, maintenance of competencies and the documentation for authorized providers;
Written policies and procedures requiring for the use of a 1cc syringe, a 23 gauge, 1 inch intra-muscular
safety needle and single dose 1:1000 epinephrine packaged in a 1mg/ml vial;
A description of how the syringes, needles and medication will be kept secure in the vehicles and the
station(s);
A plan for appropriate and safe disposal of medical waste;
A description of how the medication will be maintained within manufacturer’s approved temperature and
light ranges; and
Documentation of an administration and the medical director’s plan for quality assurance and
appropriateness review of utilization.
Once the EMS service has decided to implement a syringe epinephrine program, the EMS Service
must provide the Department with an updated Medical Director Verification Form (DOH4362).

Resources
Medical Director Verification Form (DOH-4362) – fill-in-able
http://www.health.ny.gov/forms/doh-4362.pdf
Check & Inject NY
https://www.mlrems.org/check-inject-ny/check-inject-ny-training-materials
Anaphylactic Reaction with Respiratory Distress and Hypoperfusion Protocol – M-3
http://www.health.ny.gov/professionals/ems/pdf/statewide_prehospital_treatment_protocols_ve
r16-04.pdf
Emergency Medical Technician Instructional Guidelines – Intramuscular Injections and
Psychomotor Evaluation Tool (pages 2 – 4)
http://www.health.ny.gov/professionals/ems/national_education_standards_transition/docs/nys
_emt_education_standards.pdf
17-06 Syringe Epinephrine for EMTs
Page 2 of 2
No.
17 - 07
Date: August 18, 2017
Bureau of Emergency Medical Services
And Trauma Systems
POLICY STATEMENT
Supersedes/Updates:
Re: EMT-Critical Care
Certification
Sunset/Transition
Page 1 of 1
Background
A Technical Advisory Group (TAG) was established the New York State Emergency Medical Services
Council (SEMSCO) at their September 2016 meeting. The TAG was established to examine ongoing
concerns about the future viability of the EMT-Critical Care (CC) level of certification in New York State.
The TAG was charged with examining the past and present operation of the CC program with the goal
of making recommendations on the CC going forward.
The TAG reviewed CC utilization in each region, the curriculum, administrative burden and costs of
sustaining CC education curriculum and exam development and maintenance, original course
participation, refresher course attendance, use of CME refreshers and the comparative scope of
practice and availability of AEMT educational programs. In the final analysis, the TAG concluded:




The CC provider numbers have been steadily declining since 1997 and continue to trend downward;
The number of CC original and refresher courses offered has also declined while the number of course
sponsors have remained stable. The decline in course offerings is likely related to declining enrollments.
Simultaneously, the CC program would require extensive curriculum, practical skills and written
examination extensive revisions.
The CC has no national equivalent from which curriculum and test items can be drawn.
The TAG proposed to SEMAC and SEMSCO a number of actions to gradually end the CC level of
certification in NYS. These actions would allow continued CC certification renewals, affording
REMSCOs and REMACs a prolonged period in which to sustain or reconfigure their systems, based on
regional needs. These were approved by the SEMSCO at their May 10, 2017 meeting.
Transition Implementation Process
The following actions are being implemented to gradually end the CC level of certification.
1. Continue the CC Continuing Medical Education (CME) refresher program.
2. The Department will no longer approve original CC courses with a start date after January 1, 2018.
3. The Department will no longer approve CC refresher or rapid refresher courses whose written
examination would that place after August of 2019.
4. The development and release of an advanced standing/ bridge program from CC to Paramedic. This will be
open to any NYS CC with 3 years of documented continuous practice1. This program will include, but not
be limited to on-line didactic content with availability of skills and testing by local course sponsors.
1 The
term “continuous practice” is defined by 10 NYCRR Part 800.3(w)
17-07 EMT-CC Sunset/Transition
Page 1 of 1
No.
16 - 01
Date: June 14, 2016
Bureau of Emergency Medical Services
And Trauma Systems
POLICY STATEMENT
Supersedes/Updates: New
Re: Basic Life Support
Acquisition and
Transmission of 12 Lead
ECGs
Page 1 of 2
At the March, 2016 meetings of the State Emergency Medical Advisory Committee (SEMAC)
and the State EMS Council (SEMSCO), the acquisition and transmission of 12 lead
electrocardiograms (ECG) by Basic Life Support (BLS) and Advanced Emergency Medical
Technician (AEMT) level providers was approved for use by New York State’s EMS agencies.
This decision was based on the results of a demonstration project, which established that BLS
providers acquiring and transmitting a 12-lead ECG from the field to physicians in hospitals
may substantially improve the timeliness of identification and intervention in patients suffering
from an ST Elevation Myocardial Infarction (STEMI).
The SEMAC approved BLS/AEMT 12 lead ECG acquisition as a regional option. Should an
EMS agency wish to implement a 12 lead ECG program at the BLS/AEMT level, the EMS
agency must be granted approval by their Regional Emergency Medical Advisory Committee
(REMAC) and each certified EMS provider must complete a REMAC approved training
program. The acquisition and transmission of 12 lead ECG will be an option in the NYS BLS
Protocols, but training will not be included in the state approved original or refresher
curricula/courses.
In systems heavily reliant on BLS providers, acquiring and transmitting 12-lead ECG from the
field to physicians in hospitals can substantially improve the timeliness of identification and
intervention in patients suffering from STEMI. This may also improve care in two-tiered
systems where BLS is likely to be on scene and working in conjunction with, or intercepting
with Advanced Life Support (ALS) providers.
Policy
REMACs may choose, but are not required, to allow the BLS/AEMT acquisition and
transmission of 12 lead ECGs into their systems. If approved, the REMAC may develop a
policy for which devices may be used and how they will integrate into the existing systems for
STEMI care. Any device approved must be capable of transmitting 12 lead ECG data to the
receiving hospital.
EMS Agencies wishing to implement a BLS/AEMT 12 lead acquisition and transmission
program must make a written request to their REMAC. The request should include, but may
not be limited to the following:
16-01 BLS 12 lead ECG
Page 1 of 2
 A letter from the agency medical director supporting the implementation of the 12 lead
program, including the physician’s plan for training, quality assurance and
appropriateness review.
 A letter from the receiving hospital(s) advising that they are capable of receiving the 12
lead data and providing it to the appropriate hospital personnel.
 Agency policies and procedures for the 12 lead program that are consistent with state
and regional policies and protocols. This should include, but may not be limited to, the
following:
o
o
o
o
Use of the approved training program, requirements for continuing education, maintenance of
competencies and the documentation for authorized providers;
A description of how the agency will follow the NYS Statewide Adult and Pediatric Protocols –
Adult Cardiac Related Problem (M-5) http://www.health.ny.gov/professionals/ems/protocol.htm;
A description of the 12 lead device proposed to be utilized by the EMS agency; and
Assurance that 12 lead ECGs obtained while caring for a patient will be subject to physician
review.
Once the EMS agency has received written approval from the REMAC, the EMS Service must
provide the Department with an updated Medical Director Verification Form (DOH-4362)
http://www.health.ny.gov/forms/doh-4362.pdf indicating approval to participate in the 12 lead
acquisition program.
16-01 BLS 12 lead ECG Page 2 of 2
No.
15 - 06
Date: September 25, 2015
Bureau of Emergency Medical Services and
Trauma Systems
POLICY STATEMENT
Supersedes/Updates: New
Re: Transporting
Patients with
Blood/Blood Products
Page 1 of 3
The Department of Health’s Bureau of Emergency Medical Services and Trauma Systems and the
Blood and Tissue Resources Program have collaborated on a process to allow advanced life support
ambulance services that have been approved as Ambulance Transfusion Services (ATS), to provide
inter-facility transports for patients who are receiving blood or blood products.
In order for an ambulance service to transport a patient receiving blood/blood products from one
hospital to another, the ambulance service must be approved by the Department as an Ambulance
Transfusion Service (ATS). An ATS is defined in Section 58-2.1(ae) as:
…an ambulance service certified by the department that administers blood
components during transport from one hospital to another hospital.
A new Section 58-2.16(h) adds provisions to permit Emergency Medical Technician (EMT) - Critical
Care and EMT-Paramedics (EMT-CC/EMT-P) with specialized training to monitor transfusions and
initiate additional units during inter-facility transport to facilitate expeditious transport of patients
requiring transfusion during transport.
Notification Process:
In order for an ambulance service to be an ATS for the administration of blood/blood products to a
patient being transported between hospitals, the ambulance agency must have the following in place
and receive written acknowledgement from the Department:

The ambulance service medical director must approve the personnel training and quality
assurance programs for the EMS service, as well as all personnel who will be involved in
administering of blood/blood products.

The ambulance service should make written notification to the REMAC.

Only those individuals certified at the EMT-CC/EMT-P level may administer blood/blood
products and monitor the medical status of those patients.

Each EMT-CC/EMT-P must complete the training requirements required by the Department.
The training must be conducted by the agency medical director, a NYS EMT-P Certified
Instructor Coordinator in conjunction with the blood bank physician with whom the agency has
an agreement. Additionally, each EMT-CC/EMT-P will be required to receive updated training
on an annual basis.
15-06 Transporting Patients with Blood/Blood Products
Page 1 of 3

In order to obtain permission from the Department to be an ATS, the ambulance service must
submit a complete Notice of Intent to Provide Ambulance Transfusion Services (ATS) to the
Bureau of EMS The Notice must be accompanied by the following documentation:
o
o
o
o
A letter from the medical director accepting full responsibility for training staff, as well as oversight and
quality assurance for the administration of blood/blood products.
A copy of the ambulance service’s policies, procedures, and protocol for the transport of patients
receiving blood/blood products.
A list of all advanced EMS providers approved and trained to administer/monitor patients receiving
blood/blood products. The list must include EMT-CC/P certification numbers and current expiration
dates.
A written agreement with a hospital blood bank must specify roles and responsibilities for assuring
compliance with all applicable DOH regulations. The written agreement must include, but not be limited to
the following:
 Description and information on storage and transportation devices;
 emergency protocols and procedures for adverse reactions;
 process for providing the blood bank with appropriate patient records; and
 participation in quality improvement programs.
The written agreement must be approved and signed by the hospital’s transfusion service
director, ambulance agency medical director and chief executive officer.

The ambulance service must be able to do the following:
o
o
o
o

The ambulance service must submit to the Department, policies and procedures for the
administration and monitoring of blood/blood products with each Notice of Intent. The
policies and procedures must include, but not be limited to, the following:
o
o
o

Transport blood/blood products in a cooler provided and tested by the hospital transfusion center.
Purchase and utilize an appropriate electronic patient thermometer.
Monitor and document the condition of the patient receiving a transfusion, which will include, but not be
limited to, physical assessments, and vital signs, including temperature.
Recognize and treat adverse transfusion reactions in accordance with regional protocols and/or medical
control.
A detailed description of the process for the procurement of blood and maintaining the
temperature and integrity as required by the hospital transfusion center.
A program of 100% quality assurance case review by the service medical director for all patients
transported with blood/blood products having been administered.
The training program used to in-service all EMT-CC/P staff.
In the event of an adverse reaction, the ambulance service medical director is required
to submit a report to the Department within 24 hours. The report shall include, but not
be limited to, the following items:
o
o
o
o
o
A copy of the patient record.
A summary of the patient’s presenting problems.
A narrative summary highlighting the Quality Assurance reviews conducted for each blood/blood
product administration.
A copy of the medical director’s review and comments.
The report should be sent to the following address:
Bureau of Emergency Medical Services and Trauma Systems
NYS Department of Health
875 Central Avenue
Albany, NY 12206
15-06 Transporting Patients with Blood/Blood Products
Page 2 of 3

Mail the completed packet, with the signed agreement, standard operating
procedures, and other relevant documents to:
Bureau of Emergency Medical Services and Trauma Systems
NYS Department of Health
875 Central Avenue
Albany, NY 12206
 After the Department’s review of the ambulance service’s Notice of Intent, policies and
procedures, training program and implementation plans, the Department will issue a
written approval to operate as an ATS. The ambulance service may not transport a
patient receiving blood/blood products until it has received the written notification.
 Every ambulance service approved to operate as an ATS will be required to submit a
renewal Notice to the Department along with the agency’s biennial certification renewal
application.
 The Department will closely monitor all ambulance agencies that transport patients with
blood/blood products being infused to insure that there is strict compliance with all of the
applicable sections of Public Health Law, the Codes, Rules and Regulations. The
Department, in accordance with 10 NYCRR Part 800, Subpart 58-2, and Article 30
of the NYS Public Health Law, may conduct a site inspection, including required
documents, without prior notice of an applicant or approved Ambulance
Transfusion Service. Failure to comply with any of the applicable regulations and
policies may result in the revocation of the ambulance service’s ATS designation.
15-06 Transporting Patients with Blood/Blood Products
Page 3 of 3
No.
15 - 05
Date: July 20, 2015
Bureau of Emergency Medical Services
& Trauma Systems
Re: EMS Certification
Exam ADA
Accommodation
Requests
POLICY STATEMENT
Supersedes/Updates: New
Page 1 of 3
Background
The New York State Department of Health (Department), Bureau of Emergency Medical
Services and Trauma Systems (BEMS) administers certification examinations to persons who
meet the minimum requirements for NYS certification in accordance with Chapter VI of Title 10
(HEALTH) of the Official Compilation of Codes, Rules and Regulations, Part 800.
Purpose
This policy is intended to provide guidance to persons with documented disabilities who
request reasonable accommodations to take the NYS DOH BEMS certification examination.
The Department, in accordance with the requirements of Title II of the Americans with
Disabilities Act (ADA), as amended, will not discriminate on the basis of disability.
Procedures
The Department offers reasonable and appropriate accommodations for its certification
examinations for those persons with documented disabilities, as required by the Americans
with Disabilities Act (ADA).
The Department will review each request on an individual basis and make its decisions relative
to appropriate accommodations based on the following guidelines:
1. An individual requesting an accommodation under ADA must present adequate
documentation demonstrating that his/her condition substantially limits one or more
major life activities.
2. Requested accommodations must be reasonable and appropriate for the
documented disability and must not fundamentally alter the examination’s
effectiveness in assessing the essential functions of pre-hospital care, which the
examinations are designed to measure.
3. Professionals conducting assessments, rendering diagnoses of specific disabilities
and/or making recommendations for appropriate accommodations, must be qualified
to do so.
15 - 05 EMS Certification Exam ADA Accommodations
Page 1 of 3
4. All documentation submitted in support of a requested accommodation will be kept
in confidence and will be disclosed to Department staff and consultants only to the
extent necessary to evaluate and/or provide the accommodation. No information
concerning an accommodation request will be released to third parties without
written permission from the candidate.
In order for an individual to be eligible to take a NYS DOH BEMS certification examination, the
individual must:
1. Enroll in a NYS DOH BEMS approved course offered through an approved
educational entity (course sponsor).
2. Complete and submit, through the EMS course sponsor, an Application for
Emergency Medical Services Certification, form number DOH-65.
3. Persons requesting an accommodation must submit their request in writing to the
Department via fax to 518-402-0985 or to:
New York State Department of Health
Bureau of EMS – Certification Unit
875 Central Avenue
Albany, New York 12206
Requests should include the following information:
Individual’s first and last name.
Individual’s mailing address.
Individual’s telephone number and email address.
Course number the individual is enrolled in (obtain from instructor).
What accommodations the individual is requesting, if known.
Any documentation from professionals who have conducted assessments or
who have rendered diagnoses to support the accommodation request.
g. In many cases, this can be in the form of an Individualized Education
Program (IEP), a formal psycho-educational evaluation.
a.
b.
c.
d.
e.
f.
All requests for reasonable accommodations must be received by the
Department no later than 8 weeks prior to the date of the certification
examination scheduled for the class in which the individual is enrolled.
Ideally, the request should be made at the start of the course or as soon as
possible.
15 - 05 EMS Certification Exam ADA Accommodations
Page 2 of 3
Individuals requesting an accommodation will be notified in writing of the
Department’s decision to either grant, deny or modify the requested accommodation.
In the event the individual does not agree with the Department’s decision, the
individual requesting the accommodation may file an appeal by contacting:
Designated Reasonable Accommodation Coordinator
New York State Department of Health
Empire State Plaza, Corning Tower, Room 2284
Albany, NY 12237
(518) 474-4398
4. Meet all requirements for Initial Certification Requirements in Part 800.6 or
Recertification Requirements in Part 800.7.
5. Complete all requirements for course completion through a course sponsor.
15 - 05 EMS Certification Exam ADA Accommodations
Page 3 of 3
No.
15 – 04
Date: May 26, 2015
New York State
Department of Health
Bureau of Emergency Medical Services
Re: Certification of
Individuals with Criminal
Convictions
POLICY STATEMENT
Supersedes/Updates: 00-12, 02-02, 09-05
Page 1 of 3
On May 6, 2015 Title 10 of the New York Codes, Rules and Regulations Part 800 were amended as they relate
to certification, recertification and continuing medical education recertification requirements. These sections
reflect New York State’s policy of removing barriers to the licensure and employment of persons previously
convicted of one or more criminal offenses and incorporate Article 23-A of the Corrections Law into the review
of an applicants’ prior criminal offenses.
The following provisions are contained in Part 800:
…if the applicant has been convicted of one or more criminal offenses, as defined in §800.3(ak), be found eligible after a balancing of
the factors set out in Article 23-A of Corrections Law. In accordance with that Article, no application for a license shall be denied by
reason of the applicant having been previously convicted of one or more criminal offenses unless (i) there is a direct relationship
between one or more of the previous criminal offenses and duties required of this certificate or (ii) certifying the applicant would
involve an unreasonable risk to property or the safety or welfare of a specific individual or the general public. In determining these
questions, the agency will look at the eight factors listed under New York State Corrections Law Section 753.
…not have been found guilty or in violation, in any jurisdiction, of any other non-criminal offense or statutory and/or regulatory
violation, as those terms are defined in Section 800.3 of this Part, relating to patient safety unless the department determines such
applicant would not involve an unreasonable risk to property or the safety or welfare of a specific individual or the general public.
Purpose:
This policy specifies the process for the review of applicants seeking Emergency Medical Services (EMS)
certification with a history of criminal convictions. It also describes the responsibilities of the applicant, the
Certified Instructor Coordinator (CIC) and the Department of Health.
Applications for Original EMS Certification or Recertification:
In accordance with the provisions of the State Emergency Medical Services Code, 10 NYCRR Part 800,
applicants for EMS certification or recertification must not have been convicted of certain misdemeanors or
felonies. The Department will review all criminal convictions from any federal, military, state and/or local
jurisdiction to determine if such convictions fall within the scope of those specified in Part 800. If the applicant
has been convicted of one or more criminal offenses, the Department will consider the eight factors listed
under New York State Corrections Law Section 753, to determine if the applicant represents an unreasonable
risk to property or the safety or welfare of the general public.
Certain Family Court or other designated governmental agency findings are also subject to review by the
Department. If an applicant is unsure as to the status of any court proceeding, he/she SHOULD NOT sign the
Application for Emergency Medical Services Certification (DOH-65).
10 NYCRR Part 800 does not prevent an applicant with a criminal conviction from attending and completing all
of the training requirements of an EMS certification course. However, it may prevent the applicant from
15 – 04 Individuals with Criminal Convictions
Page 1 of 3
becoming certified in New York State until the Department has conducted a review and investigation of the
circumstances of the conviction(s) and made a determination that the applicant does not represent an
unreasonable risk to property or the safety or welfare of the general public.
If the Department makes a determination allowing certification, the applicant will be eligible to take the
applicable New York State practical and written certification examinations, if otherwise qualified. All applicants
must be fully informed of these requirements by the Certified Instructor Coordinator (CIC) at the
beginning of a course.
Applicants will not be permitted to take the NYS practical or written certification examination until the
background review and investigation is completed and a final written determination is received by the
applicant.
The Certification Application:
All applicants applying for NYS EMS certification at any level must complete the Application for Emergency
Medical Services Certification (DOH-65). The bottom of the application contains an affirmation that states "Do
not sign this if you have any convictions". Under no circumstances should an applicant sign this
application if he or she has a criminal conviction of any type.
The CIC must identify all unsigned applications and send them with the course memorandum and all other
applications to the Department immediately after the second class session. The CIC should include a separate
memorandum or note identifying each unsigned application. The applicant(s) will be listed on the class list but
will not be issued an examination ticket until cleared in writing by Department. It is the responsibility of the
applicant to understand this policy, gather the required documentation and provide it to the Department. An
EMS representative from the Department may conduct an interview. This may take the form of a personal
meeting or telephone interview. In an effort to permit a timely review and determination, the applicant must
provide all the required documentation within 30 days of the initial Department contact. If the applicant does
not provide the documentation, the investigatory review will be closed and the applicant will not be able to seek
EMS certification.
The applicant should not contact the Bureau of EMS (BEMS) directly. Upon the receipt and processing of the
unsigned DOH-65 application form, the applicant will be sent a package of information outlining the
investigative process, the required information to be supplied and the contact name and telephone number of
the Bureau of EMS Representative reviewing their case.
The Department will only discuss issues related to criminal convictions with the applicant or their legal
representative. There is no requirement or need for the applicant to disclose the circumstances of any
conviction(s) with the CIC.
The Review Process:
All applicants entered in the review process will need to provide the following written documentation
concerning all convictions. This information must be sent directly to the Department regional office as detailed
in the letter sent to the applicant.
1. A notarized sworn affidavit stating that the applicant has not had any conviction(s) for a crime or crimes
other than those currently identified.
2. If the applicant is recertifying and has signed previous certification applications, he/she must provide an
explanation as to why these applications were signed.
3. A signed and dated statement describing the reason that they are seeking EMS certification.
15 – 04 Individuals with Criminal Convictions
Page 2 of 3
4. A signed and dated written narrative description of the circumstances leading to and surrounding each
conviction.
5. An original or certified copy of the plea and sentence minutes, certificate of disposition and the presentencing report (if available) from the court. A Certificate of Relief from Disabilities does not fulfill this
documentation requirement. If any of these items are not available, an original letter from the court
must be supplied attesting that the documentation does not exist or is no longer available. Please note
that the applicant may be responsible for the cost of obtaining these documents.
6. A letter from the applicant's probation/parole officer (if applicable) documenting compliance with their
probation/parole. A copy of the final probation/parole report must also be included.
7. If the applicant's conviction resulted in any court ordered therapy, clinical evaluations or counseling, a
letter or report from the organization or individual who provided the evaluation, counseling or therapy is
required. The letter or report should indicate if treatment is ongoing or if it has been completed and
whether or not it was considered to have been successful. The letter should also indicate that the
counselor/therapist believes that the applicant is suitable to perform patient care in a prehospital
setting.
8. The applicant is required to submit letters from the administration of each EMS agency with whom they
are affiliated. These letters must be on official letterhead and presented to the Department EMS
Representative in a sealed and signed envelope. These letters must describe any involvement in EMS
or other health care settings, the length of the affiliation with the agency, an awareness of the specific
conviction(s), the circumstances and the agency's willingness to monitor the individual during
the performance of his/her EMS duties.
9. The applicant should submit other letters of recommendation. These letters must also be presented to
the EMS Representative in a sealed and signed envelope. These recommendations must include a
description of the relationship with the applicant, have knowledge of the conviction, an understanding of
the EMS environment, and can attest to the applicant's good character. The letters may include, but not
be limited to:
1. current employers;
2. health care professionals;
3. community leaders (i.e. clergy, law enforcement or educators)
10. Each applicant may have a personal interview with a Department EMS Representative after all the
documentation requirements have been met. A telephone interview may be conducted in the place of a
personal meeting. Upon completion of the investigation and review, the applicant will be notified in
writing of the Department's decision.
While the investigation and review is ongoing, an applicant may attend all classes. However, the applicant will
be prevented from taking any NYS certifying examination, including the challenge practical skills examination
at the beginning of the refresher program, the practical examination at the conclusion of the training program
and the final written certification examination, until all course requirements are completed and a favorable
determination is made in writing by the Department.
Applicants possessing current NYS EMS certification will be afforded a hearing in accordance with the
provisions of Section 12-a of the Public Health Law if the Department seeks suspension, revocation or any
other legal action.
15 – 04 Individuals with Criminal Convictions
Page 3 of 3
No.
15 - 03
Date: July 16, 2015
New York State
Department of Health
Bureau of Emergency Medical Services and
Trauma Systems
Re: Recommended
Pediatric Equipment
for Certified EMS
Response Vehicles
POLICY STATEMENT
Supercedes/Updates: 10-06
Page 1 of 2
Emergency Medical Services (EMS) providers care for patients of all ages, who present with a wide
variety of illnesses or injuries. Nationally and in New York State, 9-10% of all EMS responses are for
pediatric patients; in New York that amounts to approximately 270,000-300,000 pediatric patients
annually who are treated by EMS. The enclosed guidance is intended to ensure that ambulance
services in New York State are properly equipped to provide appropriate care to pediatric patients.
In an effort to better care for pediatric patients, the federal Emergency Medical Services for Children
(EMSC), in collaboration with the American Academy of Pediatrics (AAP), American College of
Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP),
National Association of EMS Physicians (NAEMSP), Emergency Nurses Association (ENA), and the
National Association of State EMS Officials (NASEMSO) have jointly developed a list of standardized
equipment for emergency ground ambulances. All seven organizations adhere to the principle that
EMS providers at all levels must have the appropriate equipment and supplies to optimize prehospital
delivery of care.
This recently updated list of Equipment for Ground Ambulances (2014) has been approved and
endorsed by New York’s State EMS Council (SEMSCO), State Emergency Medical Advisory
Committee (SEMAC) and the EMS for Children Advisory Committee (EMSCAC) for certified EMS
agencies in New York.
Equipment for Ground Ambulances - Online Version:
http://informahealthcare.com/doi/pdf/10.3109/10903127.2013.851312
(Publisher Name: American Academy of Pediatrics & Journal of Prehospital Care).
This link references the complete document/equipment list for both BLS and ALS ambulances.
The chart found below lists pediatric BLS items required in New York State Part 800 regulations, and
also includes the national Equipment for Ground Ambulances recommendations. The additional
recommended equipment to current Part 800 regulations are shaded on the list. Adult-sized
equipment is included with pediatric sizes as many children are the size of small adults. The
SEMSCO and SEMAC recommend that Regional Medical Advisory Committees (REMAC) should
consult the national Equipment for Ground Ambulances list when updating the regional ALS
equipment requirements.
15 - 03 Recommended Pediatric Equipment for Certified EMS Response Vehicles
Page 1 of 2
Bureau of Emergency Medical Services and Trauma Systems
BLS Equipment
# Pieces of Equipment
Suction catheters
Rigid tonsil tip
Flexible between 6-10 french
2
2 each
*Flexible between 12-16 french
1
Nasal cannula- Adult
Nasal cannula- Child
Non-rebreather masks- Adult
Non-rebreather masks- Child
4
2
4
2
Hand operated self-expanding bags child 450-750 ml
Hand operated self-expanding bags adult >1000 ml
1
1
Adult
Child
Infant
*Neonate
1
1
1
1
*Nasal Airways 1 size between 16-24 fr
*Nasal Airways 1 size between 26-34 fr
Oral airways size 0-1
Oral airways size 2-3
Oral airways size 4-5
*Pulse oximeter
*with pediatric probe
*with adult probe
*AED that includes pediatric capability
*adult pads
*child pads or dose attenuator with adult pads
1
1
2
2
4
1
1
1
1
1
1
Rigid cervical collar - small
Rigid cervical collar - medium
Rigid cervical collar - large
Lower extremity traction - adult
Extremity immobilization small
Extremity immobilization - medium
Extremity immobilization - large
OB Sterile Kit (Commercial or locally packed)
Receiving blanket
*Head cover
Bulb Suction for Infants
1
1
1
1
1
2
2
1
1
1
1
Sphygmomanometer adult cuff
Sphygmomanometer pediatric cuff
*Length-based resuscitation tape or reference material that provides
appropriate guidance based on length or age
*Age/size appropriate restraint systems for all passengers and patients
transporting in ground ambulances. (For children, this should be according
to the National Highway Traffic Administration’s document; Safe Transport
of Children in Emergency Ground Ambulances)
1
1
Oxygen delivery
Bag valve mask
Masks for BVM
Airways
Immobilization devices
Miscellaneous
*Access to pediatric and adult patient care protocols
1
Various
1
*Shading indicates recommended equipment in addition to Part 800.
15 – 03 Recommended Pediatric Equipment for Certified EMS Response Vehicles
Page 2 of 2
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
New
No.
15 - 02
Date:
April 29, 2015
Re: Continuous
Positive Airway
Pressure (CPAP)
for BLS EMS
Agencies
Page 1 of 1
Based on the results of a demonstration project, at the September 9, 2014 meeting of
the New York State Emergency Medical Service Advisory Council (SEMSCO), the use of
Continuous Positive Airway Pressure (CPAP) by Emergency Medical Technicians (EMT) in
Basic Life Support (BLS) EMS agencies was approved. The SEMAC approval was granted
with the specific condition that an EMS service wishing to use a CPAP device at the BLS
level, be granted approval by their Regional Emergency Medical Advisory Committee
(REMAC) and that each EMT complete an approved training program. The Commissioner
of Health has approved the addition of CPAP as a part of the scope of practice for
certified EMTs in New York State.
Policy
The SEMAC has approved a statewide protocol for the use of CPAP devices by EMT
personnel for patients in respiratory distress. The REMAC must also adopt a single
standardized training program, approved by the Department, which will be used by all
agencies electing to utilize CPAP at the EMT level.
EMS Agencies wishing to be authorized to use CPAP devices must make a written request
to their REMAC. The request should include, but may not be limited to the following:

A letter from the agency medical director supporting the request for use of CPAP,
including the physician’s plan for quality assurance and appropriateness review of
each utilization.

Written policies and procedures for the use of CPAP that are consistent with
regional policies and protocols. This shall include the following:


Written policies and procedures requiring the approved training program, requirements for
continuing education, maintenance of competencies and the documentation for authorized
providers;
A description of the CPAP device being utilized by the EMS agency.
Once the EMS service has received written approval from the REMAC, the EMS Service
must provide the Department with an updated Medical Director Verification Form
(DOH-4362) indicating CPAP approval.
15-02 CPAP for Basic Life Support EMS Agencies
Page 1 of 1
No.
New York State
Department of Health
Bureau of Emergency Medical Services and
Trauma Systems
15 – 01
Date: February 23, 2015
Re: EMS Student Field
and/or Clinical Rotations
POLICY STATEMENT
Supersedes/Updates: New
Page 1 of 2
Background
The New York State Department of Health (Department), Bureau of Emergency Medical
Services (EMS) is responsible for the oversight of New York State (NYS) EMS education and
training programs, leading to NYS EMS certification. Courses leading to certification at all
levels of Emergency Medical Technician, are required to contain learning objectives, which are
to be completed through field observation, hospital observation, field clinical, and/or hospital
clinical methods.
Purpose
This policy is intended to provide guidance to NYS EMS agencies, course sponsors, hospitals,
and other affiliated institutions who may be accepting EMS students for the purpose of
completing field and clinical educational objectives that lead to NYS EMS certification.
Procedures
1. NYS EMS Education Programs - In order for an individual to begin and complete any of
the field and/or clinical learning objectives, individuals must be enrolled in a NYS
Department of Health approved EMS certification course. In order to be considered a
student, the following conditions must be met:
a. A Department approved Course Sponsor must oversee all educational components;
b. An affiliation agreement between the Course Sponsor and the clinical or field EMS agency
and/or institution must be approved and on file with the Department;
c. Form DOH-782, Course Application must be approved and on file with the Department;
Form DOH-65, Application for Emergency Medical Services Certification must be completed
by all students and on file with the Department;
d. Student must have met all Course Sponsor educational requirements to begin
aforementioned learning objectives as approved by the Department;
e. A Course Sponsor approved preceptor must oversee all aspects of the clinical and/or field
objectives that are completed outside of the classroom;
f. Department and Course Sponsor approved student and preceptor documentation must be
complete; and,
g. Only those skills, previously and successfully completed in the classroom environment and
approved by the Certified Instructor Coordinator (CIC) for the course, may be performed by
the student, and under the direct supervision of their assigned preceptor outside the
classroom.
2. Out-of-state EMS Education Programs - Individuals who are students in courses held
outside of NYS and are not enrolled in a NYS Department of Health approved EMS
15 - XX EMS Student Field and/or Clinical Rotations
Page 1 of 2
certification course must have the following:
a. An affiliation agreement between the NYS EMS agency and/or medical institution and the
out-of-state educational institution that is approved and on file with the Department;
b. A NYS EMS certified provider must act as a preceptor for any student completing their
objectives at a NYS EMS agency. The preceptor must be currently certified at or above the
level of training the student is seeking and approved by the agency Medical Director, or in
the case of hospitals and/or other medical institutions, in accordance with their policies;
c. Objectives completed at a hospital or other non-EMS agency medical institution, must follow
the policies and procedures of that medical institution as outlined in the affiliation
agreement;
d. Students who are completing learning objectives for a national Emergency Medical
Responder (EMR) or EMT course may only observe; they may not provide direct patient
care;
e. Students who are completing learning objectives for any EMS course above the level of
EMT that include advanced level skills, must be certified as a NYS EMS EMT prior to
beginning any learning objectives or skills in NYS;
f. Students may apply for and must be granted NYS EMS Reciprocity prior to beginning
clinical and/or field rotations;
g. Documented behavioral and learning objectives for each student must be provided by the
out-of-state educational institution and maintained on file with the preceptor’s EMS agency
and/or institution;
h. Students may only perform those ALS skills, for which their lead instructor documented
successful demonstration in the classroom environment and under the direct supervision of
their assigned preceptor; and,
i. All aspects of the student’s learning experience must be documented by the preceptor and
kept on file at the agency or medical institution.
3. Affiliation Agreements Requirements – All of these agreements must include, but not be
limited to the following:
a. The contact information, including names, addresses, telephone numbers, e-mail addresses
and other demographic information for each of the entities involved in the agreement;
b. The start and expiration date of the agreement. The duration of the agreement may not be
more than four (4) years and must be reviewed and approved by the Department annually.
c. The written responsibilities for the preceptor, student and agency/institution;
d. Liability and malpractice insurance requirements for all parties; and
e. The process that the preceptor, student and educational institution utilize to correspond
regarding student progress.
Adherence to this policy will insure patient safety, appropriate prehospital care, completion of
the field and/or clinical education goals and objectives, as well as protect the EMS community.
For further questions, please contact:
Education Unit
New York State Department of Health
Bureau of Emergency Medical Services and Trauma Systems
518-402-0996
15 - XX EMS Student Field and/or Clinical Rotations
Page 2 of 2
No.
14-03
Date: 12/31/2014
Re: EMS Vehicle Signage
& Labeling
New York State
Department of Health
Bureau of Emergency Medical Services & Trauma Systems
Page: 1 of 2
POLICY STATEMENT
Supersedes/Updates: Policy Statement 98-08
PURPOSE:
The purpose of this policy statement is to provide clarification of the requirements
pertaining to the labeling and signage of NYS Certified ambulances and emergency
ambulance service vehicles (EASVs). The applicable governing regulations are 10
NYCRR Part 800.21(e), which defines the requirements for the exterior labeling of all
ambulances and emergency ambulance service vehicles (EASVs) and 10 NYCRR Part
800.4(a), which restricts the display of the word “Ambulance” to only motor vehicles,
aircraft, and boats certified by the Department.
BACKGROUND:
These regulations, 800.21(e) and 800.4(a), were adopted to protect the public. They
were respectively intended to clearly identify the DOH certificate holder operating a
certified EMS vehicle, and to prohibit the display of the word “ambulance” on all land,
air, and water vehicles, other than Department of Health certified ambulances.
For contract, marketing and other reasons, some agencies may have placed the names
and logos of organizations other than the DOH certificate holder on vehicles as part of
the signage or labeling displayed. Other services may have used modern design
technology to create striking vehicle graphics for their EMS vehicles. In certain
situations, either of these actions may have the unintended consequence of violating
Part 800.21(e) or Part 800.4(a).
REGULATION:

All certified ambulance services must: “Display on the exterior of both sides
and the back of all ambulances and emergency ambulance service vehicles
the name of the service in letters not less than 3 inches in height and
clearly legible. The logo provided by the department shall also be
displayed on both sides and the back of every ambulance and shall be
removed upon sale or transfer of the vehicle.” [10 NYCRR Part 800.21(e)]

“The word "ambulance" may not be displayed on a vehicle, aircraft, or boat
except on a vehicle, aircraft, or boat registered with the department as an
ambulance except to comply with 800.21 (e).” [10 NYCRR Part 800.4(a)]
POLICY

It is the Department’s duty to protect the public’s right to easily identify the DOH
certified provider of an EMS service, and to protect the public from labeling and
signage that may be misleading, or in the worst case, blatantly fraudulent.

The name (or DBA) of the certified entity, as it appears on the DOH Ambulance
Service Certificate, must be displayed predominately, larger than any other
name, and in a manner that does not confuse the identity of the actual DOH
certified operator. Any other name or lettering displayed (hospital, industrial
corporation, etc.) must be smaller in size and secondary in relationship to the
name of the DOH certified entity.

The statement ‘Operated for’ may be used, as appropriate, to indicate a
relationship to the second entity.

Any labeling design which includes a second name is subject to the approval of
the Department. Services are required to submit actual or conceptual designs to
the Bureau of EMS & Trauma Systems for prior approval.

If a certified EMS agency’s name contains the word “ambulance”, the word
“ambulance” may be displayed on an EASV operated by the agency, but only to
the extent necessary to comply with Part 800.21(e), and only as part of the
agency’s complete and entire name. Additionally, the word “ambulance” must be
of the same size, or smaller than, other labeling that identifies the DOH certified
operator.

If a vehicle is marked with “advanced life support”, “paramedics” or with any
similar level of care identification, the service operator must ensure that the
vehicle is staffed by personnel at the advertised level of care, at all times when
the vehicle is in service.

Labeling a certified EMS vehicle in any manner that constitutes “false
advertising”, as declared unlawful and defined by Article 22-A of NYS General
Business Law, is also a violation of 10 NYCRR Part 800.2 [“Applicability of Other
Laws, Codes, Rules, and Regulations”].
MUNICIPAL CONTRACTUAL IDENTIFICATION
The name of the service requirement does not apply to an agency when operating a
service for a municipality under the provisions of PHL 3008.7a. In these cases all
operations are the responsibility of the licensed entity and since the service is operated
by the municipality, all vehicles must bear the name of the entity. The specifics of any
such arrangement should be discussed with the Department prior to implementation.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
14 – 01
Date: Dec. 8, 2014
Re: EMS Provider
Patient Care
Restriction
Guidance
Supercedes/Updates: None
Page 1
of 4
This policy was developed in conjunction with the State Emergency Medical Services Council
(SEMSCO) and State Emergency Medical Advisory Committee (SEMAC). It is intended to
provide guidance to EMS Agency Medical Directors, Regional Medical Directors, and Regional
Emergency Medical Advisory Committees (REMACs) to promote an ongoing EMS patient care
performance monitoring and quality improvement relationship between EMS providers and the
Physician Medical Directors ultimately responsible for authorizing EMS provider practice.
Purpose
1. To protect EMS patients by providing the means for remediating and if necessary
restricting the practice of an EMS provider when a Physician Medical Director has
concern about the EMS provider’s ability to competently provide medical care.
2. To provide fair and consistent due process for the EMS provider in resolving and/or
appealing a patient care restriction.
3. To ensure that patient care restrictions are enacted fairly and in accordance with an
EMS agency’s or region’s quality improvement (QI) program.
4. To ensure that the QI process is not used in a punitive fashion.
5. To promote interagency and interregional QI initiatives in cases where EMS providers
operate in multiple regions.
Definitions
1. “Agency Medial Director (AMD)” means a physician identified by an EMS agency as
providing medical oversight for the agency.
2. “Regional Medical Director (RMD)” means a physician identified by a REMAC as
providing medical oversight for the region.
3. “Patient care restriction” means any restriction placed on an EMS provider by an AMD,
RMD, or REMAC that limits an EMS provider’s ability to perform, in whole or in part, to
the EMS provider’s level of certification and/or regional authorization.
A patient care restriction may restrict all care (the provider may not practice either basic
or advanced level care), restrict only advanced level care (the provider may still practice
basic level care), restrict an individual skill or procedure, and/or remove standing orders
14 – 01: EMS Provider Patient Care Restriction Guidance
Page 1 of 4
(the provider would have to contact Medical Control and receive specific on-line orders
to perform procedures, treatments, and therapies).
Patient care restrictions should be considered separate from and in addition to any nonpatient care related restrictions that may be placed on a provider by an EMS agency
(i.e., violation of agency rules and procedures, lateness, uniform issues, drivers’ license
restriction, etc.).
4. “Medical Case Review (MCR)” means a confidential review of a patient care restriction
performed under the auspices of the regional QI program.
5. “Medical Review Board (MRB)” means a board of physicians convened by the REMAC
to perform a medical case review and/or to hear an appeal of a patient care restriction.
Procedure for Enacting/Remediating a Restriction
The care administered by EMS providers is authorized and overseen by physicians. In some
cases, these physicians may be AMDs, while in other cases these physicians may be RMDs
and/or a REMAC.
1. An AMD may place an EMS provider on a patient care restriction when there is concern
regarding the provider’s ability to render appropriate EMS care. The AMD must provide
appropriate immediate notification to the affected provider, followed by written
notification to the provider within five (5) business days. For any restriction lasting more
than 30 calendar days, the AMD must notify the REMAC in writing within five (5)
business days of it being known that the duration will surpass 30 days. The AMD may,
at any time, notify other respective AMDs, the RMD, the REMAC, and/or the Bureau of
EMS and Trauma Systems of any matter felt serious enough to warrant such
notification(s) and possible further action.
2. A RMD may (independent of the AMDs) place a provider on a patient care restriction
when there is concern regarding the provider’s ability to render appropriate EMS care.
The RMD must provide appropriate immediate notification to the affected provider,
followed by written notification to the provider within five (5) business days. Such
restriction may be concurrent with or in addition to restrictions enacted by an AMD. The
RMD must report any such restrictions to the respective AMDs and REMAC in a timely
manner and may, at any time, notify the Bureau of EMS and Trauma Systems of any
matter felt serious enough to warrant such notification and possible further action.
3. A REMAC may (independent of the AMDs or RMD) place a provider on a patient care
restriction when there is concern regarding the provider’s ability to render appropriate
EMS care. The REMAC must provide appropriate immediate notification to the effected
provider, followed by written notification to the affected provider within five (5) business
days. Such restriction may be concurrent with or in addition to restrictions enacted by
an AMD or RMD. The REMAC must report any such restriction to the RMD and
respective AMDs in a timely manner and may, at any time, notify the Bureau of EMS
and Trauma Systems of any matter felt serious enough to warrant such notification and
possible further action.
14 – 01: EMS Provider Patient Care Restriction Guidance
Page 2 of 4
4. When notified of a patient care restriction enacted by an AMD or RMD, the REMAC may
enact a greater patient care restriction further limiting the care a provider may render
within the region. The REMAC must provide appropriate immediate notification to the
affected provider, followed by written notification to the provider within five (5) business
days.
5. For any restriction coming before the REMAC, the REMAC is responsible to make
timely written notification of such restriction to all EMS agencies, and the respective
AMDs, where the provider is listed as practicing. If appropriate, the REMAC will notify
in writing all other affected REMACs and the Bureau of EMS and Trauma Systems for
possible further action. All patient care restrictions coming before the REMAC will be
reviewed by the Regional QI Program committee.
6. The respective AMDs, RMDs, and REMACs will be responsible for ensuring that any
patient care restriction is honored.
7. Any patient care restriction should be followed by a definitive course of provider
remediation, including a timeframe for the restriction/remediation, developed in
partnership with the provider, AMD, RMD, REMAC, EMS agency, local EMS training
center, and/or local hospital as appropriate and allowable. Once the provider has
successfully completed remediation and the restriction removed, written notification
must be provided to the appropriate persons and entities. If it is determined that the
issue cannot be corrected through remediation or the provider is no longer affiliated with
the respective EMS agency or REMAC region, the matter will come before the REMAC
(in consultation with the Bureau of EMS and Trauma Systems as necessary) for
appropriate further action.
Procedure for an Appealing a Restriction
1. A provider may appeal any patient care restriction by an AMD or RMD in writing to the
REMAC.
2. Within 30 days of receipt of an appeal, the REMAC must convene a MRB to conduct a
MCR under the auspices of the Regional QI Program.
3. The MRB may request relevant documentation including pre-hospital patient care
reports, hospital records, training records, QI records, and written statements from
patients, providers, bystanders, etc. The MRB may invite the provider, AMD, RMD,
patient, other providers, EMS agency officials, or other parties who may be able to
provide relevant information.
14 – 01: EMS Provider Patient Care Restriction Guidance
Page 3 of 4
4. As the MRB is a committee of the REMAC, after hearing the appeal the MRB must
make a recommendation to the REMAC, which in turn shall make the determination on
the appeal. The MRB may recommend to the REMAC:
a. that the REMAC remove all or part of the restriction;
b. that the provider successfully complete appropriate remediation before the
REMAC removes all or part of the restriction;
c. that the REMAC revoke the provider’s credentials/authorization to practice;
and/or
d. that the REMAC refer the matter to the Bureau of EMS and Trauma Systems for
investigation/enforcement action.
5. After an appeal is determined, the REMAC must provide follow up notification of the
determination to all those originally notified of the restriction.
6. In accordance with Public Health Law Article 30, Section 3004-A:
4. Any decision of a regional emergency medical advisory committee regarding
provision of a level of care, including staffing requirements, may be appealed to
the state emergency medical advisory committee by any regional EMS council,
ambulance service, advanced life support service, certified first responder,
emergency medical technician, or advanced emergency medical technician
adversely affected. . . . Any decision of the state emergency medical advisory
committee may be appealed pursuant to subdivision two-a f section three
thousand two-a of this article.
Issued and Authorized by
Lee Burns, Director - Bureau of EMS
14 – 01: EMS Provider Patient Care Restriction Guidance
Page 4 of 4
No.
13 - 10
Date: Dec. 10, 2013
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: New
Re: Intranasal
Naloxone (Narcan®) for
Basic Life Support EMS
Agencies
Page 1 of 3
At the October, 2013 meeting of the New York State Emergency Medical Advisory Committee
(SEMAC), the administration of naloxone (Narcan®) using a mucosal atomizer device (MAD)
for patients experiencing opioid overdoses was approved for use by certified Basic Life
Support EMS providers in Basic Life Support (BLS) EMS agencies. The Commissioner of
Health has approved the administration of intranasal naloxone as a part of the scope of
practice for certified Basic Life Support EMS providers in New York State.
The purpose of this policy is to explain the process for agencies wishing to implement an
intranasal naloxone program. The addition of administration of intranasal naloxone is
intended to provide prompt emergency medical care to patients with symptomatic acute
opioid overdoses as described in prehospital protocol.
In order to participate in the BLS intranasal naloxone program, the EMS agency must have
approval from its medical director, complete the approved training program which includes
watching a video, reviewing written materials and a brief supervised practice session and
make notification to the local Regional Emergency Medical Advisory Committee (REMAC).
BLS INTRANASAL NALOXONE PROGRAM
The SEMAC has approved an amendment to the Altered Mental Status protocol in the New
York State CFR and EMT/AEMT BLS Protocols which will enable EMS agencies and certified
Basic Life Support EMS providers to administer intranasal naloxone to patients experiencing
an acute opioid overdose. A NYS EMS Lesson Plan Guide has been developed for use by
EMS course sponsors. Additionally, the REMAC may approve training programs and
determine the type and level of record keeping and quality assurance requirements for this
procedure.
PARTICIPATION
EMS agencies intending to participate in the intranasal naloxone program, must:
1. Notify the local REMAC in writing;
2. Utilize an intranasal naloxone kit that contains the following:
a. Two (2)- naloxone hydrochloride pre-filled Luer-Lock (needleless) syringes containing 2mg/2ml
b. Two (2)- mucosal atomization devices (MAD): and
c. One (1)- container for security/storage
13 - 10 Intranasal Naloxone for Basic Life Support EMS Agencies
Page 1 of 3
Additionally EMS agencies must do the following as a minimum:
1. Develop written policies and procedures for the intranasal naloxone program that are
consistent with state and local protocol. This shall include, but not be limited to the
following:





policies and procedures for the EMS training, credentialing and continuing
education;
documentation of credentialed users;
appropriate patient documentation;
a defined quality assurance program, including appropriateness review by the
medical director;
policies and procedures for:
> inventory;
> storage, including environmental considerations;
> security; and
> proper disposal of medication and administration devices.
2. Perform quality assurance evaluations on each administration for the initial six (6)
months of the program, or longer at the request of the medical director.
3. Provide data to the REMAC upon request.
CONCLUSION
With a growing number of prehospital opioid overdoses throughout the NYS, all EMS
agencies are encouraged to train their certified BLS providers in the administration of
intranasal naloxone) and stock the medication and mucosal atomizer devices (MAD) on their
certified EMS response vehicles. The addition of intranasal naloxone has life-saving benefits
in reversing opioid overdoses in the prehospital setting. EMS providers are frequently the
first to arrive at the scene of an overdose putting them in the best position to administer this
time-sensitive, life-saving intervention. The use of a nasal atomizer device reduces the
potential for occupational exposure to needle stick injuries. Widely available evidence exists
to indicate that the medication is equally effective when administered intra-nasally and
suggests no negative health outcomes.
The New York State EMS Demonstration Project concluded with the following:





2,035 EMTs trained;
223 opioid overdose reversals;
No adverse events;
No significant hazards to EMS personnel; and
10% of contacted reversals entered rehabilitation programs
13 - 10 Intranasal Naloxone for Basic Life Support EMS Agencies
Page 2 of 3
RESOURCES
•
CFR/BLS Altered Mental Status Protocol (attached)
•
BLS Drug Formulary – Naloxone (attached)
•
NYS EMS Lesson Plan Guide
•
Reversing Opioid Overdose: Training for EMS and Public Safety Personnel
Course Link: http://hivtrainingny.org/Account/LogOn?crs=821
This link will take you to the DOH website which hosts the training video and
associated materials. To access the materials, you must establish an account which is
free and takes only a couple of minutes. Once you establish an account, you will be
directed to the training materials.
•
“Substance Abuse and Mental Health Administration - Opioid Overdose Prevention
Toolkit .”
http://store.samhsa.gov/product/SMA13-4742
Issued and Authorized by
Lee Burns, Director - Bureau of EMS
13 - 10 Intranasal Naloxone for Basic Life Support EMS Agencies
Page 3 of 3
No.
13 - 08
Date: 11/06/13
New York State
Department of Health
Bureau of Emergency Medical Services
Re: EMS Response
Planning to a Suspected
Biological/Infectious
Disease Incident
POLICY STATEMENT
Supersedes/Updates: 03-02
Page 1 of 6
Recommendation on CBRNE AWARENESS
This policy was developed to assist EMS providers and agencies in adopting policies and procedures that will
address all-hazards awareness to incidents that include acts of terrorism involving Weapons of Mass
Destruction (WMD) specifically chemical & biological agents, radiological, nuclear and explosive (CBRNE)
incidents. The intention is for responders to have a keen understanding on how to recognize the unfamiliar
risks they may encounter at the scene of a CBRNE event.
Background
The use of terrorism is not a new phenomenon; however, since the early 1970’s terrorist attacks on U.S.
interests and citizens has grown in popularity as a strategy or tactic to elicit change. There are many definitions
for terrorism, but all contain factors that use force or fear to further an objective.
Terrorism is about the fear of violence. The availability of CBRNE elements allows for a variety of weapons.
Additionally, there is increased concern that arson and firearms may also be used as a tactic. History shows
that explosives are overwhelmingly the weapon of choice, yet all forms of terrorism have the potential to
impact all responders. Although the probability of a significant CBRNE incident is low, the consequences are
too severe to ignore. A CBRNE incident can happen anywhere, anytime! EMS providers must be alert and
recognize what they may confront when responding to an act of terrorism involving CBRNE.
FBI Definition of Domestic Terrorism
Activities that involve acts dangerous to human life that are a violation of criminal laws of the United States or
of any state; appear to be intended to intimidate or coerce a civilian population; to influence the policy of a
government by mass destruction, assassination, or kidnapping; and occur primarily within the territorial
jurisdiction of the United States. (U.S. Congress, par. 3)
Policy
EMS responders will operate within the Incident Command System (ICS). ICS is one element of the National
Incident Management System (NIMS). During a CBRNE response, EMS shall follow ICS as the New York State
standard for command and management system.
Department of Homeland Security maintains a two tiered terrorism alert, non-credible & credible threat. EMS
agencies should maintain a working relationship with other local and regional responding agencies i.e. law
Policy Statement 13 - 08
Page 1 of 6
enforcement, fire, county emergency management office, local & county elected officials. When a credible
threat has been determined, these disciplines, including EMS, should meet to be briefed and discuss a
mitigation strategy. Consideration should also be given to information and intelligence products which are
available to the emergency services community. Maintaining an awareness of events which may impact your
community, such as severe weather or mass-gatherings, is a good way to be better prepared for potential
incidents.
EMS responders must play a role in the prevention and anticipation of a terrorist attack. The threat of a
terrorist attack is real and responders need to understand what makes up the components of such aggression.
These factors include:
• Element of surprise. Few people may have prior knowledge of the attack. The suddenness of an attack has
much shock value.
• Means of the attack. Attacks can be conducted using a range of CBRNE elements, with improvised
explosive devices (IEDs) being the most common. Arson and firearms may be used as well.
• Foreknowledge of a response. Terrorists will gather intelligence by conducting surveillance of potential
targets to understand first responder’s response and resource capabilities.
• EMS is in a unique position to observe things. We are invited into areas to provide care. During this
response we may see things that are not right. Be observant when doing the Scene Safety Survey. “IF
YOU SEE SOMETHING, SAY SOMETHING”, report any suspicious activity to the NYS Terrorism Tips Line at
1-866-SAFE-NYS (866 723-3697). Or call your dispatch; do not transmit over the radio.
• Significant dates. Terrorist attacks may occur on noteworthy dates i.e. April 19th, September 11th.
• Target of the attack. Targets can include: responders (secondary device/ambush), the public, critical
infrastructures and other potential targets such as schools, sports arenas, malls, places of worship and
mass gathering special events.
Scene Awareness:
Scene awareness begins well before any response to a CBRNE incident. Each community should conduct a
collaborative effort among emergency responder disciplines and their regional Office of Emergency
Management to conduct a threat and vulnerability analysis. Pre planning and preparedness should include
assessing resource capabilities, potential terrorist targets, training and exercising together, and knowing each
agency’s roles and responsibilities. Responders need to be familiar with their community, existing violence
from gangs, protests, union/labor/political issues, nearby military bases, nuclear plants, VIP visits,
pharmaceutical plants, interstate commerce, railways, federal buildings and mass gathering events.
Terrorists will plan their impending attacks by acquiring CBRNE materials necessary for their attacks. As
responders, we need to maintain a situational awareness when approaching and on scenes. Are there
suspicious materials or supplies that indicate preparation of a weapon? For example:
• nitrogen-based fertilizer
•
fuel containers/drums
•
bomb making materials
•
pipes with caps
Policy Statement 13 - 08
Page 2 of 6
•
propane tanks
•
strong chemical smells
•
large quantities of fire strike match books
•
unknown powder
•
castor beans or plants, which could be used to make Ricin
•
bottles of hydrogen peroxide
•
containers filled with urine
•
fireworks, gun powder
•
spraying equipment for dissemination
•
blueprints of a facility to gain illicit entry
•
books or literature on bombing making, etc.
•
extremist materials, such as flags, posters, literature, and websites
•
the presence of potentially hazardous materials (especially high concentrations are present)
•
the unusual presence of equipment which could be used to manufacture CBRNE materials (such as
grinders, blenders, mixers, glassware, ice bath, distillers, filters, hot plates, and/or safety equipment to
provide protection from hazardous materials)
•
quantities of an item, which is unusual for the context in which it is found (such as the presence of
several GPS devices, cell phones, backpacks, or other items which could be used to construct an
explosive device or aid in an attack)
Be aware of:
• suspicious persons who exhibit apprehensive behavior, improperly dressed for the location or season
• vehicles abandoned with multiple parking tickets, unattended or appear to be out of place
• abandoned packages, luggage or mail left unattended in a crowded place
• mail packages with excessive postage and signage alerts i.e. fragile or handle with care, no return
address, oil stains and wires protruding
• chemical fires or toxic odors
• unusual explosions in rural or wooded areas
• the theft or attempted theft of gear, equipment, or vehicles, which could be used to gain access into
Policy Statement 13 - 08
Page 3 of 6
secure areas, or aid in criminal or terrorist activity
• statements by individuals that they may engage in violent acts
• individual(s) posing unusual questions related to staffing levels, security, and response plans related
to your facility or a location where you may respond
• any unusual activity or circumstance in your community or workplace.
A CBRNE incident can be violent. While enroute, listen to the radio traffic and ask for informational updates.
The scene will be the hot zone, and may include CBRNE hazards, weapons being fired, secondary devices,
partially exploded devices, booby traps, blood from arterial bleeds, body parts, debris, collapsed structures,
fire, smoke, and injured victims screaming for assistance. Know your wind direction!
Responders need to recognize the hazard/threat and make a mental assessment. Avoid the hazard by not
getting contaminated or injured. Stay away from liquids, unknown powders, clouds or vapors. Remain alert for
suspicious objects/packages/vehicles, and persons who appear to be acting unusual for the circumstances
(such as not panicked or surprised by an explosion). If a hazard is detected, isolate or remove yourself from
the threat, remove others from the contaminated zone and keep civilians/people from going into the
contaminated zone. Encourage anyone within the danger zone to self-evacuate if possible. Notify your
dispatch. Ask or find the command post (CP) or establish a CP. Identify the kill zone. Practice the concept of
time, distance and shielding. Keep victims within the CBRNE hot zone.
General scene precautions to protect providers include:
•
•
•
•
•
•
•
•
•
Take protective actions to preserve health and safety i.e. retreat. Have a verbal (code) phrase with your
partner to initiate retreat. Understand the first in responders may be in the hot zone and become a victim
of the attack. At this time, the exposed responder can still be a resource in providing intelligence i.e.
description of the firearm, signs & symptoms, etc.
Stage in an area upwind, uphill and upstream from the incident.
Isolation involves preventing others from entering the affected area.
Shelter in place if evacuation is not possible or is not appropriate i.e. when evacuation would put others at
greater risk. This means shelter inside a building and remain there until the danger passes.
If providers have exited their vehicles and are ambushed, hide behind your wheels to prevent being struck
by ricochet bullets fired under your vehicle.
Try to recognize by sight the following: visible corrosion, chemical reactions, pooling of liquids,
condensation on pressure tanks, dead animal, insects, plants, fire or vapor clouds, injured victims or
casualties. Multiple victims with same signs & symptoms may indicate a WMD release i.e. seizures, excess
salivation, lacrimation, loss of bladder (urination) & bowel control (defecation), gastro-intestinal cramping,
emesis, mitosis, better known as SLUDGEM of an organophosphate poisoning/nerve agent.
Listen for sounds i.e. hissing indicative of a pressure release.
BE AWARE AND SUSPECT SECONDARY EXPLOSIVE SCENE DEVICES.
Smell is a good initial indicator, but the sense of smell can be overwhelmed and cause the responder to
think the odor has gone away, for the presence of hazardous materials. If an odor is smelled, you are too
close.
Do not touch or taste any substance that has not been identified!
Policy Statement 13 - 08
Page 4 of 6
•
•
Use PPE that includes: gloves, goggles/face shields, masks/positive pressure, full tyvek suits with hoods &
booties.
Taking note of the appearance of smoke, sounds, odors at the scene and on patients, and the image of the
scene in general can aid law enforcement in the investigation.
Use your Emergency Response Guidebook (ERG). This is an aid to identify a hazardous material and should be
used during the initial phase of arriving on an incident. Refer to guide 111 of the orange pages if the hazard is
unknown.
Chemical Agents:
Terrorists may use a toxic warfare chemical i.e. choking, blood, blister or nerve agent, but more likely a more
readily available source for WMD will be a toxic industrial chemical (TIC). TICs are within many communities
i.e. chlorine, hydrogen cyanide and anhydrous ammonia. Chemical agents can exist in a solid, liquid or gaseous
state. Chemical incidents have a rapid onset of symptoms (minutes to hours) and reveal easily seen
observations i.e. dead foliage, pungent odor, dead animals/insects and colored residue.
Biological Agents:
A biological agent includes: bacteria, virus or a toxin. These agents cause the same symptoms as a naturally
occurring disease. Exposures to a biological agent will begin with flu-like symptoms. There may be delayed
onset of symptoms (incubation period) making the initial diagnosis difficult and the actual location of infection
difficult to determine. Diseases from a biological attack may be contagious. Public health will be the first to
detect such an outbreak.
Radiological Materials and Nuclear Weapons:
Radiological materials emit invisible, unstable energy in the forms of: alpha particles, beta particles, gamma
rays and/or neutrons. All forms of radiation are odorless and colorless, thus radiation detectors must be
utilized to detect decaying radioactive isotopes. Dependent on the type and dose of energy, radiation can
travel in all directions exposing or penetrating individuals causing radiation sickness (ARS). ARS includes:
nausea, diarrhea, burns and possible death. Like biological attacks, radiation incidents will take several days to
weeks to appear.
A nuclear weapon incident has a low probability of use, but if detonated can produce devastating large scale
damage, much larger than a conventional high explosive. A nuclear weapon detonation may not have a
mushroom shaped cloud. Remember time, distance and shielding.
Explosives Devices:
Explosive materials have two categories: low and high. Seventy percent of all terrorist incidents involve
explosives and can present as an Improvised Explosive Device (IED). IEDs can be deployed in any shape, form or
size including: package-type, vehicle-type or suicide (human-borne). When responding, think secondary
device!
References:
www.FirstResponderTraining.gov - FEMA /DHS funded training courses
www.NDPC.US – National Domestic Preparedness Consortium
Policy Statement 13 - 08
Page 5 of 6
www.cdp.dhs.gov - Center of Domestic Preparedness, Alabama
- National Center for Biomedical Research & Training, Louisiana
www.teex.com/nerrtc - National Emergency Response & Rescue Center, Texas
www.emrtc.nmt.edu - Energetic Materials Research & Testing Center, New Mexico
www.dhses.ny.gov/training - NYS Division of Homeland Security and Emergency Services, New York
www.dhses.ny.gov/oct/safeguardNY/ - NYS Division of Homeland Security and Emergency
Serviceswww.bt.cdc.gov/masscasualties/index.asp - Centers for Disease Control and Prevention
Understanding Terrorism and Managing the Consequences, Paul Maniscalco, and Hank Christen
Hazardous Waste Operations and Emergency Response, 29 C.F.R. 1910.120 (2010)
U.S. Department of Transportation. (2012). 2012 Emerge
Policy Statement 13 - 08
Page 6 of 6
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supplements/Updates: 92–02, 03-02, 03-11
13-05
Date: 04/03/2013
Re: Respiratory Disease
Precautions
Page 1 of 3
Introduction:
This policy was updated in consultation with NYS Department of Health (DOH) Bureau of
Communicable Disease Control, NYS DOH Occupational Health and Safety, and NYS Department of
Labor Public Employee Safety and Health. It is the intention of this policy statement to provide
information and recommendations for the transport of patients with potentially infectious respiratory
illnesses, such as influenza and tuberculosis (TB). This policy will also provide updated guidelines for
“respiratory etiquette” and the use of Personal Protection Equipment (PPE) as well as
recommendations for preventive health care measures for EMS providers.
The Bureau of Emergency Medical Services (BEMS) strongly recommends that all EMS agencies
review this guidance document, along with other State and county public health recommendations, to
prepare your EMS agency response to a patient with a potentially infectious respiratory illness.
EMS providers should be aware of the signs and symptoms of infectious respiratory diseases and the
procedures necessary for protecting themselves. Not all respiratory infections are transmitted in the
same way. Transmission can occur from direct or indirect contact, large droplets, or small droplet
nuclei. The mode of transmission will depend on the etiological agent. When encountering patients
with symptoms of potentially infectious respiratory illness, the CDC recommends the use of surgical
masks. Certain procedures can also impact transmission of infectious agents by producing aerosols.
These are deemed “high risk respiratory procedures” and include intubation, extubation, deep tracheal
suctioning, nebulized respiratory treatments and bronchoscopy. When performing these high risk
procedures, the CDC recommends the use of appropriate and/or adequate "NIOSH APPROVED /
RATED" respirators. The use of NIOSH approved respiratory protection may be required under
pandemic influenza or other emerging disease alerts issued by CDC.
More often in the field of emergency medicine, the etiologic agents of infections are unknown. Given
this, it is paramount that good infection control practices be followed for contact with all patients.
Respiratory Etiquette Strategy



Implement the use of surgical masks by healthcare personnel, during the evaluation of patients with
respiratory symptoms.
Provide surgical masks to all patients with symptoms of a respiratory illness. Provide instructions
on the proper use and disposal of masks.
For patients who cannot wear a surgical mask in addition to any medical treatment being provided,
provide tissues and instructions on when to use them (i.e., when coughing, sneezing, or
controlling nasal secretions), how and where to dispose of them, and the importance of hand hygiene
after handling this material.
1
Recommendations:
1. Personal Protection
When assessing a patient with symptoms of a febrile respiratory illness, the use of a surgical mask is
recommended. When performing high risk aerosolizing procedures the use of a NIOSH
approved/rated respirator is recommended. When directed by a BEMS Advisory, the REMAC or the
EMS agency medical director, use the highest level of respiratory protection available. The employer
is responsible for ensuring the proper PPE is utilized and when respirators are used, conforming with
requirements (i.e. medical screening, fit testing, training, user seal checks, respiratory protection plan,
etc.) as prescribed by the OSHA Respiratory Protection standard. In all cases, adhere to Standard
Precautions - the use of gown, gloves and eye protection if contact with bodily secretions or a
contaminated environment is anticipated. Additionally, EMS providers must be familiar with PPE
application (donning) and removal (doffing) procedures. The routine use of Standard Precautions will
allow EMS providers to protect themselves and their patients against known infectious diseases or
other new emerging diseases.
•
•
•
•
Place a surgical mask on the patient if not medically contraindicated.
Prior to transporting a patient with an infectious respiratory symptom, the door between the driver and
the patient compartment should be closed. If the vehicle does not have a barrier between the cab and
the patient compartment, the driver and front seat passenger should, wear a surgical mask, if the patient
cannot wear one.
Practice good hand hygiene. Hands must be properly washed before donning and after removal of
gloves with warm soapy water or disinfected with a waterless hand sanitizer if a sink is not immediately
available. Do not wait until you return to the ambulance station to practice hand hygiene.
Assure adequate cleaning of the equipment and vehicles between transports. This cleaning should
minimally include:
a. Use of Environmental Protection Agency (EPA) approved disinfectant;
b. Disinfecting any reusable equipment used on the patient as per the manufacturer’s instructions;
c. Frequently touched surfaces of the vehicle;
d. Visibly soiled surfaces.
2. Medical Procedures
Medical procedures, such as nebulized respiratory treatments, that may re-aerosolize infectious
material should only be done if medically necessary. It is recommended that mechanical ventilators,
including BVM devices and suction equipment, should be fitted with a HEPA filter, if available, to
prevent re-aerosolization. EMS agencies should contact equipment manufacturers for
recommendations on a HEPA filter. When performing these high risk procedures, the CDC
recommends the use of appropriate and/or adequate "NIOSH APPROVED/RATED" respirators.
3. Tuberculosis
Although the overall risk is low, there has been documented transmission of M. tuberculosis in EMS
occupational settings. EMS personnel should be included in comprehensive training, education, and
testing programs for TB infection, and follow-up testing as indicated by the risk classification of the
setting. Drivers, HCWs, and other staff transporting patients with suspected or confirmed TB should
wear an N95 respirator, and the patient should wear a surgical mask. In addition, ambulances should
allow for the maximum amount of outdoor air to be circulated in the vehicle.
2
EMS Provider Health Precautions
1. BEMS strongly recommends providing the following to EMS agencies and providers:
a. Enforce the use of surgical masks and/or adequate "NIOSH APPROVED/RATED" respirators when
assessing or performing aerosolizing procedures. When respirators are used, the employer shall
conform with requirements (i.e. medical screening, fit testing, training, seal checks, respiratory
protection plan, etc.) as prescribed by the OSHA Respiratory Protection standard.
b. Frequent and on-going education including, but not limited to infection control measures, PPE as well as
proper personal/hand hygiene.
c. Annual flu vaccinations and other preventive health measures.
2. EMS agencies should monitor their crews for any type of infectious illness. EMS management
should monitor any provider that presents with signs and symptoms of a febrile respiratory illness.
Agencies should consider the following (in order of preference):




Release staff from duty until they have sought medical attention and have sufficiently recovered.
Assigning staff to non-patient care related duties for the duration of their illness.
Require EMS providers to don surgical masks to protect their patients while providing care.
The EMS agency medical director and the County Public Health Office should be advised of any EMS
healthcare provider who is hospitalized with pneumonia.
Conclusion:
Adherence to the above respiratory protection guidance will allow the EMS community to protect itself
when assessing and treating patients with a potentially infectious respiratory disease. The routine use
of standard precautions will protect against other types of infectious diseases.
For Additional Resources:
Please review the information provided at the following web sites:
 www.health.state.ny.us
 http://www.nyc.gov/html/doh/html/home/home.shtml
 http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
 http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
 http://www.labor.state.ny.us/workerprotection/safetyhealth/dosh_pesh.shtm
Issued by:
Lee Burns, Director
Bureau of EMS
3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 09-13
13 - 04
Date: March 15, 2013
Re: Alternative
Medication Formulary For
Prehospital Drug
Shortages
Page 1 of 8
BACKGROUND
Drug shortages, including controlled substances, are occurring frequently. Drug shortages can
adversely affect patient care and may result in medication errors. According to the American
Society of Health-System Pharmacists (ASHP) Guidelines on Managing Drug Product
Shortages in Hospitals and Health Systems (8/1/09), pharmacy departments must take a
leadership role in efforts to develop and implement appropriate strategies and processes for
informing practitioners of shortages and ensuring the safe and effective use of therapeutic
alternatives. EMS agencies that have contracts or MOUs with a hospital pharmacy, are
considered “practitioners” and therefore should be notified by the pharmacy.
The main sources to use for the most up to date information should be your pharmacy or
medication vendor as well as the Federal Drug Administration (FDA). The FDA has a web site
that contains the most current information on national drug shortages. The web site is:
http://www.fda.gov/Drugs/DrugSafety/DrugShortages/default.htm
Planning for any type of drug shortage can be divided into three phases: identification and
assessment, preparation, and contingency.
1. Identification and Assessment
Assessment requires a critical evaluation of the current situation and the potential effect the
shortage may have on the healthcare system. For patients whose treatment depends on the
unavailable drug product, alternative therapies must be identified. EMS agencies should
review their past patient data to assess the projected needs for their community.
2. Preparation
EMS agencies should first review their current medication inventory policies to determine if
changes to those policies need to be made. For example, a new policy that may allow for only
stocking first line EMS response units with medications that may be on the shortage list, while
assuring those units that are out-of-service or not used for primary emergency response are
not carrying any medications that may be in short supply. Additionally EMS agencies should
review their medication stock to determine the usage trends, current supplies, expiration dates
and replacement availability or the need to order alternative medications.
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 1 of 8
3. Compliance
At no time can an EMS agency borrow, supply or sell any medication to another entity
unless they possess a distributor’s license. The movement of medications is strictly
regulated by the Food and Drug Administration (FDA) and the Drug Enforcement
Agency (DEA).
10 NYCRR §80.136 - Controlled substances for emergency medical services: purchasing,
possessing, delivering, administering and safeguarding of controlled substances authorizes a
certified advanced life support EMS agency to possess the following controlled substances
approved by the Department and BEMS Policies; ketamine, midazolam, diazepam, morphine
and fentanyl.
The Department has changed the Controlled Substance (CS) licenses for all EMS agencies to
include Schedules II,III and IV. This will allow EMS agencies to possess and administer
medications that are approved by Department to address drug shortage issues and changes in
prehospital protocols.
Medication Expiration Dates
All medications have expiration dates that are developed by each specific manufacturer and
reviewed by the FDA. When a drug shortage occurs, the FDA is able to review data from
manufacturers pertaining to using a drug past its expiration date. The FDA may determine if
they will approve extended expiration dating to increase supplies until new productions are
available. If the FDA does allow this, it will be posted on the aforementioned FDA web site.
Please be advised, that the Department must also approve the extension of medication
expiration dates. Therefore, no expired medications may be administered to patients without
the approval of the FDA and the NYS Department of Health.
Commissioner’s Ruling Exempt Distribution
A hospital pharmacy may purchase or transfer controlled substances from another hospital or
retail pharmacy for their immediate, legitimate medical needs.
Definition of an immediate need exists when the facility or retail pharmacy is not capable of
preparing a controlled substance medication or does not have a controlled substance in stock
and immediate administration or dispensing of the drug is necessary for proper treatment.
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 2 of 8
Procedures
DOH - Bureau of EMS
•
•
Will establish a state-wide medication formulary for alternative medications. This formulary will allow
REMACs to better prepare for, and initiate changes to regional protocols to meet the changing needs of a
region.
Continue its work with the State Emergency Medical Advisory Committee (SEMAC) to make additions
and subtractions to the alternative formulary as necessary.
REMAC
•
•
•
•
•
•
•
Will open communication with hospital systems within their region to identify and share information
regarding drug shortage issues.
Establish communication with all EMS agencies within the region to monitor potential local drug shortage
issues.
When a region-wide drug shortage issue has developed, submit a letter of request to BEMS advising that
a portion of the state-wide alternative medication formulary is being utilized. Specific medications and
protocol changes must accompany this letter of request. BEMS will review the request and issue a
determination.
The alternative medication formulary (attached) was developed to include up to four (4) alternative
medications. Alternate A should be the first consideration, followed by alternate B, alternate C and then
finally alternate D. Each REMAC needs to evaluate which of the alternative medications is best for their
region.
Will coordinate provider education for all new medications or uses of medications using the provided
educational template.
Every 30 days after approval of the alternative formulary, the REMAC must evaluate the need to continue
the use of the alternative formulary.
Every 6 months after approval of the alternative formulary, the REMAC must submit a written request for
extension to BEMS.
EMS Agencies
•
•
•
•
•
Must continue to evaluate potential drug shortages within their operating territory.
Notify the REMAC of any potential or current drug shortages.
If any changes are made to the controlled substances inventory at an agency, an updated CS plan must
be submitted and approved by the Department.
Assure education of certified providers within the agency follows the BEMS educational template.
If a specific medication is no longer available, and there is no BEMS approved alternative, the EMS
agency must still continue to provide care to the best of its ability. The lack of a medication should not
prohibit any response and care of patients in your area. EMS agencies must follow their regionally
approved protocols to the best of their ability with the medications available to them.
Issued and authorized by the Bureau of EMS Director
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 3 of 8
Requirements for any New Medication added to the Prehospital Formulary
by any Region or EMS Agency
Background:
During the course of initial certification at the EMT- Critical Care and Paramedic levels,
medications are introduced in a systematic fashion. This provides for extensive and detailed
information on each medication they are authorized to use according to the NYS curriculum.
Issue:
After the providers are certified and are using their skills in the field, the education
modalities used to introduce new medications or medications specific to a region have no
uniformity or standardized educational methodology. Many times it is up to the individual
certified provider to learn about medications.
Solution:
In consultation with the SEMAC, the Bureau of EMS has established a required outline
to be used by all agencies, regions and course sponsors as a minimum requirement of
objectives for any new medication added to the scope of practice, protocols or regional and
state medication formulary.
Completion of all educational requirements must be kept on file for all personnel.
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 4 of 8
LESSON PLAN GUIDE
Cognitive Objectives
At the completion of this session, the advanced EMT student will be able to:
1. Describe mechanisms of drug action.
2. List and differentiate the phases of drug activity, including the pharmaceutical,
pharmacokinetic, and pharmacodynamic phases.
3. Describe the process called pharmacokinetics, phamocodynamics, including theories of
drug action, drug-response relationship, factors altering drug responses, predictable
drug responses, iatrogenic drug responses, and unpredictable adverse drug responses.
4. Differentiate among drug interactions.
5. Discuss considerations for storing and securing medications.
6. List the component of the drug profile by classification.
7. Integrate pathophysiological principles of pharmacology with patient assessment.
8. Synthesize patient history information and assessment findings to form a field
impression.
9. Synthesize a field impression to implement a pharmacologic management plan.
Components of a drug profile
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Drug names
Classification
Mechanisms of action
Indications
Pharmacokinetics
Side/adverse effects
Routes of administration
How supplied
Dosages
Contraindications
Considerations for pediatric patients, geriatric patients, pregnant patients, and other
special patient groups
L. Other profile components
Educational Resources:
A.
B.
C.
D.
E.
F.
New York State EMS certification curriculum
Physician’s Desk Reference
Drug manufacture’s information
Federal Food and Drug Administration
Paramedic text books
Additional resources as necessary
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 5 of 8
New York State EMS Alternative Medication Formulary
Valid Through December 31, 2013
Current
Medication
Alternate
A
Alternate
B
Alternate
C
Alternate
D
Notes
Ondansetron
(Zofran)
Promethazine
Droperidol
0.625 mg IV/IM
Metoclopramide
(Reglan)
Diphenhydramine
25-50 mg IV/IM
ADULT ONLY
12.5 mg IM
10mg IV/IM
Etomidate
Midazolam CIV
Ondansetron 4 mg ODT also an
option
Ketamine CIII
Propofol
Induction
(Versed)
Lorazepam CIV
(Ativan)
1 mg/kg IV
2 mg/kg IV
5 mg IV
2 mg IV
OR
Ativan (Lorazepam) must be
refrigerated following
manufacturers guidelines
3 mg/kg IM
Morphine CII
Fentanyl CII
50 mcg IV
(Inventory 400 mcg)
Fentanyl CII
Morphine CII
4-6 mg IV
Ketorolac
(Toradol)
30 mg IV or IM
Ketorolac
(Toradol)
30 mg IV or IM
Fentanyl CII
Midazolam CIV
(Versed)
Diazepam CIV
(Valium)
Anti-emetic
Remifentanyl CII
0.5 mcg/kg or 50
mcg IV
Hydromorphone
CII (Dilaudid)
Remifentanyl CII
0.5 mcg/kg or 50
mcg IV
Hydromorphone
CII (Dilaudid)
Remifentanyl CII
0.5 mcg/kg or 50
mcg IV
Lorazepam CIV
2 mg or 0.05
mg/kg IV
Midazolam CIV
5 mg IV
Pain Management Protocol Only
0.5 mg
Pain Management Protocol Only
0.5 mg
ROSC Protocol Only (shivering)
Diazepam CIV
5 mg IV
Lorazepam CIV
2mg IV
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Seizure management
Seizure management
Page 6 of 8
New York State EMS Alternative Medication Formulary
Lorazepam CIV
(Ativan)
Midazolam CIV
Diazepam CIV
5 mg IV
5 mg IV
Ketorolac
Ibuprofen
(Caldolor)
Seizure management
NSAID pain management
(not mandatory substitution
because of cost)
400-800 mg IV
Ketamine CIII
Etomidate
0.1 mg/kg IV
Midazolam CIV
2-5 mg IV
and/or
Patient disentanglement
Fentanyl
50 mcg IV
Sodium
Bicarbonate
Midazolam CIV
(Versed)
Epinephrine
1:10,000
No substitution available
Droperidol
Haloperidol
Ketamine
2.5 mg IM
5 mg IM
1-3 mg/kg IM
Epinephrine 1:1,000 30mL Vial
1. Expel 1mL of normal saline
from a 10mL syringe (prefilled)
2. Instill 1mg(mL) of
Epinephrine 1:1,000 from 30
mL vial in to pre-filled
syringe
Patient chemical restraint
Epinephrine 1:1,000 1mg/ml
Ampule
1. Expel 1mL of normal saline
from a 10mL syringe (prefilled)
2. Instill 1mg(mL) of
Epinephrine 1:1,000 from
ampule in to pre-filled syringe
3. 30mL vials are to be single
patient use only
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 7 of 8
New York State EMS Alternative Medication Formulary
Suggestion:
Make medication substitutions that will allow minimal formulary changes when possible, even when this means moving
into secondary alternates to allow for maximum safety. Example: if adding Droperidol for nausea, consider adding an
option for patient restraint.
12-07 Alternative Medication Formulary for Prehospital Drug Shortages
Page 8 of 8
No.
13-02
Date: 02/14/13
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Recommendation
for Health and Safety
Officer (HSO)
Supercedes/Updates: New
Page 1 of 2
This policy was created by the Safety subcommittee of New York State Emergency
Medical Services Council. The subcommittee recommends that each agency establish
the position of Health and Safety Officer (HSO) to develop, implement and maintain a
system to address the potential health and safety hazards encountered by their EMS
providers and patients. Additionally, it is suggested that agencies appoint a committee to
support the HSO position. This policy is intended to improve EMS health and safety
practices for the provider, the patient and the public as well as ensure regulatory
compliance and to further promote a strong safety culture.
Background
EMS works in a very challenging environment in which providers face a multitude of
inherent risks to themselves, their patients, their families and the public. The risk of
injury, infection, vehicle crashes, emotional stress, physical violence, medical error,
serious harm or even death is very real. Safety standards and procedures are learned
and reinforced through education, annual training, lessons learned, best practices and
responses experienced. Though many EMS providers understand the risks and how to
reduce them, preventable incidents causing injury and death still occur.
Policy
An EMS agency manager/administrator may designate an HSO as well as the
supporting safety committee, to work jointly to oversee the development and
sustainment of a health and safety program. The HSO should hold, at a minimum, a
current NYS EMT certification and maintain this certification throughout their
appointment.
An HSO’s Roles and Responsibilities may include, but not be limited to;
•
Being an advocate for safe practices and procedures to better protect providers,
the patient and the public. The HSO will be accountable for continual attention to
safety issues and trends involving safety and wellness.
•
Being familiar with regulatory standards that apply to EMS. The HSO should be
well versed with infection control practices and knowledgeable on the hazards of
diseases and illness. An HSO can provide information about workplace hazards
and what protective practices and equipment are available to reduce preventable
incidents from occurring. The HSO can assist in sponsoring health and wellness
programs to address issues related to weight, diet, fitness and psychological
stress.
•
The role may include tracking safety organizations’ principles and be aware of
current safety products that reduce unsafe practices. An HSO can investigate
accidents, injuries and near misses. The HSO should have the authority to track
and monitor workplace safety, identify hazards as well as to correct them.
•
The responsibility of ensuring that all incidents i.e. medical equipment
malfunction or a vehicle crash with serious injury are reported in accordance with
the appropriate authority’s mandates. This reported data is important to
identifying safety issues within the EMS system. This will allow the state to
compile measurements on EMS related injuries, illnesses, medical adverse
events and fatalities. This data driven information will promote procedures and
initiatives to improve our EMS system.
Conclusion
EMS agencies must consciously understand the risks involved that are related to its
responders and patient safety. The objective is to lower unfortunate, preventable
incidents and to ensure our providers, patients and the public have a safe outcome. A
designated HSO may assist with promoting a healthy and safe work environment within
an EMS organization. An HSO contributes to a positive safety culture that will improve
the health and safety awareness of EMS providers.
Key Responsibilities for an HSO:
Bloodborne Pathogens Exposure Control Plan
Driver Safety, Emergency Vehicle Operations, Investigations
Scene Safety, Scene Operations, Violent Scenes, Workplace Violence
Patient Handling, Stretcher Operations, Severe Weather
HazMat/WMD Awareness, Emergency Response Guide
Personal Health, Wellness, Ergonomics
Annual/Training, Records, Reported Data
Reference Sites for Health & Safety
www.cdc.gov
www.osha.gov/dts/oom/clinicians
www.health.ny.gov
www.labor.ny.gov/workerprotection/safetyhealth/DOSH_INDEX.shtm
www.nsc.org
www.naemt.org
No.
New York State
Department of Health
Bureau of Emergency Medical Services
12 - 06
Date: June 7, 2012
Re: EMS Mutual Aid
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 11
This policy was developed in conjunction with the New York State Emergency Medical
Services Council (SEMSCO) and an appointed Technical Advisory Group (TAG) comprised
of various representatives of the State’s EMS community. In addition to the guidance
policy, included this policy is an updated definition of Mutual Aid and a tool kit (Appendix
A) intended to be a resource to EMS agencies, County EMS Coordinators and Regional
EMS Councils (REMSCO) when developing, evaluating and reviewing EMS Mutual Aid
plans.
PURPOSE:
The purpose of this policy is to update and clarify the appropriate uses of EMS Mutual Aid
and to address issues faced by many New York State EMS agencies as a result of
frequent shortages of certified personnel available to respond to requests for emergency
medical assistance.
This policy is based on these previous policy statements which remain in effect: 89-02 –
EMS Mutual Aid Planning Guidelines; 95-04 – EMS Mutual Aid; 95-09 – Developing EMS
Agency Policies and Procedures; 01-02 – EMS use of the Incident Command System; 0104 – EMT Staffing Standard for Voluntary Ambulance Services; and PHL Article 30, and
Part 800 - The State EMS Code.
All of the above policy statements, laws, and regulations are available on the Bureau of
EMS website: www.health.state.ny.us/nysdoh/ems/main.htm . All EMS agency
leadership and staff are encouraged to review each of these documents.
OBJECTIVES:
1. To provide a clear, comprehensive definition of EMS Mutual Aid, and how mutual
aid should be used appropriately;
2. To reaffirm the role of the Regional EMS Councils (REMSCO) and EMS Program
Agencies in developing, reviewing and approving mutual aid plans;
3. To provide guidelines for mutual aid plans that EMS agencies, 911 Communication
Centers and County EMS Coordinators can follow that adhere to Article 30
requirements with respect to Primary Operating Territory, and the concept of
closest appropriate EMS agency:
4. To encourage collaboration and cooperation between REMSCOs, County EMS
Coordinators, 911 Communication Centers, and all EMS agencies in the
development, review and approval of EMS mutual aid plans.
5. To delineate different types of mutual aid plans according to the scale of the
required response.
12-06 EMS Mutual Aid
Page 1 of 11
DEFINITION OF MUTUAL AID:
 Article 30 of Public Health Law does not directly define mutual aid, but rather it
identifies and defines Mutual Aid Agreements in Section 3001.20 as follows:
“‘Mutual aid agreement’ means a written agreement, entered into by two or more ambulance
services or advanced life support first response services possessing valid ambulance service or
advanced life support first response service certificates or statements of registration, for the
organized, coordinated, and cooperative reciprocal mobilization of personnel, equipment, services, or
facilities for back-up or support upon request as required pursuant to a written mutual aid plan. An
ambulance service and advanced life support first response service may participate in one or more
mutual aid agreements.”

Article 5 of County Law, section 223-B (3) EMS Training and Mutual Aid Programs
states:
“If the office of county EMS coordinator is created in any county, a county EMS coordinator shall be
appointed. It shall be his or her duty to administer the county programs for EMS
training and mutual aid in cases of emergencies in which the services of EMS providers would be
used… “

Policy Statement 89-02 defines Mutual Aid in the following manner:
“MUTUAL AID – means the pre-planned and organized response of emergency medical services, and
other emergency personnel and equipment, to a request for assistance, in an emergency, when local
resources have been expended. The response is predicated on formal agreements among
participating agencies or jurisdictions.”

Policy 95-04 mentions the use of EMS mutual aid in this way:
o
o
o
o
“From time to time, to meet peak demand or extraordinary resource utilization, it may be
necessary to request assistance to answer a call or provide additional resources. This is the
concept and intent of EMS mutual aid.”
“EMS mutual aid requests must be made with the intent of having the closest (usually means
the unit with the shortest response time to the patient) available EMS unit respond to a
patient’s medical need, at a time when the resources of the requesting agency are temporarily
unavailable or have been expended.”
“Mutual aid plans and agreements for normal day to day requests are the responsibility of the
individual EMS service.”
“Service type (eg. volunteer, fire, hospital, commercial) must not be a consideration in any
plan or to any request.”
With consideration of the aforementioned documents, a combined and updated five part
definition of EMS mutual aid that supersedes previous definitions and reflects the current
state of EMS operational coverage, is stated as:
1. A preplanned, organized and coordinated response of EMS agencies to a request
for assistance when local EMS resources are either temporarily unavailable, or
have already been expended;
2. The elements of any response under a mutual aid request will be determined by a
formal written mutual aid plan or agreement among participating EMS agencies
and/or jurisdictions, and approved by the REMSCO having jurisdiction for the
geographic area in question. EMS agencies may participate in more than one
mutual aid plan;
12-06 EMS Mutual Aid
Page 2 of 11
3. Mutual aid plans or agreements must be designed to address all possible
applications of mutual aid, whether for large scale multiple casualty incidents, or
for the needs of EMS operational assistance for neighboring EMS agencies.
However, mutual aid plans are not intended substitute for the following:
a.
An EMS agency’s continued, routine, ongoing or frequent inability to provide EMS response
when requested or dispatched due to staffing and/or equipment shortages
b.
A determination of need for an expansion of operation territory for routine, frequent or
ongoing response outside of an agencies primary operating authority.
c.
Contracting with an appropriately authorized EMS agency.
4. The plan or agreement must also be designed to utilize the EMS agency having
the appropriate resources with the shortest response time to the scene of the call.
For the purposes of this section, response time is defined as time of dispatch to
time on scene.
5. The provisions of Article 30 with respect to the Primary Operating Territory of an
EMS agency must be considered when designing the EMS mutual aid plan.
ROLE OF REGIONAL EMS COUNCILS





Article 30, Section 3003.3 (f), states that REMSCO have the power to: “undertake, or cause to be
undertaken plans, surveys, analyses and studies necessary, convenient, or desirable for the
effectuation of its purposes and powers, and to prepare recommendations and reports in regard
thereto;”
Article 30, Section 3003.4 state that “Each regional council shall have the responsibility to coordinate
emergency medical service programs within its region…”
Under Article 30, section 3003-A-1, EMS Program Agencies: “….may be responsible for facilitating
quality improvement of emergency medical care within its region… and other activities to support
and facilitate regional emergency medical systems.”
Article 30 section 3010.1(b) states: “…An ambulance service shall receive patients only within the
primary territory specified on its ambulance service certificate or statement of registration, except:
(b) as required for the fulfillment of a mutual aid agreement authorized by the regional council;”
Additionally, Part 800.21(p) requires every EMS service to have a written mutual aid plan.
REMSCOs have a responsibility to participate in the development, review and
authorization of mutual aid plans of all types. By virtue of their statutory authority,
REMSCOs, with assistance from EMS Program Agencies, are expected to initiate efforts
with 911 Communication Centers, County EMS Coordinators and all EMS agencies, to
develop, review and authorize EMS mutual aid plans that reflect the needs and resources
of their particular region of the state.
TYPES OF MUTUAL AID PLANS
The types of mutual aid plans can range from complex statewide plans to simple
interagency agreements. Examples of mutual aid plans, in descending order of
complexity, include:

The Statewide Mobilization Plan;

Multiple casualty incidents, and other large events that require single or multiple
jurisdictional response plans within or between regions;

Countywide plans that cover the geography of particular primary operating territories
within a county in the event resources are expended or unavailable;
12-06 EMS Mutual Aid
Page 3 of 11

Individual, or multiple, interagency plans, that are in compliance with all applicable
laws, that provide coverage assistance to neighboring agencies in the event
resources are expended or otherwise unavailable.
In order to provide the closest appropriate EMS unit, and to foster ease of
implementation by 911 Communication Centers and County EMS Coordinators, these
plans shall designate the following:

Those services having appropriately staffed, readily available units in closest
proximity and with direct access to the district involved, thereby being capable of
providing an optimal response time;

Beginning first with services possessing operating authority for the requesting
district;

In cases where no service with operating authority exists or is willing/able to
participate, proceeding next to those services without operating authority for the
requesting district;

Additional mutual aid plan participants shall be based on the next closest,
appropriately staffed and readily available services.
All listed EMS agencies should agree, by positive affirmation in the plan, their
commitment and willingness to participate and respond to the service areas identified on
the list.
CONCLUSION
The New York State EMS Council Technical Advisory Group (TAG), with whom this policy
was developed, have prepared a Mutual Aid Planning Tool Kit. This tool kit (Appendix A)
is intended to be a resource to EMS agencies, County EMS Coordinators and Regional
EMS Councils (REMSCO) when developing, evaluating and reviewing EMS Mutual Aid
plans.
It is imperative, for the efficient and timely operation of EMS systems across the state
that all REMSCOs, County EMS Coordinators, 911 Communication Centers, and all EMS
agencies collaborate and cooperate in the development, review and authorization of EMS
mutual aid plans.
Again, mutual aid plans are not intended substitute for an EMS agency’s
continued, routine, ongoing or frequent inability to provide EMS response when
requested or dispatched due to staffing and/or equipment shortages; a
determination of need for an expansion of operation territory for routine,
frequent or ongoing response outside of an agencies primary operating
authority and contracting with an appropriately authorized EMS agency. But
rather to address all possible applications of mutual aid, whether for large scale multiple
casualty incidents, or for the needs of EMS operational assistance for neighboring EMS
agencies
12-06 EMS Mutual Aid
Page 4 of 11
Appendix A
New York State EMS Agency Mutual Aid Planning Worksheet
The following Mutual Aid worksheets are intended to give EMS agencies, County EMS/Emergency Services Coordinators,
and Regional EMS Councils a logical and objective pathway to evaluate, formulate, and approve EMS Mutual Aid plans.
They attempt to gather the most pertinent information for mutual aid decision making. However, additional information
that is unique to a given area may also need to be considered. This information should be documented on additional
sheets, along with any information requested that does not fit in the space provided.
Section 1: EMS Agency instructions:
This worksheet is intended to identify all EMS agencies that should be considered to respond as mutual aid to a
requesting EMS agency. Please list all EMS agencies that are willing to respond as mutual aid to all or a portion of the
requesting agency’s service area, and what minimum response time is expected. When considering which agency should
be first call for mutual aid, any agency that has overlapping operating authority with the requesting agency should, in
most cases, be the first call agency. However, there may be geographic or operational reasons to utilize an adjacent
agency that has separate operating authority from the requesting agency. As a result, agencies with overlapping
operating authority may be designated to participate as secondary mutual aid coverage if needed. In all cases,
adequately document the reasons for all choices.
Section 2: EMS Coordinator instructions:
By completing this form you are affirming the choices for EMS mutual aid made by the agencies in your jurisdiction.
Please attach any supporting documentation or narrative comments that will substantiate your determination. During this
process it is expected that you will confer with your Regional Council to clarify any of the information you have been
given by your agencies, and to discuss the broad outline of the plan you will submit for approval.
Section 3: Regional Council instructions:
It is expected that Regional Councils will collaborate with County EMS Coordinators to either initiate a review and revision
to existing EMS mutual aid plans, or develop EMS mutual aid plans that meet the standards of this policy. During that
process there should be cooperation and collaboration with County EMS Coordinators, agencies, and concerned
governmental bodies to affirm the validity of the plans submitted. This form is designed to facilitate that process. Please
attach any additional supporting documentation not included by EMS Coordinators, and/or attach a brief narrative
substantiating your approval.
12-06 EMS Mutual Aid
Page 5 of 11
Section 1: EMS Agency Review
1. Name of EMS Agency:
2. Ambulance Operating Territory:
(as written on the current Ambulance Certificate)
3. Does another EMS Agency possess a valid NYS DOH operating certificate for this area?
[ ] YES [ ] NO
4. Please list all current EMS Agencies possessing valid operating certificates:
Name
Is this EMS Agency able to provide Mutual Aid to you?
a. _
[ ] YES, [ ] NO Reason:
b. _
[ ] YES, [ ] NO Reason:
c. _
[ ] YES, [ ] NO Reason:
d. _
[ ] YES, [ ] NO Reason:
5. Other than current valid operating certificate holders for your area, are there other EMS Agencies that, while not
possessing a valid operating certificate for your area, can respond in a more timely and reliable manner to your
mutual aid requests?
[ ] YES
[ ] NO
If “YES”, please identify these EMS agencies:
a. _
b. _
c. _
d. _
6. Please provide the time criteria (in minutes), that you utilize to determine what constitutes a “reasonable response
time” for the geographical service area in question (For the purposes of this section, response time is defined as
time of dispatch to time on scene):
12-06 EMS Mutual Aid
minutes.
Page 6 of 11
7. Please indicate below the EMS Agency and the specific portion(s) of your certified area of operations you designate
for Mutual Aid coverage (please attach any written agreements and maps or territorial descriptions necessary):
EMS Agency
Designated to Cover:
a. __
[ ] Entirety of area,
[ ] Specific Portion:
b.
[ ] Entirety of area,
[ ] Specific Portion:
c. _
[ ] Entirety of area,
[ ] Specific Portion:
d. _
[ ] Entirety of area,
[ ] Specific Portion:
Affirmation:
I, the undersigned, verify that I represent and am duly authorized by the EMS
Agency identified above to designate the EMS Agencies identified to provide Mutual Aid
assistance to our organization consistent with all applicable laws and regulations.
Print Name:
Signature:
Title:
Date:
12-06 EMS Mutual Aid
Page 7 of 11
Section 2: County EMS Coordinator Review
1. Name of County EMS Coordinator:
2. County of Jurisdiction:
3. After your review of the information submitted by this EMS Agency designating their choices for other EMS
Agencies to provide Mutual Aid assistance to their area of operations in accordance with all existing regulations, do
you find:
a. That the primary EMS Agencies designated are the most technically capable with meeting initial medical
requests to respond?
[ ] YES [ ] No
b. If any of the designated EMS Agencies do not possess a valid operating certificate from the DOH, have you
verified in collaboration with the local Regional EMS Council that all existing EMS agencies identified by the
NYSDOH, Bureau of EMS (BEMS) as having valid operating certificates for this area either cannot, or will not
have the capability to respond in a reasonable response time? [ ] YES
[ ] NO
c. Please provide the time criteria (in minutes), that you utilize to determine what constitutes a “reasonable
response time” for the geographical service area in question (For the purposes of this section, response time
is defined as time of dispatch to time on scene):
minutes.
To support your determination, please provide supporting documentation such as BEMS service lists, levels of care
provided, municipal preference lists, alternative mutual aid coordination processes utilized (i.e., system status
management, GPS tracking, or other technologies), or any other verifiable method that substantiates a history of
local mutual aid.
12-06 EMS Mutual Aid
Page 8 of 11
4. Do you have any special considerations or concerns associated with any element of the aforementioned EMS
Agencies designated to respond under this Mutual Aid agreement? [ ] NO,
[ ] Yes: Please describe:
Affirmation:
I,
, the County EMS Coordinator for
County, have reviewed the
aforementioned elements of this Mutual Aid Agreement for: (EMS Agency)
, and find it to be both reasonable and compliant with all applicable regulations.
Print Name:
Signature:
Date:
12-06 EMS Mutual Aid
Page 9 of 11
Section 3: Regional EMS Council Review
1. Name of Regional EMS Council:
2. Name of Reviewer:
3. Title:
4. After your review of the information submitted by this EMS Agency designating their choices for other EMS
Agencies to provide Mutual Aid assistance to their area of operations in accordance with all existing regulations,
do you find:
a. That the primary EMS Agencies designated are the most technically capable with meeting initial medical
requests to respond?
[ ] YES [ ] No
b. If any of the designated EMS Agencies do not possess a valid operating authority, have you verified in
collaboration with the local County EMS Coordinator that all existing EMS agencies identified by the
NYSDOH, Bureau of EMS (BEMS) as having valid operating authority for this area either cannot, or will
not have the capability to respond in a reasonable response time? [ ] YES [ ] NO
c. Please provide the time criteria (in minutes), that you utilize to determine what constitutes a “reasonable
response time” for the geographical service area in question (For the purposes of this section, response
time is defined as time of dispatch to time on scene):
minutes.
To support your determination, please provide supporting documentation such as BEMS service lists, levels of care
provided, municipal preference lists, alternative mutual aid coordination processes utilized (i.e., system status
management, GPS tracking, or other technologies), or any other verifiable method that substantiates a history of
local mutual aid.
12-06 EMS Mutual Aid
Page 10 of 11
5. Do you have any special considerations or concerns associated with any element of the aforementioned EMS
Agencies designated to respond under this Mutual Aid agreement? [ ] NO,
[ ] Yes: Please describe:
Affirmation:
I,
, the authorized reviewer for the
Regional EMS Council, have
reviewed the aforementioned elements of this Mutual Aid Agreement for: (EMS Agency)
, and find it to be both reasonable and compliant with all applicable
regulations.
Print Name:
Signature:
Title:
Date:
12-06 EMS Mutual Aid
Page 11 of 11
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
12 - 05
Date: 06/05/2012
Re: EMS Provider
Certification and
Identification.
Supersedes/Updates: 96-02, 88-15 & 03-08
Pages: 3
BACKGROUND:
This policy statement is intended to provide clear direction to EMS providers,
EMS agencies and the emergency service community regarding the
requirements for the possession and production of NYS Department of Health
issued EMS certification. This policy statement also addresses the certification
period, security and alteration of DOH issued certificates.
CERTIFICATION PERIOD:
EMS certificates issued by the Department are valid for 37 months from the date
of issue and expire at 11:59 p.m. on the date indicated on the document. The
following are the only exceptions to this certification period:
1. The provider is a participant in an approved pilot re-certification program that allows for
certification for a period different than three years and such provider has received a
certification from the Department with an expiration date more than 37 months in the future.
2. The provider has been approved for extended certification as allowed for by Public Health
Law.
CERTIFICATION EXPIRING AFTER STATE EXAMS:
The New York State Administrative Procedures Act (SAPA), Article 4, (401.2)
allows EMS provider’s certifications to remain valid after it has expired under
certain circumstances.
If a certified provider’s expiration date occurs after he/she has completed a
recertification course, has taken the NYS Written Certification Examination, but
has not yet received their examination results, their certification will remain valid
until such time as he/she receives their official examination results. Official
examination results are considered to mean an official failure letter from BEMS,
certification renewal certificate from BEMS, or on-site scoring results.
If a certified provider’s expiration date occurs prior to taking the NYS Written
Certification Examination, their certification is not eligible to remain valid under
SAPA.
In order to comply with SAPA the provider must provide proof that he/she
completed the NYS Written Certification Examination. This proof will usually be
in the form of the signed examination ticket received at BEMS within 1 week of
completing the NYS Written Examination. If written documentation of current
Policy Statement 12-05
Page 1 of 3
certification is required under SAPA, the individual must call BEMS and make a
formal request. BEMS will not provide additional documentation under SAPA
until such time as we receive the signed examination ticket.
CERTIFICATION DOCUMENTS:
Pursuant to provisions of 10 NYCRR Part 800 the Department issues an original
certificate to persons whom:

Successfully complete the requirements set forth for obtaining an original certification as
a Certified First Responder (CFR), Emergency Medical Technician (EMT) or Advanced
Emergency Medical Technician (AEMT).

Successfully completes the requirements set forth for obtaining re-certification as a CFR,
EMT or AEMT.

Obtains certification as an EMT or AEMT through the reciprocity process by having such
certification issued by another state or approved military program.

Have no legal barrier to the issuance of such certificates.
ALTERATION OR FORGERY OF DOH ISSUED EMS CERTIFICATES:
Department certificates are printed in a unique font on security paper that will
show the word “VOID” when the card is photocopied.
Upon receipt of the certificate from the Department the holder should sign
and immediately laminate the card for its protection.
Any adulteration of a certificate issued by the Department or any production of a
document that is offered to be a certificate issued by the Department shall be
prosecuted to the fullest extent the law allows and may bar the individual from
any future certification by the Department.
SERVICE REQUIREMENTS:
EMS services are required by 10 NYCRR Part 800.21(k)(1) to maintain
personnel files for all members/employees. The file must include a copy of the
member’s/employee’s state issued EMS certificate.
The certified provider should be required to provide the original certification to the
agency for the agency to inspect and copy. If there are any questions regarding
the validity of the certification, notify the Bureau of EMS immediately.
An agency shall be held responsible for the outcomes and actions of any
provider whom they allow to practice without positive proof that the certification
offered by that individual is valid.
PROVIDER IDENTIFICATION:
Agencies/systems are encouraged to have a policy that governs the proper
identification of members/employees while providing care or while responding.
Such identification is particularly useful when members of an agency respond
beyond their local area when participating in mutual aid responses.
Policy Statement 12-05
Page 2 of 3
While there is no statutory or regulatory requirement to do so, all EMS agencies
or systems should consider the issuance of identification to members/employees.
Such identification may include, but not be limited to:










Agency name
Provider name
Provider photograph
Provider level of certification
DOH certification number
Level of care authorized by agency and/or REMAC
Agency and/or REMAC identification number
Date of Birth
Blood Type
Expiration date of identification card.
Certified providers are discouraged from using their laminated, Department
issued certification card as a displayed form of identification.
Although it is not a requirement of 10 NYCRR Part 800 that Department issued
certificates be carried by individuals while providing care, it is strongly
encouraged.
LOST OR DESTROYED CERTIFICATES:
Should the certificate issued by the Department be lost, destroyed or if it
becomes unreadable you may request a replacement certificate. Requests must
be submitted using the form DOH – 4453, which can be found on our web site.
The EMT must sign the request. No verbal requests will be processed.
VERIFICATION OF CERTIFICATION:
Any individual or entity, who is seeking to verify current or past BEMS
certification for an individual, may do so by completing the official request form
found on our web site under the Verification Information section.
EMS agencies may also utilize the NYS DOH Health Commerce System (HCS)
to obtain current provider verifications. To obtain an HCS account, please go to:
http://www.health.ny.gov/prevention/immunization/information_system/providers/hpn_ac
count_instructions.htm.
INSIGNIA & PATCHES:
The NYS Department of Health does not issue any type of patch, shield or other
worn insignia. In accordance with PHL §3003(4) a Regional Emergency Medical
Services Council (REMSCO) may issue, “uniform emergency medical technician
insignia and certificates”.
A person who chooses to wear a patch, shield or other insignia may only indicate
the level of care at which the Department certifies them. To do otherwise would
be indicating certification not held by the provider. This may constitute a criminal
offense.
Policy Statement 12-05
Page 3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
12 - 04
Date: February 27, 2012
Re: Advisory on
Patient Care in a
Moving Ambulance
Supercedes/Updates: New
Page 1 of 1
This policy was developed to assist EMS providers and agencies in adopting policies and procedures
that will address issues of improved and appropriate personal safety while treating and transporting
patients in the patient care compartment of the ambulance. Additionally, this policy is intended to
articulate the need for provider, patient and equipment restraint in the patient compartment. It is also
intended to improve the EMS agency’s awareness of the inherent risks to unrestrained personnel and
encourage agencies to be proactive in making this aspect of the prehospital environment safer for their
personnel and patients.
Background
The patient care compartments of ambulances are not generally designed to protect people in the
event of a motor vehicle crash (MVC). Most fatalities and serious injuries in ambulance crashes involve
unrestrained or poorly restrained passengers in the patient care compartment. The use of seatbelts
and patient care device restraints have been recommend by numerous emergency vehicle crash safety
experts as a method of reducing injuries in ambulance crashes. However, many EMS providers still do
not use seatbelts or restrain their equipment properly. One motivation for failing to follow this simple
safety technique is the belief that EMS providers should be unrestrained in order to provide appropriate
patient care. Only a very few prehosptial care interventions are so essential they should be performed
regardless of an EMS providers ability to restrain themselves.
Policy
Whenever possible, EMS providers should perform patient care skills when they are appropriately
restrained in a moving vehicle or done when the vehicle is stopped. As long as it is safe and
appropriate to do so, the ambulance should be pulled off the road and stopped for the duration of
necessary interventions and procedures. As a matter of safety, EMS providers should plan their patient
care so that essential interventions are performed prior to beginning transport and have ready access
to patient care equipment that might be expected to be used during a transport while maintaining
provider safety restraints.
Agencies should strongly consider technological adjuncts such as automated vital signs monitors and
multiple control panels that will allow providers to continue to perform essential aspects of patient care
while seat belted. As an agency considers the purchase of new vehicles, or is retrofitting current
vehicles, design considerations such as access to sharps containers, the ability to secure equipment,
rounded corners, radio access, and padded head strike zones should be considered and adopted as
appropriate. Additionally, new technology such as ventilators and automatic chest compression
devices should be evaluated for use in required situations.
Conclusion
Very few patient care interventions are so essential to the preservation of a patient’s life or limb that
they should be performed regardless of the EMS provider’s ability to restrain themselves. EMS
providers should attempt to perform all patient interventions while they are appropriately restrained in a
vehicle that is in motion. As with all protocols, there will be exceptions, however it should be a very rare
occasion where an EMS provider is unrestrained in the back of a moving ambulance for any reason.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 04-05, 08-01
12-03
Date: 1/23/2012
Re: Electronic PCR
Data Submission
Page
1 of 4
The New York State Department of Health, Bureau of Emergency Medical Services is responsible,
pursuant to Article 30 of the Public Health Law (PHL) for the collection of prehospital patient
documentation data. The paper Prehospital Care Report (PCR) has been the primary instrument used
for patient care and EMS event documentation. The primary purpose of the PCR/ePCR is to document
all prehospital care and pertinent patient information for medical and legal purposes, as well as serving
as a data collection tool for local and statewide quality improvement, protocol development and when
approved, research.
The Department collects and compiles raw data into quantitative and summary data as a retrospective
review of EMS activity throughout the state. Recently, links were made to match out-of-hospital
PCR/ePCR data with in-hospital data from the NYS Trauma Registry and the Statewide Planning and
Research Cooperative System (SPARCS) Emergency Department data sets to create a more complete
and inclusive patient care record. The PCR information is provided to the State and Regional EMS
Councils and the State and Regional Emergency Medical Advisory Committees.
PHL Article 30 requires that all ambulance and advanced life support first response services (ALS-FR)
submit all call reporting documentation to the Department, in a format approved by the Department.
The NYS EMS Code, 10NYCRR Part 800.15, requires that every person certified as an EMS provider,
at any level, must complete a PCR/ePCR for each request for EMS response received by his/her
agency, in accordance with the Department’s established policy.
Article 30 § 3053 Reporting
Advance life support first response services and ambulance services registered or certified pursuant to article
thirty of this chapter shall submit detailed individual call reports on a form to be provided by the department, or
may submit data electronically in a format approved by the department. The state emergency medical services
council, with the approval of the commissioner, may adopt rules and regulations permitting or requiring
ambulance services whose volume exceeds twenty thousand calls per year to submit call report data
electronically. Such rules shall define the data elements to be submitted, and may include requirements that
assure availability of data to the regional emergency medical advisory committee.
Part 800.15 Required Conduct
Every person certified at any level pursuant to these regulations shall:
(a) at all times maintain the confidentiality of information about the names, treatment, and conditions of
patients treated except:
(1) a prehospital care report shall be completed for each patient treated when acting as part of an
organized prehospital emergency medical service, and a copy shall be provided to the hospital receiving
the patient and to the authorized agent of the department for use in the State's quality assurance
program;
12-03 Electronic PCR Data Submission
Page 1 of 4
As more regions and EMS agencies look toward the implementation of an electronic patient
documentation platform, it is the Department’s intention to continue to collect patient care data through
regionally based systems and/or through the State EMS Bridge.
The National EMS Information System (NEMSIS)
NEMSIS is a national effort to standardize the prehospital data collected by EMS agencies. NEMSIS is
the national repository that will be used to potentially store EMS data from every state in the nation.
Since the 1970s, the need for EMS information systems and databases has been well established, and
many statewide data systems have been created. However, these EMS systems vary in their ability to
collect patient and systems data and allow analysis at a local, state, and national level.
For this reason, the NEMSIS project was developed to help states collect more standardized elements
and eventually submit the data to a national EMS database.
Electronic Data Submission in New York State
As the federal government continues coordinating the national EMS data set, called National EMS
Information System (NEMSIS), New York State has updated its method for collecting the prehospital
patient care data. In consultation with the NYS EMS Council, the Department has published a NEMSIS
compliant data dictionary. The additional information will provide a vast new look at the EMS picture in
NYS and allow for an improved evaluation of the system at the local, regional and state levels. The
New York State EMS Data Dictionary is available at the following URL:
http://www.health.ny.gov/nysdoh/ems/electronic_data_submission.htm
Policy
The Department works with Regional EMS Councils, ambulance and first response services in an effort
to facilitate the submission of the required data elements through an electronic medium. In an effort to
insure an acceptable format, prior to implementing an electronic data collection product for the
submission of ePCR data, the EMS agency MUST RECEIVE WRITTEN APPROVAL FROM THE
DEPARTMENT and the applicable Regional EMS Council(s). This policy statement is intended to
define the criteria necessary for an EMS Agency to convert its paper PCR system to the electronic
submission of patient care report data.
In order to be considered for approval by the Department to submit PCR data electronically,
EMS agencies MUST adhere to all of the following:
1. Be in compliance with all applicable sections of Article 30 and Part 800.
2. Be submitting paper PCRs to the Regional Program Agency on a routine and on-going basis.
3. Contact the Department, in writing, to determine electronic reporting requirements and request approval for
electronic submission.
4. For EMS services that receive one-time, start up funding (i.e., grant funds) to purchase ePCR
software/hardware, the written request for approval will need to include a plan of funding sustainability of
the software/hardware after the initial funding stream has been depleted.
5. If the software being considered for purchase is not currently mapped and submitting to the NY state data
repository, testing of the data compliance must occur to insure proper format and electronic transmission to
the satisfaction of the Department and the Regional Program Agency.
6. Submit PCR data to the Department in the specified data file format at predetermined and scheduled
intervals.
7. Receive approval from the appropriate Regional Emergency Medical Services Council(s) (REMSCO) and
Regional Emergency Medical Advisory Committee(s) (REMAC) in writing.
8. All EMS services must submit the standard NYS data file to the Regional Program Agency in a compatible
format on a regular and routine schedule determined by the program agency.
12-03 Electronic PCR Data Submission
Page 2 of 4
9. Apply for, and receive an account with the Department’s Health Commerce System (HCS). This may be done
with assistance from the Regional Program Agency.
10. If any changes or interruptions are made to the electronic patient record system that may affect data
submission, the EMS service must notify the Department, in writing, ten (10) business days in advance of
implementation. It is the Department’s expectation that once a service converts to an electronic data
collection (ePCR) system, that service will maintain the electronic system and NOT revert back to a paperbased system.
Additional Requirements
EMS agencies considering the submittal of patient care data through an electronic medium are also
required to maintain records in accordance with established policies, laws and regulations. This must
include, but may not be limited to:




Strict written confidentiality policies, including a written statement, addressing the electronic
transmission, storage and security.
Be in compliance with the Federal Regulations pertaining to the transfer of electronic patient
information and HIPPA.
Use an electronic data collection product that meets or exceeds the National EMS Information
System (NEMSIS) data set and includes minimum statewide required data fields.
Records retention policies which must include, but not be limited to:










If maintaining original records, they must be secured and available for retrieval within 24 hours of request.
Patient records may be stored electronically, however a hardcopy of the like image must be readily
available upon appropriate request.
Federal Law (HIPPA) requires that medical records be retained for six years (6). If the call involves the
treatment of persons under age 18, the PCR must be retained for three years after the child reaches age
18.
Records must be made available for review by the Department upon request as required by
regulation.
Provide the REMAC or its designee, with additional data elements as requested for use with quality
improvement programs, specific studies or approved research projects.
The maintenance of patient records in a readable format and be capable, upon request by patient
or designee, of providing the patient record.
The patient records have to be provided to the receiving hospital at the time the patient care is
transferred or a predetermined written plan with the hospital must be in place.
EMS services are required to leave a paper copy or transfer the electronic PCR information to the
hospital prior to the EMS service leaving the hospital. This document must minimally include,
patient demographics, presenting problem, assessment findings, vital signs, and treatment
rendered.
Failure to leave patient information with the emergency department upon the delivery of the patient
may compromise medical treatment and interrupt the continuity of patient care.
All electronic patient records should be completed and closed prior to the end of the shift during
which the patient was treated. There should be no access to patient records on personally owned
computers. Agencies should have policies restricting the use of personally owned computers for
completing ePCRs.
Other Important Considerations
There are many details surrounding electronic patient record systems. It is the Department’s
expectation that every EMS agency choosing to implement an electronic patient documentation system
will carefully examine these details and while this list may not be comprehensive, consider the following
issues:


Understand and adhere to the applicable HIPAA regulations.
Have an appropriate secure method of data transmission.
12-03 Electronic PCR Data Submission
Page 3 of 4




Have the necessary technical staff support to the electronic program.
Have appropriate infrastructure, security and back up for the system.
Have the funding available to maintain the hardware and software associated with the system.
Researched the product and vendor to ensure that all of the state, local and legal requirements are met by the
product to be utilized.
The Review Process
Once the Department receives a written request to submit patient data electronically, it will review the
request, and require the EMS service through a Memorandum of Understanding, to agree to the
conditions set forth by the Department.
The conditions may include, but not be limited to:
1. The provision of a confidentiality statement.
2. Description of system infrastructure.
3. Proof of system back up or redundancy.
4. Proof of contracts for technical support, maintenance, upgrading and trouble- shooting.
5. Information about the hardware and software products chosen for the system.
6. Proof of REMSCO/REMAC approvals.
7. Proof of continuous transmission of data to the Department, REMSCO/REMAC and the EMS
service(s).
8. Proof that patient care records are provided to the receiving hospital, long term care facility or
alternative destination, as appropriate, at the time the patient is delivered or a written agreement
with the hospital for the delivery of the patient record at an alternative time or method.
9. Proof of compliance with PHL Article 30 requirements for service level Quality Improvement
Committee.
10. Proof that there is a regular and routine process for providing data to the applicable REMSCOs,
REMACs and Program Agencies.
11. The Department has the ability to amend the data collection method or elements as may be
required by any future changes to the New York State data set.
Notice
In accordance with section 3053 of the PHL, the Department may immediately revoke the authority to
submit data electronically from an agency or regional program upon written notice. If the authority is
revoked, the agency will be mandated to submit paper PCRs through the Regional Program Agency.
12-03 Electronic PCR Data Submission
Page 4 of 4
No.
New York State
Department of Health
Bureau of Emergency Medical Services
12 - 02
Date: 1/23/2012
Re: Prehospital Care
Reports (PCRs)
POLICY STATEMENT
Supersedes/Updates: 85-01, 96-01, 02-05
Page 1 of 5
Documentation is an essential part of all prehospital medical care. It must include, but not be
limited to the documentation of the event or incident, the medical condition, treatment provided
and the patient’s medical history. The primary purpose of the Patient Care Report (PCR) is to
document all care and pertinent patient information as well as serving as a data collection tool.
Article 30, section 3053 of the Public Health Law requires all certified EMS agencies to submit
PCR/ePCRs to the Department. The completion of a PCR is a requirement for all certified
EMS providers in accordance with Title 10 NYCRR Part 800.15. This also includes all of the
electronic PCR (ePCR) programs. While Basic Life Support – First Response (BLS-FR)
agencies are not specifically required to submit PCR/ePCR data, their participation in the EMS
system, quality assurance and data collection are critical to system management and patient
care. All BLS-FR agencies are encouraged to submit EMS data through the Regional Program
Agencies.
The documentation included on the PCR/e-PCR provides vital information, which is necessary
for continued care at the hospital. As part of transferring the patient to the Emergency
Department Staff the agency must provide an appropriate medical record that includes
the demographic, event/incident, assessment findings and treatment details upon
delivery of the patient.
PCR/ePCR Use:
A PCR/ePCR should be completed each time the EMS agency is dispatched for any type
response. This includes (but is not limited to):




Patients transported to any location,
Patients who refuse care and/or transport,
Patients treated by one agency and transported by another,
Calls where no patient contact is made, such as
 Calls cancelled before reaching the scene
 Calls where no patient is located
 When dispatched for a stand by
 Events
If an agency is dispatched to a stand-by and while there they treat a patient, two PCRs should
be completed. One as a record of the event and one for the patient care provided.
Policy Statement 12-02
Page 1 of 5
Information Entry:
All information written on the paper PCR should be legible and printed in blue or black ink.
Any member of the crew may enter information on the PCR/ePCR. The individual indicated as
“In Charge” should be the person who provided or directed the care to the patient. There is no
requirement that the person in charge be certified as the highest level of care present.
However the individual indicated as in charge is responsible for the care provided and
documented. The provider listed as “In Charge” must be at least an EMT. If any advanced life
support care was provided to the patient, the provider listed as “In Charge” must be an
advanced EMT at the level appropriate for the care provided.
A complete PCR/e-PCR must include the fields required by the New York State Data
Dictionary. The complete data dictionary can be found at the following URL:
http://www.health.ny.gov/nysdoh/ems/electronic_data_submission.htm
Distribution of Paper PCRs:
Pink (Hospital Patient Record) Copy:
 Ambulance Service: Leave the “pink” copy at the hospital prior to the agency leaving
the hospital. In instances where this is not possible, all attempts should be made to
provide the completed document to the receiving hospital as soon as reasonably
possible. However, the ambulance crew must provide an appropriate medical record
that includes the demographic, event/incident, assessment findings and treatment
details upon delivery of the patient to the receiving facility.

Advanced Life Support First Response (ALS FR) Agency: If no representative of the
ALS agency will be accompanying the patient to the hospital, the transporting agency
must be provided with an appropriate medical record that includes the demographic,
event/incident, assessment findings and treatment details, if possible prior to leaving the
scene. If an ALS provider is accompanying the patient than they must provide the
completed medical record to the receiving facility prior to leaving (as above).

Basic Life Support First Response (BLS FR) Agency: Same as for ALS FR Agency.
Yellow (Research) Copy:
 Ambulance Service: Yellow copy shall be submitted by the service to the Regional
EMS Program Agency as designated by the Department. PCRs shall be submitted at
least monthly, or more often if so indicated by the program agency.


Advanced Life Support First Response (ALS FR) Agency: Yellow copy shall be
submitted by the service to the Regional EMS Program Agency as designated by the
Department. PCRs shall be submitted at least monthly, or more often if so indicated by
the program agency.
Basic Life Support First Response (BLS FR) Agency: While not required by statute,
the yellow copy shall be submitted by the service to the Regional EMS Program Agency
Policy Statement 12-02
Page 2 of 5
as designated by the Department. PCRs shall be submitted at least monthly, or more
often if so indicated by the program agency
White (Agency) Copy:
 All Agencies: The original white copy should be retained in a secure location at the
service’s permanent office as designated to the Department for the following time
periods:
NOTE: Federal Law (HIPPA) requires that medical records be retained for Six Years. If
the call involves the treatment of persons under age 18, the PCR must be retained for three
years after the child reaches age 18.
Electronic PCRs (ePCR):
 EMS services are required to leave a paper copy or transfer the electronic PCR
information to the hospital prior to the EMS service leaving the hospital. This document
must minimally include, patient demographics, presenting problem, assessment
findings, vital signs, and treatment rendered.

Failure to leave patient information with the emergency department upon the delivery of
the patient may compromise medical treatment and interrupt the continuity of patient
care.

All electronic patient records should be completed and closed prior to the end of the
shift during which the patient was treated. There should be no access to patient records
on personally owned computers. Agencies should have policies restricting the use of
personally owned computers for completing ePCRs.
Confidentiality & Disclosure of PCRs/Personal Healthcare Information:
Maintaining confidentiality is an essential part of all health care, including prehospital care. The
confidentiality of personal health information (PHI) is covered by numerous state and federal
statutes, Polices, Rules and Regulations, including the Health Insurance Portability &
Accountability Act of 1996 (HIPAA) and 10 NYCRR.
Title 10 NYCRR Part 800.15:
Every person certified at any level pursuant to these regulations shall:
(a)
At all times maintain the confidentiality of information about the names, treatment, and
conditions of patients treated except:
(1)
A prehospital care report shall be completed for each patient treated when acting as
part of an organized prehospital emergency medical service, and a copy shall be
provided to the hospital receiving the patient and to the authorized agent of the
department for use in the State's quality assurance program;
Title 10 NYCRR Part 800.21:
An ambulance/ALS-FR service shall:
(l)
maintain a record of each ambulance call…
Policy Statement 12-02
Page 3 of 5
Health Insurance Portability & Accountability Act of 1996 (HIPAA):
Federal Law (HIPAA) requires all healthcare providers to have a written policy on protecting
Personal Health Information (PHI), including PCRs.
Such a policy should include (but not be limited to):
 Indicate that requests from patients for PCR/ePCR copies be in writing;
 That the agency will maintain a copy of the written request with the original PCR/ePCR;
 Maintaining the confidentiality of the information contained on a PCR/ePCR as well as the
actual PCR/ePCR;
 Conducting security training for all employees/members in proper security procedures to
protect personal health information; and
 Documenting security training of employees/members.
Providing PCR/ePCR copies to the receiving hospital, other providers giving care in a tiered
system and to the EMS program agency for QI does not constitute a violation of the HIPAA
regulations. For additional agency specific questions regarding HIPAA agencies should contact
their legal counsel and/or the U.S. Department of Health and Human Services.
Other PCR/ePCR Disclosures:
The PCR/ePCR may also serve as a document called upon in legal proceedings relating to a
person or an incident. No EMS agency is obligated to provide a copy of the PCR/ePCR simply
at the request of a law enforcement or other agency. If a copy of the PCR/ePCR is being
requested as part of an official investigation the requestor must produce either a subpoena,
from a court having competent jurisdiction, or a signed release from the patient. PCR/ePCR
must be made available for inspection to properly identified employees of the NYS Department
of Health.
A person may request a copy of a PCR/ePCR completed for themselves as the patient or the
parent or legal guardian of a patient may obtain a copy of a PCR/ePCR completed for that
patient. In cases where the patient is now deceased the person who is the court appointed
legal representative of the patient’s estate may request a copy of the PCR/ePCR.
An agency may provide a copy of a PCR/ePCR to those entities that represent that agency
either for the purpose of collection of fees from the patient or their insurance carrier or as part
of any legal proceedings relating to the agency. In such situations those representative are
also responsible for protecting the personal health information contained within the document.
Policy Statement 12-02
Page 4 of 5
Disposition Codes:
All hospitals in New York State have a three digit code indicting the hospital. In addition the
name of the hospital must be indicated.
Non Hospital
Disposition
Codes
Meaning
001
Nursing Home
002
003
Other Medical
Facility
Residence
004
Treated By This
Unit &
Transported By
Another Unit
005
Refused Medical
Aid and Or
Transport
006
Call Cancelled
007
Stand By Only
(No Patient)
008
No Patient Found
010
Other
Example
(See Note)
Any nursing home, rehabilitation center, respite home or
extended care facility not listed with a hospital disposition code.
Includes outpatient and specialty clinics, doctor’s offices,
diagnostic and testing facilities.
When a patient is transported to a private residence.
In a multi tiered response system this disposition would be used
by any BLS FR or ALS FR agency. This code would also be used
if one ambulance service provides ALS interface for another
ambulance. It would not be used by multiple vehicles from the
same agency i.e. two ambulances are dispatched to the same
call.
Any time contact is made and a person is evaluated, to include
such procedures as vital signs being taken, or any treatment is
provided. The documentation included on the PCR must indicate
that the patient was advised of the need for care and the patient
was competent to make an informed refusal of such care.
Any time a call is canceled prior to the arrival of the EMS agency
this disposition code should be used. When possible the crew
should document what other agency canceled the response or
the reason for the cancellation.
Used if a service is dispatched for a call such as to stand by
during a fire or other incident. If any person is treated at the
scene an additional PCR should be completed for them.
If a service arrives at a scene and there is no one there with any
complaint or injury, this code should be used. This would include
being dispatched to a motor vehicle crash at which there are no
persons who require any evaluation or care to. Document
completely under Comments
Any instance not indicated or explained above. This might include
a lift assistance call for a person who has fallen. Document
completely under Comments
NOTE: It is impossible to include every possible scenario an effort is made to provide guidance on many common occurrences.
Policy Statement 12-02
Page 5 of 5
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 09-13
12-01
Date: January 10, 2012
Re: Blood Glucometry
and Nebulized Albuterol
for EMS Agencies
Page 1 of 2
BACKGROUND
The New York State Emergency Medical Advisory Committee (SEMAC) has approved the use
of glucometers and nebulized albuterol by Emergency Medical Technicians (EMT) who are
employees/volunteers of an EMS agency (i.e. ambulance service, ALS-FR, BLS-FR). The
SEMAC approval was granted with the specific condition that the EMS agency wishing to use
a glucometer or nebulized albuterol, be granted approval by the Regional Emergency Medical
Advisory Committee (REMAC), that each EMT from that EMS agency complete a REMAC
approved training program, and that the EMS agency be granted a Limited Service Laboratory
Registration (for blood glucometry only).
The purpose of this policy is to explain the approval process for EMS agencies wishing to
implement a nebulized albuterol and/or blood glucometry program.

Prehospital blood sugar evaluation is intended to assist in the recognition of hypoglycemia and
improve the speed with which proper treatment is received.

Nebulized albuterol, when administered under the Statewide BLS Adult and Pediatric Treatment
Protocols has been shown to decrease respiratory distress in patients between one and sixtyfive years of age who are experiencing an exacerbation of their previously diagnosed asthma.
AUTHORIZATION FOR BLOOD GLUCOMETRY AND/OR NEBULIZED ALBUTEROL
Each REMAC will adopt protocols which will allow an EMT to obtain a blood sample, using a
lancet device or equivalent, and test the blood sample in a commercially manufactured
electronic glucometer. The REMAC will determine the type and level of record keeping and
quality assurance required for both blood glucometry and/or nebulized albuterol. Please note
that a protocol for nebulized albuterol has been approved by SEMAC and is included in the
Statewide BLS Adult and Pediatric Treatment Protocols for EMT-B and AEMT.
To be authorized to use an electronic glucometer or nebulized albuterol, the EMS agency must
make written request to the appropriate REMAC. The request must include, but not
necessarily be limited to, the following items:
 A letter from the EMS agency physician medical director supporting the request and
indicating an understanding of their role in the Clinical Laboratory requirements (blood
glucometry only) and quality assurance process.
12-01 Blood Glucometry and Nebulized Albuterol for EMS Agencies
Page 1 of 2
 A completed NYS Department of Health Clinical Laboratory Evaluation Program Limited
Service Laboratory Registration Application (form DOH-4081) for blood testing licensure
(blood glucometry only).
 Written policies and procedures for the operation of the glucometer and storage and
maintenance of nebulized albuterol that are consistent with applicable Regional and State
protocols. These policies and procedures shall include, but not necessarily be limited to
the following:







didactic and psychomotor objectives for training of authorized users including who will be
authorized to conduct this training;
documentation and attendance records of the training of authorized users;
a defined quality assurance program, including appropriateness review by the EMS agency
physician medical director;
documentation of control testing process (blood glucometry only);
written policies and procedures for storage of the glucometer and/or nebulized albuterol, and
proper disposal of sharps devices (blood glucometry only);
notice to the EMS agency physician medical director of the use of the glucometer and/or
nebulized albuterol, and;
requirements for documentation when the glucometer and/or nebulized albuterol is used for
patient care.
LIMITED LABORATORY REGISTRATION FOR BLOOD GLUCOMETRY
New York State Public Health Law requires that any EMS agency testing blood glucose,
whether by electronic glucometer or chemstrip, be required to possess a Limited Service
Laboratory Registration. In order to obtain the Registration, EMS agencies must complete
and submit the following document:

Limited Service Laboratory Registration Application (form DOH-4081)
Information and application materials are available at:
http://www.wadsworth.org/labcert/limited/index.htm
No EMS agency may engage in the testing of
blood glucose without a Limited Service Laboratory Registration Certificate.
NOTIFICATION
Once the EMS agency has received written approval for blood glucometry and/or nebulized
albuterol from the REMAC, the EMS agency must provide BEMS with an updated and signed
Medical Director Verification Form (form DOH-4362), indicating the Limited Laboratory
Registration permit number (if applicable) and authorization by the EMS agency physician
medical director.
Issued and authorized by the Bureau of EMS Acting Director
12-01 Blood Glucometry and Nebulized Albuterol for EMS Agencies
Page 2 of 2
No. 11- 08
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Date: October 6, 2011
Re:
Epinephrine
Auto-Injectors
(epi-pen)
Supersedes/Updates: 00-01 & 00-02
Page 1 of 2
The purpose of this policy is to assist a children’s camp or EMS agency in understanding the notification process for utilizing
epinephrine auto-injectors under the provisions of Article 30, section 3003 of the Public Health Law authorizing the use of an
epinephrine auto-injector (epi-pen). An epinephrine auto-injector program is designed to encourage greater acquisition,
deployment and use of epinephrine auto-injectors at children’s camps and EMS agencies around the State in an effort to
reduce the number of deaths associated with anaphylaxis [hypersensitivity (as to foreign proteins or drugs) resulting from
sensitization following prior contact with the causative agent].
At present, only New York State Department of Health Bureau of Emergency Medical Services (BEMS) certified ambulance
services are required to have epinephrine auto-injectors and trained providers available when in-service. The exception to this
rule is when the ambulance is staffed at the time of the call with an EMT –Critical Care or EMT-Paramedic authorized by the
appropriate Regional Emergency Medical Advisory Committee (REMAC) to administer epinephrine via subcutaneous or
intramuscular injection. All other recognized EMS agencies such as certified Advanced Life Support First Responder
(ALSFR) agencies, Basic Life Support First Responder (BLSFR) agencies with a BEMS issued agency code and children’s
camps as defined by subpart 7-2 of the New York State Sanitary Code are strongly encouraged to participate in the
epinephrine auto-injector program.
To be authorized to purchase, acquire, possess and use an epinephrine auto-injector under this statute, the entity is required
to file a completed and signed Notice of Intent to Provide Epinephrine Auto-Injector (NOI) DOH-4188 and collaborative
agreement with the appropriate Regional Emergency Medical Services Council (REMSCO) who will then forward a copy of the
NOI to BEMS.
There are no approvals or certifications issued by REMSCO/REMAC/BEMS
Epinephrine Auto-Injector Program Requirements
Original Notification Process
To be authorized to purchase, acquire, possess and utilize an epinephrine auto-injector, the following steps must be
completed:


Identify a New York State licensed physician or New York State based hospital knowledgeable and experienced in
emergency cardiac care to serve as Emergency Health Care Provider (EHCP) and participate in a collaborative
agreement;
Select and utilize the appropriate New York State Emergency Medical Services Council (SEMSCO)/BEMS
approved epinephrine auto-injector training course curricula for epinephrine auto-injector providers. At present,
the two (2) approved curricula are as follows (see attached):




Develop with the EHCP, a written collaborative agreement which must include, but not be limited to the following:






NYS DOH BEMS EMT-Basic original curriculum (EMT/AEMT providers)
NYS DOH BEMS Training Program Outline for unlicensed/uncertified personnel (children’s camp)
Other curricula as approved on a case to case basis by NYS DOH Bureau of Community Environmental
Health & Food Protection
written policy and procedure for acquisition, storage, accounting, and proper disposal of used auto-injectors.
written policies and procedures for the training of authorized users;
written practice protocols for the use of the epinephrine auto injector;
a method of notifying the EHCP of the use of the epinephrine auto injector;
documentation of the use of the epinephrine auto injector;
Provide written notice to the 911 public safety answering point (PSAP) or equivalent ambulance dispatch entity of the
availability of epinephrine auto-injectors at your location
Policy Statement 11-08

File with the appropriate REMSCO a completed and signed original of the NOI along with a completed and signed original of
the Collaborative Agreement

File a new NOI and Collaborative Agreement with the REMSCO if the EHCP changes or with a change in content of the
Collaborative Agreement
REMSCO Responsibility With Regard To Epinephrine Auto-Injector Programs
Each REMSCO is responsible for receiving and maintaining notification and utilization documentation submitted by the epinephrine
auto-injector program. The REMSCO shall develop and implement the following policies and procedures:





Ensure that a copy of each original or updated NOI is forwarded to BEMS;
Maintain the original of the NOI and the Collaborative Agreement;
Collect utilization documentation and information;
Provide detailed quarterly reports to BEMS regarding epinephrine auto-injector programs in the region, and;
Develop Continuous Quality Improvement (CQI) participation, data submission and documentation requirements for
participating entities.
Data Collection Requirements
The following minimum data shall be developed and collected as a part of the REMSCO epinephrine auto-injector CQI process:








Name of entity providing the epinephrine auto-injector;
Date of incident;
Time of Incident;
Patient age;
Patient gender;
Number of epinephrine auto-injections administered to the patient;
Name of the transporting ambulance service, and
Patient status at time of transport
A copy of the data set shall be provided quarterly to BEMS by the REMSCO.
Reporting an Epinephrine Auto-Injector Use
In the event that an epinephrine auto-injector is administered to a patient experiencing anaphylaxis, the entity must report the incident
to their EHCP. While it is not required by Article 30 of Public Health Law (PHL), BEMS policy dictates that epinephrine auto-injector
entities provide written notification to the REMSCO within 48 hours of the epinephrine auto-injector use. At a minimum, the following
should be provided as part of this written notification:







The name of the epinephrine auto-injector entity;
Location of the incident;
The date and time of the incident;
The age and gender of the patient;
The number of epinephrine auto-injectors administered to the patient:
The name of the ambulance service that transported the patient, and
The name of the hospital to which the patient was transported.
A copy of the above written notification shall also be provided to the EHCP.
In addition, Subpart 7-2 of the State Sanitary code requires children's camp operators to report in writing any epinephrine administration
to the permit-issuing official within 24 hours of the administration.
Attachments
1.
2.
3.
EMT-Basic original curriculum Lesson 4-5 on Allergies
Training Program Outline for Unlicensed/Uncertified Personnel to Administer Epinephrine by Auto-Injector In Life Threatening
Situations
REMSCO Listing
Policy Statement 11-08
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: NEW
11 - 06
Date: July 28, 2011
Re: Clarification of
Operating Territory (COT)
Page 1
of 3
Purpose:
To create a method for certified EMS agencies to have their operating certificate territory
description changed to reflect the actual area served, without adding new territory. Rewording
may be desirable when an existing description is either vague, imprecise, or uses descriptors
that may no longer be an accurate representation of the geography served. This policy may
also serve as a guideline for the Regional EMS Council to use when reviewing and considering
a Clarification of Operating Territory request.
Incorrect territory descriptors may exist for a number of reasons, for example:





The original description used vague language - vicinity of, surrounding area, adjacent to, etc.
The description is no longer a valid municipal entity – city, town or village restructured or geography
legally changed.
The description was never a valid naming convention – for example, municipal subdivisions
described by north, south, east or west when there is no such legal name.
Service to a district, such as a fire district, where no valid geographical boundaries were ever
documented to define its boarders. This descriptor variance may apply to entities that provided
services under contracts that changed over time. The most frequent instance of such variations has
been observed due to changes in fire protection districts.
Entities serving an area that has an “excluded” portion of geography, the exclusion descriptors being
imprecise, or using descriptors based on vague local terminology.
While the most common reason for an agency to request a COT may be financially motivated,
there is merit to evaluating the areas served in each county to insure that no geography is left
without authorized ambulance service coverage. Also, it is difficult for agencies to create
effective mutual aid agreements if a given EMS agency’s territory is not accurately described.
County EMS Coordinators and Public Safety Answering Points (PSAPs) are encouraged to
evaluate the territory of each EMS agency operating within their jurisdiction to insure that
ambulance service coverage legally exists throughout the entirety of each county.
Clarification of Operating Territory Process:
Each REMSCO should develop a consistent methodology and written policies to process COT
requests. Copies of the adopted process and policy should be made available to EMS agencies
upon request.
It is important to note that Article 30 of Public Health Law (A30 PHL) specifically describes the
statutory authority of the Regional EMS Councils (REMSCOs) regarding the creation of new
emergency medical services or the expansion of territory of existing services. The processes to
fulfill such actions may be found in DOH Policy Statement #06-06 EMS Operating Certificate
Application Process (CON). Because the COT process does not create new authority, or
expand existing certified EMS agency operating territory, the traditional CON process is not
11-06 Clarification of Operating Territory (COT)
Page 1 of 3
required. REMSCOs may adopt a simplified version of the CON process with several specific
exceptions.


No public hearing is required because proof of “public need” is not in question.
Once the policy is established, it is recommended that the REMSCO place a deadline for
receiving COT requests. This will allow the REMSCO to entertain COTs for a limited period of
time, after which, EMS agencies must make application as described in the current EMS
Operating Certificate Application Process (CON) Policy Statement.
The following items need to be included in any COT process:

A written request for a Clarification of Operating Territory submitted to the REMSCO(s) having
jurisdiction. If more than one REMSCO has jurisdiction then simultaneous and identical requests
must be made to all REMSCOs having jurisdiction.
 A historical account, including supporting documents, explaining why the applicant’s territory qualifies
for the COT.
 A copy of the applicant’s current, and if relevant prior, Department issued service operating
certificates (DOH-4005 for ALSFR Services or DOH-3414 for Ambulance Services)
 A statement from the applicant indicating if the service has ever been instructed by NYS DOH to
apply to a REMSCO for a traditional CON to correct the service’s operating territory.
 Statements of concurrence or support, from impacted municipalities, adjoining certified services,
services holding overlapping EMS operating authority and all PSAPs or dispatch systems having
jurisdiction. The statements must be no more than 6 months old and be signed by the executive
officers or elected officials of the represented concerned parties.
Supporting documents should include, but are not limited to:







DOH issued service Operating Certificates or service records;
Contracts;
Maps;
Copies of Patient Care Reports (with patient identification removed but geographical information
included to substantiate location);
Dispatch records or call logs;
Correspondence and/or communications with municipalities, other EMS agencies, REMSCO or
Program Agency, or the Department relating to the territory needing clarification;
Media documentation and historical records.
The following steps need to be included in any COT process:







Submission of a formal request for COT, with all supporting documents to the REMSCO.
Written acknowledgment by the REMSCO to the applicant and the Department of receipt of the COT
application. The Department will verify if the applicant’s territory concerns are eligible for the COT
process.
Review of the application and supporting documents by the REMSCO’s committee / COT workgroup.
Opportunity for follow up to complete or clarify any information under consideration by the reviewing
committee.
Presentation of the COT by the reviewing committee to the REMSCO at any regular or special
meeting that has a quorum to conduct REMSCO business.
Motion, second and vote by the REMSCO to accept, modify or deny the rewording of the applicant’s
operating territory.
Written notification to the Department of the REMSCO’s motion and vote, including a copy of the
application and supporting documents. Note that the format of the notice to the Department to
change the applicant’s territory descriptor is an “Endorsement of the need for clarification and a
recommendation of the terminology and wording that will most accurately describe the applicant’s
existing operating territory without expansion.”
11-06 Clarification of Operating Territory (COT)
Page 2 of 3
After receipt by the Department of the REMSCO’s notification, a concurrence review will be
conducted. Upon establishing concurrence with the REMSCO’s recommendation the
Department will issue an “amended” DOH-4005 or DOH-3414 certificate to the applicant with
copies to all REMSCOs having jurisdiction.
Additional Considerations:





An applicant that has previously been directed by the Department or the REMSCO to apply for an
expansion of operating territory for the geography at issue will not be considered for the COT
process.
If upon review by a REMSCO an application is deemed to constitute an expansion of operating
territory and not a clarification of operating territory, the application must be returned to the applicant,
with a copy to the Department, directing the applicant to make application for an expansion of
operating territory.
A COT is not a CON process and is therefore not subject to the statutory time frames specified in
A30 PHL or DOH Policy #06-06. However the council must process and come to a determination as
expeditiously as is feasible to best serve the public interest. The Department is also not bound to
statutory time frames, but will make reasonable efforts to conclude concurrence reviews in a timely
manner.
The Department reserves the right to approve or deny final concurrence and issuance of an
amended territory on any applicant’s service operating certificate. In the event of denial the
Department will provide an explanation for the denial and any alternative course of action available to
the applicant.
A COT is not subject to appeal within the statutory definitions established by A30 PHL.
Should a COT recommendation that is concurred by the Department be appealed within 120
days, by any party having standing to appeal, the amended wording will be vacated and the
applicant referred to apply for a traditional CON.
Frequently Asked Questions:
Q: Can a COT be used as a means to “grandfather” geography that has been traditionally served by a
certified EMS agency, but where such geography has never been identified by the territory descriptor
currently on the agency’s DOH operating certificate?
A: No. The COT process is not a substitute for “grandfathering” territory. If a certified EMS agency is
providing service outside the boundaries listed on its current DOH certificate, the agency must apply for
an Expansion of Operating Territory (EOT) to the Regional EMS Council(s) having jurisdiction. It is
important to note that Article 30, section 3009 - Continuation of Existing Services is no longer applicable.
Q: May a service that is currently applying for an expansion of operating territory, request a COT for
another portion of its territory that is not subject to “demonstration of need”?
A: Because a COT is not subject to A30 PHL statutory processes, a council is not barred from
considering an application at any time convenient to its review committee and general membership.
However, the Department does not recommend conducting a CON and COT for the same applicant
concurrently if the workload or territory issues under consideration could confuse or complicate fair
evaluation of the statutorily mandated CON action.
Q: May a REMSCO charge fees to conduct a COT?
A: Yes. However, because there is no public hearing and all documentation requirements may be
assigned to the applicant, in practice there should be minimal if any additional expenses beyond the
normal course of business for a REMSCO. Therefore, the Department recommends REMSCOs keep any
fees minimal and refund any unused funds to the applicant. Nominal expenses for a COT would be
anticipated to apply primarily to document copying and postage and/or information exchange expenses.
11-06 Clarification of Operating Territory (COT)
Page 3 of 3
No. 11 - 05
New York State
Department of Health
Bureau of Emergency Medical Services
Date: June 28, 2011
Re: Medical Control and
Oversight
POLICY STATEMENT
Supersedes/Updates: 95 - 01
Page 1 of 6
PURPOSE:
This policy was developed by the State Emergency Medical Advisory Committee (SEMAC) and
the Department to better define the statutory authority, roles and responsibilities, the
development of treatment protocols, credentialing, provision of medical control and oversight to
the prehospital community. It was approved by the State EMS Council at its March, 2011
meeting and is authorized by the Department.
DEFINITIONS:
1. "State Emergency Medical Advisory Committee" (SEMAC) means the New York State
Emergency Medical Advisory Committee formed pursuant to Public Health Law Section
3002-a.
2. "Regional Emergency Medical Advisory Committee" (REMAC) As defined in section
3001.16 means a group of five or more physicians, and one or more non-voting
individuals representative of each of the following; hospitals, basic life support providers,
advanced life support providers and emergency medical services training sponsor
medical directors approved by the affected regional emergency medical services
councils.
3. "Medical control" (3001.15) means:
(a) advice and direction provided by a physician or under the direction of a physician
to certified first responders, emergency medical technicians or advanced
emergency medical technicians who are providing medical care at the scene of
an emergency or en route to a health care facility and
(b) indirect medical control including the written policies, procedures, and protocols
for prehospital emergency medical care and transportation developed by the
state emergency medical advisory committee, approved by the state council, the
commissioner and implemented by regional medical advisory committees.
4. ”Under the direction of a physician” shall mean a Physician, Physician Assistant, Nurse
Practitioner, or Registered Professional Nurse that meets or exceeds those
requirements as established in NYCRR Title 10, Section 405.19 – Emergency Services.
Registered Professional Nurses must have completed the educational requirements
within one year as stated in Section 405.19. Per Section 405.19 the following education
requirements are:
i.
ii.
iii.
iv.
Physician
Physician Assistant
Nurse Practitioner
Registered Professional Nurse
ACLS and ATLS
ACLS and ATLS
ACLS and ATLS
ACLS
5. "Course sponsor medical director" means a physician licensed in the State of New York,
identified by an approved training course sponsor and approved by the Department as
having sufficient knowledge and experience required by the Department to fulfill the
educational needs of Department certification courses.
6. "On-line (direct) medical control" means the advice and direction provided by a physician
or under the direction of a physician, operating under guidelines approved by a REMAC,
to certified EMS personnel who are providing medical care at the scene of an
emergency or en route to a health care facility.
On-line medical control must be made directly between the on-line medical control
personnel (Physician, Physician Assistant, Nurse Practitioner or Registered Professional
Nurse 1 ) and certified EMS field personnel and be in real time. Physician and Nonphysician on-line medical control personnel must successfully complete a REMAC
approved on-line medical control program. The physician on-line medical director or the
REMAC will be responsible for conducting quality assurance review of the hospital or
regional on-line medical control programs and personnel.
7. "Medical control location" means a place which has been approved by one or more
REMAC(s) as having met their policies and procedures to provide on-line medical
control.
8. "Regional EMS system" means the provision of emergency medical service, in an
organized manner, by one or more EMS services or EMS systems, utilizing certified
EMS personnel, in accordance with the medical control policies of the REMAC.
9. "EMS system" means one or more EMS services organized to provide emergency
medical service in an area served by one or more Regional EMS Councils. An EMS
system must have a system medical director and have been approved by each REMAC
as having met the medical standards of the REMAC in each Region within which the
system will provide care.
10. "Regional medical director" means a physician member of a REMAC, who has been
approved by the REMAC as having met its credentialing policies and procedures and
who may be appointed by a REMAC with specific duties and responsibilities.
11. "System medical director" means a physician identified by an EMS system who has
been approved by one or more REMAC(s) as having met their credentialing policies and
procedures and who oversees the medical care provided by all EMS services within the
EMS System.
12. "Service medical director" means a physician identified by an EMS service who has
been approved by one or more REMAC(s) as having met their credentialing policies and
procedures, who is directly responsible for the medical care provided by the certified
EMS personnel of that EMS service, and who provides and participates in the EMS
service's quality improvement program. No physician may act as service medical director
for more than 10 EMS Services. A ratio of physician to certified EMS personnel
1
Meeting the requirements of Title 10 NYCRR Part 405.19 (d) Staffing, sections (1) Emergency Service Physician
and (3) Registered Physicians Assistants, Nurse Practitioners and Registered Professional Nurses.
supervision must be provided as follows; a) 500:1 for certified EMS personnel who
provide Automated External Defibrillation, b) 100:1 for certified EMS personnel who
provide advanced life support; provided that the maximum number of personnel to be
supervised by an individual physician may not exceed 500 AED or 100 ALS personnel 2 .
13. "Certified EMS personnel" means certified first responders, emergency medical
technicians or advanced emergency medical technicians currently certified by the
Department.
MEDICAL CONTROL
Medical control is accomplished through physician participation and direction at the state,
regional, system and service levels.
State Emergency Medical Advisory Committee (SEMAC)
The state emergency medical advisory committee (SEMAC) shall:
1) develop minimum standards for:










medical control,
triage, treatment, and transportation protocols,
protocols for invasive procedures,
protocols for infection control,
the administration of drugs, by certified EMS personnel,
the use of regulated medical devices by certified EMS personnel,
equipment, staffing and documentation requirements for medical control locations,
the approval of EMS systems,
qualifications and responsibilities for regional, system, service and course sponsor medical
directors,
operational aspects of the provision of EMS related to improving patient care or outcome.
2) issue, with the consent of the Commissioner, statewide advisory guidelines that include,
but are not limited to:











medical standards for the establishment and approval of EMS services,
criteria for regional approval of dispatch, triage, treatment and transportation protocols,
criteria for statewide, regional, system and service quality improvement programs,
responsibilities of service medical directors,
inter regional ALS protocol coordination and use,
patient destination protocols,
policies to be utilized when no patient is found and/or a patient refuses services,
criteria for transfer of patient care between non-physician providers,
criteria for appropriate utilization of air medical transportation resources,
medical aspects of disaster and multiple casualty incidents and mutual aid,
any subject in section 1.
3) issue minimum statewide guidelines, in compliance with all Federal and State rules, for
inter-facility transfers including:



2
acceptance of any patient by the transferring crew,
authorization and responsibility of the sending hospital and physician,
required documentation, by the transferring physician, of the level of care to be provided
during the transfer,
10 NYCRR Part 80.136 (a)(2) …The medical director of any advanced life support system with 10 or
more advanced life support agencies and/or 100 or more advanced emergency medical technicians
(AEMTS) shall designate associate physicians…




responsibilities of the receiving facility,
use of pre hospital protocols and medical control intervention,
use of medical modalities outside the regional prehospital protocol set that require special or
additional training,
documentation and transmission of medical orders.
4) review and approve protocols developed and/or implemented by REMAC's;
5) review and make recommendations to the SEMSCO and the Commissioner regarding
demonstration projects developed pursuant to 10 NYCRR Part 800.19;
6) develop procedures for the review and approval of prehospital EMS research/evaluation
activities;
7) report to the SEMSCO on all issues brought before it.
Regional Emergency Medical Advisory Committee (REMAC)
Although by law a REMAC is given independent authority to decide EMS medical issues within
its region, it must work cooperatively and with one common purpose with its Regional EMS
Council (REMSCO) and the EMS community so that the system operates smoothly and
effectively. For that to happen, the REMAC and the REMSCO need to establish joint operating
procedures to ensure effective communications that produces a partnership of shared
responsibilities that assures the provision of quality EMS services within the region. Toward this
common objective the following goals for a REMAC are:

To establish prehospital medical standards for a region consistent with the current practice of
emergency medicine.

To provide medical leadership, education, guidance, quality assurance and appropriate
remediation to all participants in the regional EMS system

To ensure and participate in regional and agency level quality assurance activities.

To educate and credential physicians to provide on-line medical control.

To educate and credential NYS certified EMS prehospital care providers.

To ensure the availability and quality of educational programs for all pre-hospital care providers.

To coordinate the development of the regional medical control system.

To define roles and responsibilities of the REMAC physicians within the Regional EMS System.

To encourage broad medical participation and a diverse representative constituency in the
development of medical control policies and procedures, as well as dispatch, triage, treatment,
and transportation protocols which are consistent with the standards of the SEMAC and which
address specific local conditions.

To develop a methodology by which both the REMSCO and REMAC will review,
approve/disapprove, and forward recommendations to the appropriate regional and State
committees regarding pre-hospital demonstration projects.

To receive patient outcome information from hospitals and pre-hospital EMS services and
coordinate quality assurance/improvement activities for the purpose of assessing pre-hospital
care concerns.

To encourage and review pre-hospital research/evaluation.
Each REMAC, within the standards and guidelines established by the SEMAC:
1) shall develop, review and/or implement dispatch, treatment, triage and transportation
protocols, specific to the needs of its region(s). Such protocols shall delineate care to be
provided under standing orders and/or on-line medical control,
2) may develop protocols, including but not limited to the following:




determining patient destination;
procedures to be followed when a patient refuses and/or no transport of a patient occurs;
circumstances under which care may be transferred from one level of non-physician provider
to another;
utilization of air medical transportation resources.
3) may develop policies and procedures, to optimize medical control of all pre-hospital
patient care activities for all EMS services providing care within its region. Such policies
and procedures shall include, but are not limited to,

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


the initial and continuing qualifications for physicians providing on-line medical control,
minimum staffing, equipment and documentation requirements for medical control
locations,
qualifications and responsibilities for the regional, system, service and course sponsor
medical directors,
approval of EMS services, indicating they have met the requirements of the REMAC to
provide a level of care, upon initial application and any subsequent changes in the level
of service offered;
guidelines for inter-facility transfers,
the initial credentialing and continuing medical and educational qualifications of all prehospital care providers in the region;
process for disciplinary action against EMS providers;
medical requirements for and approval of EMS systems and services,
approval and use of inter regional protocols,
operational aspects of the provision of EMS related to improving patient care or outcome,
4) may develop, implement and shall participate in a region wide quality improvement plan
which addresses regional and system wide issues, and which facilitates the integration
of emergency medical service with hospital quality improvement activities,
5) shall review and make recommendations to the REMSCO for any demonstration
projects developed pursuant to Section 800.19 of this Part.
6) may designate, if appropriate, a member to act as regional medical director, who if
appointed shall have written duties, authorities and responsibilities defined by the
REMAC.
7) may develop procedures for the review and approval of prehospital EMS
research/evaluation activities.
8) shall address all issues brought before it by the REMSCO or any provider or other
interested party.
RESOURCE INFORMATION
11-03 Providing Medical Direction
http://www.health.state.ny.us/nysdoh/ems/policy/11-03.htm
American College of Emergency Physicians
http://www.acep.org
National Association of EMS Physicians
http://www.naemsp.org
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 03-07, 09-10, 10-07
I
11 - 03
Date: 3/16/2011
Re: Providing Medical
Direction
Page 1 of 4
Purpose
This policy is intended to provide assistance to Emergency Medical Service (EMS) agencies
and physician medical directors so that they may better understand medical direction for
patients of all ages at the agency level. The policy should clarify and expand upon the
definitions contained in Policy Statement 95-01, Medical Control, issued May 31, 1995. It is
also the intent of this policy to define the roles and responsibilities of the service, the service
medical director the Regional EMS Council (REMSCO) and the Regional Emergency Medical
Advisory Committee (REMAC) in relation to this topic. While the Department recommends that
every agency providing pre-hospital emergency medical care have a physician medical
director, it is a requirement for those agencies described below;






All Ambulance Services providing Defibrillation.
All Ambulance Services providing any level of Advanced Life Support (ALS).
All Advanced Life Support First Response Agencies.
All Basic Life Support First Response agencies providing Defibrillation and/or possessing a DOH
issued EMS Agency ID code number that also have REMAC issued authority to provide any adjunct
level of BLS care such as Albuterol or Blood Glucometry. 1 .
All entities authorized to provide Public Access Defibrillation under § 3000-b of Public Health Law
(PHL) shall have an Emergency Health Care Provider (EHCP).
All entities authorized to provide Epinephrine Auto Injectors under § 3000-c of Public Health Law
(PHL) must have an Emergency Health Care Provider (EHCP).
An EMS Service Medical Director shall mean a physician, licensed by New York State and
approved by the local REMAC with whom the agency has a professional relationship.
An Emergency Health Care Provider (EHCP) means: (I) a physician with knowledge and
experience in the delivery of emergency medical care; or (II) a hospital licensed under article
twenty-eight of the NYS Public Health Law that provides emergency medical care and with
whom the Public Access Defibrillation or Epinephrine Auto Injector program provider entity has
a written collaborative agreement.
1
While Basic Life Support First Response agencies are encouraged to interact with a physician medical director for all patient care responses,
these agencies are only required to have a medical director involved in training, use and quality improvement of the public access defibrillation
and/or epinephrine auto-injector program. If such agency holds a DOH issued EMS Agency ID# and has also been granted REMAC authority
to provide adjunct levels of BLS care (eg: Albuterol and/or Blood Glucometry) then the agency is required to have a REMAC approved
physician service medical director as an eligibility requirement for the EMS Agency ID.
Policy Statement 11-03
Page 1 of 4
II

Selecting an EMS Agency Medical Director
For Basic Life Support (BLS) and Advanced Life Support (ALS) ambulance services or Advanced
Life Support First Response Services (ALS-FR), the provisions of Policy Statement 95-01 regarding
service medical director states that the physician must be approved by the REMAC as having met
their credentialling policies and procedures.
The Responsibilities of the EMS Service Medical Director
Unless otherwise provided for in statute, rule or policy the responsibilities of an EMS Service Medical
Director shall include, but not be limited to:
1) Assure that service certified EMS personnel are oriented to the protocols promulgated by the
SEMAC and the REMAC(s) for the area(s) of operation of the service,
2) Interact with REMAC in the development of protocols, the regional Quality Improvement (QI)
process and in disciplinary issues,
3) Active development, review and participation in the Quality Improvement program developed by the
service as part of the Regional Council’s Quality Improvement program, as required in PHL §3006,
or §3004-a,
4) Working with the service’s providers on issues and questions regarding all ages of patient care,
5) Participate/interact in other activities that relate to the provision of medical care or affect the patient
care provided by the EMS service,
6) Participate, as necessary, with the service’s certified EMS personnel in Continuing Education
Programs and the re-certification process,
7) Verify, by affirmation provided by the department (DOH-4362 Medical Director Verification form),
that he/she serves as the medical director for the EMS service, providing medical oversight
inclusive of the levels of care and/or BLS adjunct treatment protocols specified on the form,
8) In accordance with NYS law, regulation or department policy submit any documentation required for
additional level of care approvals obtained by the EMS agency represented.
Immunity from Liability for Medical Direction
Article 30 § 3013 (5), of PHL: Notwithstanding any inconsistent provision of any general, special or local
law, any physician who voluntarily and without the expectation of monetary compensation provides
indirect medical control 2 , shall not be liable for damages for injuries or death alleged to have been
sustained by any person as a result of such medical direction unless it is established that such injuries
or death were caused by gross negligence on the part of such physician.
2
PHL Article 30 § 3001 (15) "Medical control" means: (a) advice and direction provided by a physician or under the direction of a physician to
certified first responders, emergency medical technicians or advanced emergency medical technicians who are providing medical care at the
scene of an emergency or en route to a health care facility and (b) indirect medical control including the written policies, procedures, and
protocols for prehospital emergency medical care and transportation developed by the state emergency medical advisory committee,
approved by the state emergency medical services council and the commissioner, and implemented by regional medical advisory committees.
Policy Statement 11-03
Page 2 of 4
III
Selecting an Emergency Health Care Provider for Public Access Defibrillation or
Epinephrine Auto Injector Programs


IV
For organizations engaged in the PAD program, PHL §3000-b 1 (B) requires the selection of an
Emergency Health Care Provider (EHCP). An EHCP is defined as “(I) a physician with knowledge
and experience in the delivery of emergency cardiac care; or (II) a hospital licensed under article
twenty-eight of this chapter that provides emergency cardiac care.”
For organizations engaged in the epi-pen program PHL §3000-c 1(B) requires the selection of an
Emergency Health Care Provider (EHCP). An EHCP is defined as (i) a physician with knowledge
and experience in the delivery of emergency care; or (ii) a hospital licensed under article twentyeight of this chapter that provides emergency care.
Responsibilities of a Public Access Defibrillation Program EHCP
1) §3000-b.1(E) states that, “The Emergency Health Care Provider (EHCP) shall participate in the
regional quality improvement program pursuant to subdivision one of section three thousand four-A
of this article.”
2) §3000-b.1(D) requires every use of the defibrillator to be reported promptly to the agency’s EHCP.
It will be the EHCP’s responsibility to receive and review these reports of use. They must also
communicate any concerns relating to the use of the device to the provider.
3) Serve as the physician of record for the purposes of purchasing the AED by the PAD program.
V
Responsibilities of an Epinephrine Auto-Injector Program EHCP
1) §3000-c.3(c) requires every use of an epinephrine auto injector to be reported to the agency’s
EHCP. It will be the EHCP’s responsibility to receive and review these reports of use. They must
also communicate any concerns relating to the use of the device to the provider.
2) It will be the responsibility of the EHCP to oversee the acquisition and deployment of the devices
and to assure the quality control standards implemented by the manufacturer are maintained.
3) Serve as the physician of record for the purposes of purchasing or issuing a prescription for the
program to obtain epinephrine auto injectors.
VI
Immunity from Liability for EHCP
3000-B (4) Application of other laws.
a. Operation of an automated external defibrillator pursuant to this section shall be considered first aid
or emergency treatment for the purpose of any statute relating to liability.
b. Operation of an automated external defibrillator pursuant to this section shall not constitute the
unlawful practice of a profession under title VIII of the education law.
3000-C (4) Application of other laws.
a. Use of an epinephrine auto-injector device pursuant to this section shall be considered first aid or
emergency treatment for the purpose of any statute relating to liability.
b. Purchase, acquisition, possession or use of an epinephrine auto-injector device pursuant to this
section shall not constitute the unlawful practice of a profession or other violation under title eight of
the education law or article thirty-three of this chapter.
Policy Statement 11-03
Page 3 of 4
c. Any person otherwise authorized to sell or provide an epinephrine auto-injector device may sell or
provide it to a person authorized to possess it pursuant to this section.
VII
Implementation:

All EMS agencies should immediately identify a physician medical director that meets the criteria
set forth by the REMAC.

All EMS agencies should carry a copy of off-line written protocols either on-person and/or on the
responding vehicle(s); off-line written protocols need to be available to the provider from the time of
dispatch through patient transport to a definitive care facility.

REMSCOs, when receiving a Notice of Intent to provide Public Access Defibrillation or Epinephrine
auto-injectors, shall assure the Emergency Health Care Provider meets the requirements detailed in
the applicable laws.
REMACs shall establish, maintain and make available, annually, the policies and procedures
established for the credentialling of physicians as service medical directors in the region. They shall
also maintain and make available, annually, the list of physicians who have met those credentialling
policies and procedures and are serving as medical directors. REMACs shall only grant ALS, and/or
BLS adjunct levels of care, authority to agencies that are either certified or recognized by the
Department and are under the medical direction of a physician credentialed by the REMAC. REMACs
are encouraged to collaborate with adjoining region REMACs to promote availability of medical
oversight to agencies routinely operating in more than one region.
Physicians asked to serve as EMS agency Medical Directors of BLS Ambulance or First Response
services shall maintain a ratio of physician to certified providers that is no greater than 500:1. An
Advanced Life Support Ambulance or First Response service must maintain a physician to certified
provider ratio of no greater than 100:1. However, physician may not be the medical director for more
than 10 services, unless approved by the local REMAC. These ratios were developed and approved by
the SEMAC as part of Policy Statement 95-01.
Issued and Authorized
Lee Burns, Acting Director - Bureau of EMS
Policy Statement 11-03
Page 4 of 4
No. 11-02
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Date: March 1, 2011
Re: DNR and Medical
Orders for Life- Sustaining Treatment (MOLST)
Supersedes/Updates: 99-10, 08-07, 10-05
Page 1 of 5
Purpose
This policy updates all EMS providers and agencies of changes in the laws regarding Do Not Resuscitate (DNR)
orders and Medical Orders for Life-Sustaining Treatment (MOLST). The Department now has an approved
MOLST form, DOH-5003 Medical Orders for Life-Sustaining Treatment. This form does not replace the Nonhospital Order Not to Resuscitate in either the English or the Spanish version (DOH-3474, DOH-3474es), but rather
provides an alternative. Nonhospital DNR orders are now governed by Public Health Law Article 29-CCC.
Additionally, this policy will provide an introduction to the Family Health Care Decisions Act (FHCDA). FHCDA
allows family members or certain other individuals to make health care decisions, including decisions about the
withholding or withdrawing of life-sustaining treatment, on behalf of patients who lose their ability to make such
decisions and have not prepared advance directives regarding their wishes. FHCDA went into effect on
June 1, 2010.
Nonhospital Order Not to Resuscitate
The New York State Department of Health has an approved standard Out of Hospital DNR form (DOH-3474)
that is legally recognized statewide for DNR requests occurring outside of Article 28 licensed facilities. This form
is intended for patients not originating from a hospital or nursing home.
For patients with a valid Nonhospital DNR or MOLST form with a DNR order, the Public Health Law allows a
standard metal bracelet to be worn by the patient, which includes a caduceus and the words “DO NOT Resuscitate.” EMS providers should assume that there is a valid DNR in place when a DNR bracelet is identified on a
patient.
Medical Orders for Life-Sustaining Treatment (MOLST)
MOLST is an alternative form for patients to document their end-of-life care preferences and to assure that
those preferences are made known to health care providers across the health care delivery system. Unlike the
Nonhospital Order Not to Resuscitate, the MOLST form documents DNI orders and orders regarding other lifesustaining treatment, in addition to DNR orders. MOLST should be honored by EMS agencies, hospitals, nursing homes, adult homes, hospices and other health care facilities and their health care provider staff. MOLST
has been approved by the Office of Mental Health and the Office for People With Developmental Disabilities for
use as a nonhospital DNR/DNI form for persons with developmental disabilities, or persons with mental illness,
who are incapable of making their own health care decisions or who have a guardian of the person appointed
pursuant to Article 81 of the Mental Hygiene Law or Article 17-A of the Surrogate’s Court Procedure Act.
Chapter 197 of the Laws of 2008 authorized the MOLST form to be used statewide as an alternative form for
nonhospital DNR and/or DNI and allowed EMS providers to honor this form in all counties in New York State.
Both the Nonhospital Order Not to Resuscitate form (DOH-3474) and the MOLST form (DOH-5003) are New
York State Department of Health forms. The MOLST form was updated in June 2010 to make it more userfriendly and to align the form with the recently enacted Family Health Care Decisions Act. The MOLST form is
currently utilized by many health care systems. If a patient has a prior version of the MOLST in place and
signed by a physician, the form is still considered VALID, and the patient care orders should be honored, unless it is known that the patient’s form has been revoked.
11-02 DNR and MOLST
Page 1 of 5
What are the DNR/DNI rules that affect EMS agencies and providers now?
1. Effective July 7, 2008, the MOLST form is approved for use statewide without the need for a standard
one-page Nonhospital Order Not to Resuscitate form.
2. EMS agencies must still honor the standard one-page nonhospital DNR form or bracelet.
3. When a patient wears a DNR bracelet, it refers ONLY to the do not resuscitate rules that apply to the
nonhospital DNR order. At present there are no nonhospital DNI bracelets.
4. The MOLST form also provides the patient and his/her physician with the ability to give a Do Not
Intubate (DNI) order to health care providers including EMS. Refer to Section E on the MOLST form to
review DNI information.
5. Occasionally EMS providers may encounter a patient who has a newly completed MOLST that does not
have the authorizing physician's signature. While the unsigned MOLST form may provide the EMS provider with information about the patient's treatment preferences, it is not a valid DNR or other order.
In the case of an unsigned MOLST form EMS providers should:
1. Initiate rescusitation following applicable state and/or regional protocols;
2. Obtain clinical information on status of the patient;
3. Confirm the MOLST form is specific to the patient;
4. Consult with local medical control and relay the above information; and
5. Follow the direction of the medical control physician.
What are the differences and similarities between the standard one-page nonhospital DNR order and the
MOLST form?
1. The MOLST form (DOH-5003) is a bright pink multi-page form; however, a photocopy or facsimile of the
original form is acceptable and legal. A Nonhospital Order Not to Resuscitate form (DOH-3474) is a single-page form on white paper with black ink.
2. The MOLST form is meant to be utilized by health care providers across the health care system. It is not
limited to EMS agencies; it travels with the patient to different care settings. The Nonhospital Order Not
to Resuscitate form is not intended for use in facilities.
3. MOLST provides for end-of-life orders concerning resuscitation and intubation for Advanced EMTs
when the patient is in full cardio-pulmonary arrest or has progressive or impending pulmonary failure
without acute cardiopulmonary arrest. The Nonhospital Order Not to Resuscitate form (DOH-3474) only
applies to patients in full cardio or pulmonary arrest.
4. Both forms, the MOLST form and the Nonhospital Order Not to Resuscitate form (DOH-3474) must be
authorized by a physician.
5. Unlike the Nonhospital Order Not to Resuscitate form, there are multiple patient orders contained on the
MOLST form that are intended for other health care providers to follow in other health care settings such
as the hospital or nursing home.
6. The MOLST form gives prehospital care providers and agencies direction regarding the patient’s end-oflife treatment orders in Section A (page 1) and Section E (page 2). See below.
Orientation to the MOLST Form, DOH-5003 (June 2010)
Section A – Resuscitation Instructions When Patient has No Pulse and/or is
Not Breathing
Section A is titled Resuscitation Instructions When a Patient Has No Pulse and/or Is Not Breathing. It provides
two boxes, only one of which will be checked. The first box, “CPR Order: Attempt Cardio-Pulmonary Resuscitation,” indicates that the patient wants all resuscitation efforts to be made, including defibrillation and intubation, if they are found in cardiac and/or respiratory arrest.
The second box, “DNR Order: Do Not Attempt Resuscitation (Allow Natural Death),” indicates the patient
does not want any resuscitation efforts made, and the patient wishes to be allowed a natural death. This does
not prevent treatment up to the point of resuscitation.
11-02 DNR and MOLST
Page 2 of 5
Section B - Consent for Resuscitation Instructions
This section MUST be filled out in accordance with New York State law. A box should always be checked to indicate who consented to the decision, and the name of the decision-maker should be printed. If the signature
line is left blank, the box for verbal consent should be checked. If the box for verbal consent is checked, the attending physician who signed the order should have witnessed the consent or two other adult witnesses should
be indicated.
Section C – Physician Signature for Sections A and B and for section E
A licensed physician must always sign the orders. If the physician is licensed in a border state, the physician
must insert the abbreviation for the state in which he/she is licensed, along with the license number.
As with the Nonhospital Order Not to Resuscitate form (DOH-3474), the MOLST form is required to be reviewed
by the physician periodically. However, both forms should be considered valid unless it is known that the medical order has been revoked.
Section D – Advance Directives
This section contains multiple check boxes listing advanced directives for the patient.
Section E – Orders for Other Life-Sustaining Treatment and Future Hospitalization
When the Patient has a Pulse and the Patient is Still Breathing
This section contains several parts containing treatment options that must be reviewed by prehospital care providers and includes:
Treatment Guidelines
 Comfort measures only
 Limited medical interventions
 No limitations
Instructions for Intubation and Mechanical Ventilation
 Do Not Intubate (DNI)
 A trial period
o Intubation and mechanical ventilation
o Non-invasive ventilation (e.g. BIPAP)
 Intubation and long-term mechanical ventilation
Future Hospitalization/Transfer
 Do not send to hospital unless pain or severe symptoms cannot otherwise be controlled
 Send to hospital if necessary, based on MOLST orders.
Artificially Administered Fluids and Nutrition
 No feeding tube
 A trial period of feeding tube
 Long-term feeding tube
 No IV fluids
 A trial period of IV fluids
Antibiotics
 Do not use antibiotics
 Limited use of antibiotics
 Use antibiotics
Other Instructions (e.g. dialysis, transfusions)
If any part of Section E is completed, additional consent and a physician signature, similar to Section B, must be
documented at the end of this section. Sometimes two boxes will be checked in Section E. If the form was
completed in the community (as opposed to a hospital or nursing home), a Public Health Law Surrogate may
consent to a nonhospital DNR and/or DNI order, but may not consent to withholding other life-sustaining treatment unless the consent is based on clear and convincing evidence of the patient’s wishes. For that reason, the
11-02 DNR and MOLST
Page 3 of 5
box for “based on clear and convincing evidence of the patient’s wishes” may be checked in addition to the box
for “Public Health Law Surrogate.”
Liability Protection
PHL § 2994-gg provides: "No person shall be subjected to criminal prosecution or civil liability, or be deemed to
have engaged in unprofessional conduct, for honoring reasonably and in good faith pursuant to this section a
nonhospital order not to resuscitate, for disregarding a nonhospital order pursuant to section twenty-nine hundred ninety-four-ee of this article, or for other actions taken reasonably and in good faith pursuant to this section."
Frequently Asked Questions
What should I do if I am uncertain how to proceed?
Contact Medical Control.
What do I do if the patient has both a nonhospital DNR order and a MOLST form? Which do I honor?
If the forms have different orders, you should follow the form that has the most recently dated authorization. In
all instances you should follow the DNI instructions on the MOLST form if the form is signed by a physician, as
the nonhospital DNR order does not provide this advice.
What if the old MOLST form was signed prior to June 1, 2010, the date the Family Health Care Decisions
Act became effective?
You may honor the previous versions of the form as if it were authorized after the statutory effective date.
Does the MOLST law allow EMS to honor other advance directives?
The law does not expand the ability of EMS personnel to honor advance directives such as a Health Care Proxy
or Living Will.
What procedures are, and are not, performed if the patient presents a DNR?
Do not resuscitate (DNR) means, for the patient in cardiac or respiratory arrest (i.e., when the patient has no
pulse and/or is not breathing), NO chest compressions, ventilation, defibrillation, endotracheal intubation, or
medications. If the patient is NOT in cardiac or respiratory arrest, full treatment for all injuries, pain, difficult or
insufficient breathing, hemorrhage and/or other medical conditions must be provided, unless Section E of the
MOLST form provides different instructions. Relief of choking caused by a foreign body is usually appropriate,
although if breathing has stopped, ventilation should not be assisted.
CPR must be initiated if no Out of Hospital or facility DNR is presented. If a DNR order is presented after CPR
has been started, stop CPR.
What documentation is required for a patient with a DNR order?
Prehospital care providers should attach a copy of the Out of Hospital DNR form, MOLST form, hospital DNR
order and/or copy of the patient’s chart to the patient care report, along with all other usual documentation. It
should be noted on the patient care report that a written DNR order was present including the name of the physician, date signed and other appropriate information.
If the cardiac/respiratory arrest occurred during transport, the DNR form should accompany the patient so that it
may be incorporated into the medical record at the receiving facility.
Patients who are identified as dead at the scene need not be transported by ambulance; however, local EMS
agencies should consider transportation for DNR patients who collapse in public locations. In these cases it may
be necessary to transport the individual to a hospital without resuscitative measures in order to move the body
to a location that provides privacy. Local policies need to be coordinated with the Medical Examiner/Coroner
and law enforcement.
11-02 DNR and MOLST
Page 4 of 5
MOLST Training
EMS providers and agencies who are interested in more specific training regarding the MOLST form and process may go to http://www.compassionandsupport.org. This site has a specific training program for EMS providers. The site contains frequently asked questions and a training video that would be useful to better understand
the MOLST form and process.
If you have other questions about this policy guidance please contact your DOH Regional EMS office or you
may call 518-402-0996.
Resources
New York State Department of Health MOLST Information:
http://www.health.state.ny.us/professionals/patients/patient_rights/molst/index.htm
MOLST Forms
http://www.health.state.ny.us/forms/doh-5003.pdf
Compassion and Support Website:
http://www.compassionandsupport.org
MOLST Training Center:
http://www.compassionandsupport.com/index.php/for_professionals/molst_training_center
MOLST EMS Training Page:
http://www.compassionandsupport.com/index.php/for_professionals/molst_training_center/ems_molst_training
Issued and authorized by Lee Burns, Acting Director of the Bureau of EMS
11-02 DNR and MOLST
Page 5 of 5
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 01-03
11-01
Date: 1/ 04 /2011
Re: Blood Draws for
Law Enforcement
Page 1 of 2
In 2010, the New York State Vehicle and Traffic Law ( VTL) was amended to authorize an advanced
emergency medical technician (AEMT) to draw evidentiary blood samples for the purpose of
determining alcohol or drug content solely at the request of a police officer. The law no longer
requires the procedure to be performed by AEMT’s under the supervision and at the direction of a
physician. VTL section 1194(4)(a)(1) states:
(1) At the request of a police officer, the following persons may withdraw blood for the purpose
of determining the alcoholic or drug content therein: (i) a physician, a registered professional
nurse, a registered physician assistant, a certified nurse practitioner, or an advanced
emergency medical technician as certified by the department of health…
Preface
Please note that VTL §1194 is permissive. This means that an AEMT (Intermediate, Critical Care and
Paramedic), is authorized to legally obtain a blood sample at the request of a police officer for the
purpose of alcohol/drug screening, but the AEMT is not mandated to perform the procedure.
When the AEMT is acting pursuant to a request by a police officer relying on VTL §1194, the AEMT is
acting independent of physician or medical control oversight. A patient/care-provider relationship
between the AEMT and the person from whom the blood sample is to be taken does not exist.
Consequently, it is important for AEMTs intending to act pursuant to VTL §1194 to prepare for such
law enforcement requests. This policy is intended to assist AEMTs and EMS agencies in planning
with respect to this law, but should not be considered complete and exclusive guidance.
Policy
1. VTL §1194 is permissive to all "AEMT" levels regardless of whether or not a particular level is
authorized or utilized within a particular agency and/or region.
2.
VTL §1194 permits, but does not require, an AEMT to draw blood for the purposes of blood
alcohol and/or drug content analysis upon request of a police officer. Physician authorization is
no longer required in order to comply with the request.
3.
EMS agencies, employers, and other entities that could possibly place the AEMT in the position
of receiving a request for blood draw pursuant to VTL §1194 should work with the AEMT to
prepare for dealing with such requests. AEMTs, agency heads, medical directors, 1 legal
advisors, and local police agencies should all be consulted regarding the following:
a.
b.
c.
d.
adequate AEMT training,
how requests will be made/received,
the proper handling of the blood specimen evidence,
appropriate documentation of the event.
1
Even though VTL 1194 does not provide for a physician oversight role, medical directors still have a role in blood draw training and infection
control procedures, and may be able to offer insight as to medical/legal documentation and consistency with procedures used in local
emergency departments.
Policy Statement 11 – 01
Page 1 of 2
4.
Patient care should not be compromised or delayed for the purpose of drawing a blood sample
for law enforcement. Unstable patients should not have evidentiary blood samples drawn if the
AEMT believes it will compromise prehospital medical care; instead, the patient should be
transported to the hospital where a blood draw can be performed, as may be appropriate.
5. If an AEMT has been summoned only for the purpose of obtaining a blood sample pursuant to
VTL §1194 and no obvious medical care is needed, the person submitting to the blood draw
should not be offered medical care and transport.
6. The AEMT will make a determination of the need to provide medical care and transportation for
the person from whom the blood draw is requested. If there is any uncertainty, the AEMT should
contact a medical control physician and put the physician in contact with the ranking police
officer present.
7. To document the chain of custody, any blood draw performed by an AEMT pursuant to VTL
§1194 should be performed in the physical presence of the police officer who will be taking
immediate custody of the blood sample.
8. The AEMT must confirm with the person from whom the blood sample is being requested and
the supervising police officer that the person is consenting to the blood draw.
9. There are a number of different alcohol/drug blood sampling kits on the market and being used
by police agencies. The AEMT should only use the kit supplied by the police officer at the time
of the event and follow the specific instructions indicated within that kit. AEMTs and/or EMS
agencies should not supply or stock their own kits.
10. General considerations when drawing evidentiary blood samples are:
a.
Do not use alcohol on the person's skin prior to drawing blood samples.
b.
If the person requires vascular access for medical purposes, draw the blood tubes from
the police supplied testing kit prior to attaching intravenous lines or administering
intravenous medications.
c.
If the person does not require vascular access for medical purposes, draw only the blood
tubes from the police supplied testing kit.
11. Although an AEMT may be asked to draw blood from a person who is not considered a patient,
the details of the event and venipuncture of any blood draw performed by an AEMT pursuant to
VTL §1194 should be documented on a standard paper or electronic Prehospital Care Report
(PCR) consistent with current practice.
Conclusion
Although VTL §1194 authorizes the AEMT to function independent of the physician medical director,
medical control, and the local EMS system, AEMTs, EMS agencies, medical directors, legal advisors,
and police agencies should cooperatively work together to facilitate VTL §1194 blood draws at the local
level. This policy is intended only as a guide to assist AEMTs, EMS and police agencies in planning for
the police requests. It is not intended to be all inclusive and complete guidance. Agencies should
proactively work together to address VTL §1194 issues unique to the local circumstances.
Policy Statement 11 – 01
Page 2 of 2
Drug Formulary
KETAMINE
Class
Anesthetic Induction
Description
Ketamine is a controlled substance medication that is a rapid-acting
general anesthetic producing an anesthetic state characterized by
profound analgesia, normal pharyngeal-laryngeal reflexes, normal or
slightly enhanced skeletal muscle tone, cardiovascular and respiratory
stimulation, and occasionally a transient and minimal respiratory
depression.
Onset & Duration
Onset:
Rapid – IV within 30 seconds half life 10-15 min.; IM
within 3-4 minutes
Duration:
IV 2 mg/kg lasts 5-10 minutes; IM 9 to 13 mg/kg lasts 12-25
minutes
Indications
1. Ketamine is indicated as the sole anesthetic induction agent for
management of trauma patients in extreme pain requiring proper
immobilization and/or extrication.
Contraindications
1. Ketamine is contraindicated in those in whom a significant elevation
of blood pressure would constitute a serious hazard and in those
who have shown hypersensitivity to the drug.
Adverse Reactions
1. Cardiovascular - blood pressure and pulse rate are frequently
elevated following administration of Ketamine alone. However,
hypotension and bradycardia have been observed. Arrhythmia has
also occurred.
2. Respiration - Although respiration is frequently stimulated, severe
depression of respiration or apnea may occur following rapid
intravenous administration of high doses of Ketamine.
3.
4.
5.
6.
Laryngospasms and other forms of airway obstruction have
occurred during Ketamine anesthesia.
Eye - Diplopia and nystagmus have been noted following Ketamine
administration. It also may cause a slight elevation in intraocular
pressure measurement.
Neurological - In some patients, enhanced skeletal muscle tone
may be manifested by tonic and clonic movements sometimes
resembling seizures.
Gastrointestinal - Anorexia, nausea and vomiting have been
observed; however, this is not usually severe and allows the great
majority of patients to take liquids by mouth shortly after regaining
consciousness.
General: Anaphylaxis, local pain and exanthema at the injection site
have infrequently been reported. Transient erythema and/or
morbilliform rash have also been reported.
Ketamine continued...
Drug Interactions
Prolonged recovery time may occur if barbiturates and/or narcotics are used
concurrently with Ketamine.
How Supplied
Injection:
IM or IV 15 mg (15 mg/mL) and 30 mg (30 mg/mL)
Ketamine Hydrochloride Injection, USP is supplied as the hydrochloride in
concentrations equivalent to Ketamine base.
Container Concentration
Fliptop 100 mg/mL
Vial
Fliptop
50 mg/mL
Vial
Fill Quantity
5 Box of
mL
10
10 Box of
mL
10
Color of solution may vary from colorless to very slightly yellowish and
may darken upon prolonged exposure to light. This darkening does not
affect potency. Do not use if a precipitate appears.
Store at 20 to 25°C (68 to 77°F).
Protect from light.
Dosing
Adult IV
Adult IM
1-4.5 mg/kg IV over 1 min.
6.5-13 mg/kg IM one dose
Pediatric IV >3 months 1.5 mg/kg IV over 1 min.
Pediatric IM >3 months 4-5 mg/kg one dose
Protocol
MA XX
MA XX
Adult Pain Management
Pediatric Pain Management
Special Considerations
1. Elevation of blood pressure begins shortly after injection, reaches a
maximum within a few minutes and usually returns to preanesthetic values
within 15 minutes after injection.
2. Because pharyngeal and laryngeal reflexes are usually active, Ketamine
can not be used alone for advanced airway management such as
intubation. Mechanical stimulation of the pharynx should be avoided,
whenever possible, if Ketamine is used alone.
3. The incidence of emergence reactions may be reduced if verbal and
tactile stimulation of the patient is minimized during the recovery period.
This does not preclude the monitoring of vital signs.
4. The intravenous dose should be administered over a period of 60
seconds. More rapid administration may result in respiratory depression or
apnea and enhanced pressor response.
5. Use with caution in the chronic alcoholic and the acutely alcoholintoxicated patient.
6. This medication is a Class III controlled substance medication approved
for prehospital use by the SEMAC and the Department.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 89-05, 02-03
10-03
Date: January 15, 2010
Re: EMS Agency and
Vehicle Surveillance and
Inspections
Page 1 of 3
I)
Introduction
In an effort to ensure compliance with New York State Public Health Law and the associated
Codes, Rules and Regulations and Policy Statements, the Department of Health is authorized to
conduct full service inspections/surveys as well as individual vehicle inspections. The
Department may inquire into the operation of ambulance services and advanced life support first
response services and conduct periodic inspections of facilities, communication services,
vehicles, methods, procedures, materials, staff and equipment.
II)
Full Service Inspections:
a) Department of Health Bureau of EMS Surveillance:
The Purpose of a full service inspection is to ensure that an ambulance service or Advanced
Life Support First Response (ALSFR) agency is in compliance with all the applicable laws,
regulations and department policies regarding the safe and efficient operation of the EMS
agency. In conducting these inspections department representatives assist agencies in
achieving the goal of not only overall compliance but also improved quality of care delivered to
patients.
b) Ambulance Services;
Ambulance services are required to comply with the provisions set forth in Part 800 of Title 10
NYCRR. This includes Part 800.21 General Requirements.
During a full ambulance agency inspection, representatives from the Department may inspect
any of the items outlined in Part 800.21 including, but not limited to:














Personnel files
Training records
Incident reports
Prehospital Care Reports
Agency Policies (Including all policies required in Part 800.21(p))
Mutual Aid Plans
Hazardous Materials Plans
Multiple Casualty Incident Plans
Ambulances
Emergency Ambulance Service Vehicles (EASV) including personally owned vehicles operated as EASVs as
authorized by the agency
Buildings and facilities for such items as the proper storage of supplies and equipment and the proper disposal of
regulated materials
Equipment (including all requirements listed in Part 800.22-800.25)
Vehicle check sheets and maintenance records
Personnel Rosters.
Policy Statement 10-03
Page 1 of 3
c) Advanced Life Support – First Response Agencies:
Advanced Life Support First Response (ALS FR) agencies are required to comply with the
provisions set forth in Part 800 of Title 10 NYCRR and applicable Department of Health, Bureau
of Emergency Medical Services Policy Statements.
During an ALS FR agency inspection, representatives from the Department may inspect any of
the items outlined in that policy statement including but not limited to:










Personnel files
Training records
Incident reports
Prehospital Care Reports
Agency Policies
Mutual Aid Plans
Hazardous Materials Plans
Multiple Casualty Incident Plans
All vehicles operated as emergency vehicles by the agency
Buildings and facilities for such items as the proper storage of supplies and equipment and the proper disposal of
regulated materials.
d) Controlled Substances Licensees:
Any service granted a license to possess and administer controlled substances in accordance
with Article 33 and Part 80 of Title 10 NYCRR, shall be subject to inspection of all records,
stock, sub-stock, security standards and for compliance with the operations plan submitted by
the agency and approved by the Department.
e) Quality Improvement Program:
Inspections of either an ambulance service or ALS FR agency may also include records
pertaining to the establishment of, or participation in, a Quality Improvement Program as
required in §3006 of the Public Health Law.
III)
Vehicle Inspections:
Inspections of emergency medical services vehicles may be conducted by representatives of
the Department of Health anytime the vehicles are in service. For a vehicle to be considered
“Out of Service” it should be in compliance with Department of Health Bureau of Emergency
Medical Services Policy.
a) Spot/Quick Check;
Vehicle inspections may, at the discretion of the Department representative, consist of a “Quick
Check” or a full vehicle inspection.
The "Quick Check" attempts to verify twenty-four (24) items of the required equipment and
supplies found in Part 800 of the State Health Code. These items are generally used to treat
patients suffering from life threatening illness or injury. Any ambulance found missing these
minimum standards may be removed from service, and a full vehicle inspection conducted.
b) Complete Vehicle Inspection;
Any vehicle operated by an ambulance service as an ambulance shall be required to be in
complete compliance with the applicable sections of 10 NYCRR Part 800, unless otherwise
authorized by the Commissioner pursuant to Part 800.25 or 800.27.
Policy Statement 10-03
Page 2 of 3
Any vehicle operated by an ambulance service as an Emergency Ambulance Service Vehicle
(EASV) must be in compliance with Parts 800.21, 800.23 and 800.26. This includes personally
owned vehicles authorized as EASVs by the agency.
Any vehicle operated by an Advanced Life Support First Response Service as a first response
vehicle must be in complete compliance with Parts 800.21, 800.23, 800.26 and Department of
Health Bureau of Emergency Medical Services policies.
All vehicles operated as emergency vehicles must be in compliance with the applicable sections
of the NYS Vehicle and Traffic Law.
Any vehicle that fails an inspection may be placed out of service by the Department
representative conducting the inspection. The failure may result in the issuance of a Notice of
Violation or a Statement of Deficiencies. In both cases, the service will be required to submit
plans in writing that address the deficiencies and steps taken to correct the identified violations.
In an effort to provide the most effective care in the prehospital environment, the Bureau of EMS
encourages agencies to operate with more than the minimally required supplies and equipment.
The items required by Part 800 and Bureau of EMS policy statements are the minimum
requirements for the operation of an EMS service. There are many additional policies that
agencies may implement for productive operation. There are additional supplies and equipment
that a service may wish to utilize to enhance patient care. Each agency is encouraged to
evaluate their operation to determine whether additional equipment and supplies would be
appropriate for use in their EMS system. However, medical equipment and supplies should be
in accordance with state and regional treatment protocols, the scope of practice of the service
and all applicable federal, state and regional guidelines. Should items inappropriate for the
authorized level of care be found in agency vehicles, the agency may be subject to enforcement
action.
IV)
Additional information:
In addition to the Bureau of EMS Policy statements already listed, EMS agency operators are
encouraged to refer to the Bureau of EMS Policy Statement page at:
http://www.health.state.ny.us/nysdoh/ems/policy/policy.htm for policies that include items
subject to inspection by the Department.
Issued and Authorized by:
Lee Burns, Acting Director
Bureau of Emergency Medical Services
Policy Statement 10-03
Page 3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
10 - 01
Date: January 4, 2010
Re: Defibrillators and
Epinephrine
Requirements
Supercedes/Updates: NEW
Page 1 of 1
At their December 2009 meetings, the New York State Emergency Medical Services Council
(SEMSCO) and the State Medical Advisory Committee (SEMAC) voted to amend Title 10 of the New
York Codes, Rules and Regulations – Part 800 to require that all patients transported by EMS in the
State of New York, have access to certain life saving equipment. The amendment will require that all
in service ambulances be equipped with defibrillators and epinephrine.
During the regulatory approval process, the SEMSCO and SEMAC are strongly encouraging all
ambulance agencies to comply with the following:
1.
All in-service transporting ambulances must have the ability to defibrillate patients of
all age groups.
This requirement may be met with either an Automated External Defibrillator (AED)
or through Advanced Life Support (ALS) treatment modalities, manual defibrillation.
2.
Epinephrine auto-injectors must be on all in-service transporting ambulances that
do not already have the ability to administer epinephrine through ALS modalities at
the time of interaction with the patient.
This requirement is for adult and pediatric patients. It may be met by stocking both
adult and pediatric epinephrine auto-injectors that are carried on the ambulance or
through the use of ALS modalities that are already in-place on the ambulance. The
storage and safe guarding must be maintained in compliance with BEMS policy
statement 09-11 entitled, “Storage and safe guarding of medications administered
by the EMT-Bs”.
Every agency that utilizes auto injectors must be in compliance with policy
statement 00-01 Use of Epinephrine Auto Injectors by EMS Agencies.
http://www.health.state.ny.us/nysdoh/ems/policy/09-11.htm
http://www.health.state.ny.us/nysdoh/ems/pdf/00-01.pdf
This policy for providing defibrillation and epinephrine administration capabilities will take effect on
May 1, 2010. However, all EMS agencies are encouraged to implement this policy prior to May 1,
2010. The intent of this policy statement is to promote rapid initiation of defibrillation and epinephrine
to those patients who are in need of these life saving modalities.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 00-14
09-12
Date: December 28, 2009
Re: Storage and Integrity
of Prehospital Medications
and Intravenous fluids
Page 1 of 1
Purpose
Due to the unique nature of the prehospital environment, medications and intravenous
fluids that are stored and used in the prehospital setting are subjected to extreme
environmental changes. This may have a negative impact on the stability, strength,
quality and purity of these medications. As a result, medications may become less
effective or may negatively impact the patients. Programs should be implemented with
regards to how medications and intravenous solutions are stored in the EMS stations
and vehicles. This policy applies to all BLS and ALS agencies that carry medications
and/or intravenous fluids.
Policy
In an effort to assist agencies in maintaining the integrity of prehospital medications and
intravenous fluids, the following should be the minimum requirements implemented by
each service authorized to carry prehospital medications and intravenous fluids.

All EMS services authorized by the Regional Emergency Medical Advisory
Committee (REMAC) to carry medications and intravenous fluids must develop
policies to define the appropriate storage and maintenance of all medications and
intravenous fluids. These policies should also be incorporated in to the agency’s
policies and procedures as well as the QI program.

All medications and intravenous fluids must be stored in an environment that
protects them from extreme temperature changes and light according to each
medication manufacturer’s guidelines. This includes all vehicles, stationary cabinets
or any other storage facilities where medications and intravenous fluids are stored.
According to manufacturer’s guidelines, most medications must be stored at
temperatures that range from 59 degrees to 77 degrees Fahrenheit 1 . However, the
temperature ranges may differ for many medications.

Agencies must have policies related to the recognition, destruction and replacement
of medication that have been exposed to conditions outside or have surpassed the
printed expiration date as required by the manufacture’s guidelines.

Agencies must routinely monitor and record the temperatures for all locations where
medications and intravenous solutions are stored.
1
New Jersey – Drug Adulteration Study, October, 1995
No.
09-11
Date: December 28, 2009
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: 00-15
Re: Storage and Safe
Guarding of Medications
Administered by EMT-Bs.
Page 1 of 1
Purpose
The medications approved for use by Emergency Medical Technician - Basics (EMT-B)
are considered to be lifesaving measures. As such, care should be taken to allow for
immediate access, while safe guarding the medications when not caring for a patient.
This policy is developed to address concerns regarding the storage and safe-guarding
of medications that may be administered in accordance with state and regional BLS
protocols by EMT-Bs.
Policy
Prior to implementing prehospital medication administration, each agency must receive
approval from their Regional Emergency Medical Advisory Committee (REMAC). All
EMS agencies carrying medications for use by EMT-Bs, prior to placing them in service,
must develop policies and procedures that include, but may not be limited to the
following items; inventory control, storage, expiration and replacement of these items
and the process for provider education.
In an effort to assist agencies in maintaining control of the medications that may be
administered by EMT-Bs, the following should be the minimum requirements
implemented by each service providing this level of care.

The medications must be stored in an environment that protects them from extreme temperature
changes and light. According to most medication manufacturer’s guidelines, medications must be
stored at temperatures that range from 59 degrees to 77 degrees 1 .

All medications must be secured in a container or location capable of being secured with a lock or
numbered tear-away-type inventory control tag when not being used for patient care.

The medication must be placed in either a closed ambulance compartment or inside a bag or box that
is taken to the patient’s side.

It is strongly recommended that BLS medications not be placed in the same locked cabinet with
medications, syringes or needles used by Advanced Life Support Providers.

The EMS agency must provide safe disposal for medical waste/sharps on EMS vehicles.
1
New Jersey – Drug Adulteration Study, October, 1995
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
09 - 08
Date: July 8, 2009
Re: Reporting
Incidents, Injuries and
Crashes
Supercedes/Updates: NEW
Page 1 of 2
The provision of prehospital emergency medical services inherently involves risk to the safety and
health of providers, patients and the general public. All too frequently an EMS crew is involved in a
“near miss” event or sustains actual injury. Because EMS providers are the most valuable part of the
EMS system, the New York State Emergency Medical Services Council (SEMSCO), the State
Emergency Medical Advisory Committee (SEMAC) and the Department’s Bureau of Emergency
Medical Services (BEMS) have undertaken an examination of the practice of EMS response and
prehospital care. This ongoing project is intended to promote a safe working environment and a
“culture of safety”.
Title 10 New York State Codes, Rules and Regulations – Part 800.21(q) require the EMS service to
report certain types of incidents to the Department within 24 hours of the event and in writing within five
(5) business days. These incidents include:






A patient death or injury due to the actions of the EMS provider
A response vehicle crash
Injuries to an on-duty 1 EMS provider requiring medical treatment
The death of an EMS provider while on-duty.
Patient care equipment failures that occur while being used to treat a patient and known to have
caused harm to the patient or crew.
It is alleged that any member of the ambulance service has responded to an incident or treated a
patient while under the influence of alcohol or drugs while on duty.
In addition to the above mentioned circumstances, reportable incidents also include EMS response or
on-duty related illnesses and exposures to infectious diseases or hazardous materials.
REPORTABLE INCIDENT FORM
In an effort to better capture detailed information on EMS related injuries, illnesses and reportable
events, the Department, with the assistance of the SEMSCO’s “Safety” Technical Advisory Group
(TAG) have developed the attached Reportable Incident Form (DOH-4461).
This form must be completed for any incident in which serious injury, illness or death of an EMS
provider, patient or other individual (for example, a bystander, driver of another vehicle) occurred in the
course of their EMS response and/or duties. The form must be completed and returned to the
appropriate BEMS Regional EMS Office within five (5) business days of the incident. A current list of
regional office and EMS staff is available at http://www.health.state.ny.us/nysdoh/ems/emsrep.htm.
This form does not take the place of any other local, state, federal or insurance required reporting form.
The form does not require the inclusion of individual identification or protected medical information and
such materials should not be included when submitted to the Department. The information obtained on
1
For the purposes of this Policy Statement, the term “on-duty” is defined as responding to a patient, treating and/or transporting a patient,
assigned stand-bys and returning to service, the EMS station or residence.
09-08 Reporting Incidents, Injuries and Crashes
Page 1 of 2
the form will be collected in a database to be used to study events, incidents and injury trends with the
intention to identify issues and solutions for change in order to make the EMS environment safer for its
participants, the patients and the citizens of local communities. Additionally, the completed forms will
maintained by the Department.
As an important reminder, the Part 800.21(q) also requires that an EMS agency report any situation in
which it is alleged that a member/staff of the EMS agency has responded to an incident or treated a
patient while under the influence of alcohol or drugs while on duty must also be reported to the
Department. This must be done in writing and sent to the appropriate BEMS Regional EMS Office
within five (5) business days of the incident.
FORM DIRECTIONS
The form is comprised of six (6) pages. It is only necessary to complete the pages that pertain to the
specific incident being reported. If the incident requires additional description, use the appropriate
supplemental pages provided. The pages of the form may be photocopied and attached as necessary.
Additional copies of the form are available on the Department’s web site at
http://www.health.state.ny.us/nysdoh/ems/emsforms.htm.
Only complete and return sections that pertain to the incident being reported.
1. Please attach copies of any agency specific Incident Reports. Individual and/or protected medical
information may be redacted.
2. If the type of injury, illness, or any other necessary information is not listed, Section 6 on page 6 must be
completed. If multiple pages are necessary, this page can be photocopied.
3. Section 1 is for general information relating to the incident only and must be completed for all reporting.
Only complete items in this section that pertain to the incident. Example: If no vehicle involved, do not
complete that part.
4. Section 2 must be completed if an EMS crew member is injured or otherwise meets the reporting criteria.
5. Section 3 must be completed if a patient is injured or otherwise meets the reporting criteria.
6. Section 4 must be completed if another emergency responder (outside of your agency) or civilian is
injured or otherwise meets the reporting criteria.
7. Section 5 must be completed if one or more vehicles were involved in the incident.
8. Section 6 must be completed only if additional documentation is necessary to describe this incident.
Photocopies of this sheet can be utilized for additional documentation.
9. Supplemental Page 1 is only to be used to document additional EMS crew members injured or otherwise
meets the reporting criteria.
10. Supplemental Page 2 is only to be used to document additional patients injured or otherwise meet the
reporting criteria.
11. Supplemental Page 3 is only to be used if additional emergency responders (other than your crew), or
civilians are injured or otherwise meet the reporting criteria.
12. Supplemental Page 4 is to be used as necessary to document additional vehicles involved with this
incident.
CONCLUSION
The submission of the Reportable Incident form is required should there be any serious injury, illness or
death of an EMS provider, patient or other individual (for example, a bystander, driver of another
vehicle) occurring in the course of their EMS response and/or duties. If there is a question as to
whether a specific event meets the regulatory criteria, please complete and submit the form and
documentation. It is the SEMSCO and Department’s goal to be able to study the information gathered
so that the EMS community has a better understanding of the risks it faces and is able to work to build
a safer EMS and patient care environment.
Approved by Edward Wronski, Director
09-08 Reporting Incidents, Injuries and Crashes
Page 2 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Reportable Incident Form
This form must be completed for any serious injury, illness or death of an EMS provider, patient or other individual in accordance
with Part 800.21(q) and 800.21(r). The completed form must be submitted to the New York State Department of Health’s Bureau of
Emergency Medical Services within 5 business days for every incident.
Name of EMS Service _______________________________________________________ NYS EMS Agency Code _____________
Address ___________________________________________________________________________________________________
City____________________________________________ State ______ ZIP ____________ County _______________________
Name of Contact Person and Title _______________________________________________________________________________
Business Phone ( _________ ) ___________________________ Other Phone ( _________ ) _______________________________
FORM DIRECTIONS
Only complete and return sections that pertain to the incident being reported.
1. Please attach copies of any agency specific Incident Reports.
2. If the type of injury, illness, or any other necessary information is not listed, Section 6 on page 6 must be completed.
If multiple pages are necessary, this page can be photocopied.
3. Section 1 is for general information relating to the incident only and must be completed for all reporting. Only complete
items in this section that pertain to the incident. Example: If no vehicle involved, do not complete that part.
4. Section 2 must be completed if an EMS crew member is injured or otherwise meets the reporting criteria.
5. Section 3 must be completed if a patient is injured or otherwise meets the reporting criteria.
6. Section 4 must be completed if another emergency responder (outside of your agency) or civilian is injured
or otherwise meets the reporting criteria.
7. Section 5 must be completed if one or more vehicles were involved in the incident.
8. Section 6 must be completed only if additional documentation is necessary to describe this incident. Photocopies of this
sheet can be utilized for additional documentation.
9. Supplemental Page 1 is only to be used to document additional EMS crew members injured or otherwise
meets the reporting criteria.
10. Supplemental Page 2 is only to be used to document additional patients injured or otherwise meet the reporting criteria.
11. Supplemental Page 3 is only to be used if additional emergency responders (other than your crew), or civilians are
injured or otherwise meet the reporting criteria.
12. Supplemental Page 4 is to be used as necessary to document additional vehicles involved with this incident.
This form does not replace any incident reporting forms required by a regional council,
state or federal laws and regulation, and/or insurance policies.
DOH-4461 (2/09) Page 1 of 6
SECTION 1
General Incident Information
Date of Incident _____________________ Time (24 Hour) ___________________ Day of Week _______________________
Your Agency Type (Check only one.)
Commercial
Industrial
College
Not-for-Profit
Fire Department
Municipal
Independent
Hospital
Type of Incident
Illness
Injury
Injury During Response/Scene Operations
Injury During Training Operations
Other _________________________________________________________________________________________________
Location
Roadway
Residence
Commercial Site
Other _________________________________________________________________________________________________
Agency Status at Time of Incident
Available
Responding
On Scene
En-route to Hospital
Parked (Staffed)
Parked (Unstaffed)
Weather Conditions at the Time of the Incident (Check all that apply.)
Daylight
Night
Dawn/Dusk
Clear
Fog
Rain
Snow
Ice
Other _________________________________________________________________________________________________
Motor Vehicle Involved
EMS Vehicle Involved:
Other Vehicle Involved:
Backing
Head-On
Yes
No
Ambulance
Car
Sideswipe
Law Enforcement Response
Yes
ALS-FR
Truck
Parked
EASV
Other ________________________________________
Other ___________________________________________________
Vehicle/Pedestrian
Vehicle/Responder
No
If Incident Occurred During Response, What Was the Patient Condition Based on Dispatch Information?
Minor
Moderate
Serious
Critical
If Roadway Number of Lanes _____ (All lanes. If road is bidirectional, count lanes for both directions.)
Intersection
Private
Paved
Local
Unpaved
State
Traffic Control Device
Interstate
Road Conditions
Dry
Wet
Ice
Snow
Other _________________________________________________________________________________________________
Contributing Factors
Mechanical Failure
Drug/Alcohol Impaired (EMS Provider)
Broken Traffic Control Device
Drug/Alcohol Impaired (Other Party)
_________________________________________________________________________________________________
Other
Number of Persons Involved
___ EMS Crew Member
___ Patient
___ Other Emergency Service
___ Civilian
Number of Persons Injured
___ EMS Crew Member
___ Patient
___ Other Emergency Service
___ Civilian
DOH-4461 (2/09) Page 2 of 6
SECTION 2
Injured EMS Crew Member Information
Complete this section for each injured EMS crew member. If more than one EMS crew member, use Supplemental Page 1.
Age ________
Male
CFR
EMT
EMT I
Female
EMT CC
EMT P
EMS Supervisor
Driver/Helper
Volunteer
Paid
Vehicle Operator
EVOC/CEVO Trained (Year __________ )
Restrained
Working Outside Environment
Unrestrained
Working Inside Building (Non-vehicle)
Vehicle Occupant
Restrained
Unrestrained
Working Outside Environment
Working Inside Building (Non-vehicle)
Mechanism of Injury
Animal Bite
Assault
No Weapon
With Weapon (Type ______________________ )
Carrying Equipment
Moving Patient
Transfer Onto/Off Stretcher
During Stretcher Transport
Electrical Injury
Explosion
Fire
Hazardous Materials Exposure
(Specify Product ___________________________________ )
Lifting/Bending
Needle Stick
Pedestrian Struck
Slip/Fall
Structural Collapse
Toxic Inhalation
Other ______________________________________________
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Spinal Injury
Sprain/Strain
Trauma Penetrating
Exposure
Heat
Cold
Exposure Hazmat
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
Internal Organ/System ____________________________________________________________________________________
Disposition: Admission
Emergency Department Only
Hospital General Admission
DOH-4461 (2/09) Page 3 of 6
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
SECTION 3
Patient Information
If more than one patient, use Supplemental Page 2.
Age ________
Male
Pre-event Condition
Female
Stable
Post Event Injury Condition
Unstable
Stable
Critical
Unstable
Critical
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Exposure
Spinal Injury
Heat
Sprain/Strain
Cold
Trauma Penetrating
Exposure Hazmat
Possible Cause _____________________________________
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
Internal Organ/System ____________________________________________________________________________________
Disposition: Admission
Emergency Department Only
Hospital General Admission
SECTION 4
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
Other Emergency Service Personnel (Firefighter, Police) or Civilian Information
If more than one other emergency service personnel or civilian, use Supplemental Page 3.
Age ________
Male
Female
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Spinal Injury
Sprain/Strain
Trauma Penetrating
Exposure
Heat
Cold
Exposure Hazmat
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
Internal Organ/System ____________________________________________________________________________________
Disposition: Admission
Emergency Department Only
Hospital General Admission
DOH-4461 (2/09) Page 4 of 6
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
SECTION 5
Vehicle Information
Vehicle #1 (Ambulance) Information
Type of Vehicle
Type I
Type III
Sedan
Type II
SUV
EASV
Other _________________________________________________________________________________________________
Amount of Damage
Minor
Severe
Moderate
Personal Injury
______________________________________
Vehicle Make
Insurance Code _____________________________________
Emergency Lights at Time of Collision?
Yes
No
Entrapment
Airbag Deployment
Vehicle Year ________ License Plate Number ______________
Last Maintenance Date __________________________________
Siren at Time of Collision?
Yes
No
Ambulance Operator
Driver’s Name __________________________________________________________ NYS EMT Number ___________________
Age _________
Male
Female Hours on Duty _________
CFR
EMT
EMT I
EMT CC
EMT P
EMS Supervisor
Driver/Helper
Volunteer
Paid
Reported to Duty From (Rested equals 8 hours of sleep.)
Home Rested
Home Unrested
Other Work Location Rested
Other Work Location Unrested
Investigating Agency/Precinct
State Police
Local Police Department
Sheriff
Other _________________________________________________________________________
Law Enforcement Name, Barracks or Precinct ____________________________________________________________________
Report Number _____________________________________ Total Accident Damage Estimate ($) ________________________
Vehicle #2 Information
If more than one vehicle, use Supplemental Page 4.
Type of Vehicle
Sedan
SUV
Pickup
Truck (Semi)
Truck (Straight)
Other ______________________________________________
Other Emergency Vehicle ______________________________
Severe
Personal Injury
Entrapment
Airbag Deployment
Amount of Damage
Minor
Moderate
DOH-4461 (2/09) Page 5 of 6
SECTION 6
Description of Events Leading to Injury or Illness
DOH-4461 (2/09) Page 6 of 6
SUPPLEMENTAL PAGE 1
Additional Injured EMS Crew Member Information
This page is intended to be used for documenting additional injured EMS crew members. Photocopy as necessary.
Age ________
Male
CFR
EMT
EMT I
Female
EMT CC
EMT P
EMS Supervisor
Driver/Helper
Volunteer
Paid
Vehicle Operator
EVOC/CEVO Trained (Year __________ )
Restrained
Working Outside Environment
Unrestrained
Working Inside Building (Non-vehicle)
Vehicle Occupant
Restrained
Unrestrained
Working Outside Environment
Working Inside Building (Non-vehicle)
Mechanism of Injury
Animal Bite
Assault
No Weapon
With Weapon (Type ________________________ )
Carrying Equipment
Moving Patient
Transfer Onto/Off Stretcher
During Stretcher Transport
Electrical Injury
Explosion
Fire
Hazardous Materials Exposure
(Specify Product ___________________________________ )
Lifting/Bending
Needle Stick
Pedestrian Struck
Slip/Fall
Structural Collapse
Toxic Inhalation
Other ______________________________________________
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Spinal Injury
Sprain/Strain
Trauma Penetrating
Exposure
Heat
Cold
Exposure Hazmat
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
Internal Organ/System ____________________________________________________________________________________
Disposition: Admission
Emergency Department Only
Hospital General Admission
DOH-4461 (2/09) Supplemental Page 1
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
SUPPLEMENTAL PAGE 2
Additional Patient Information
This page is intended to be used for documenting additional patients. Photocopy as necessary.
Patient #2 Information
Age ________
Male
Pre-event Condition
Female
Stable
Post Event Injury Condition
Unstable
Stable
Critical
Unstable
Critical
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Exposure
Spinal Injury
Heat
Sprain/Strain
Cold
Trauma Penetrating
Exposure Hazmat
Possible Cause _____________________________________
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
____________________________________________________________________________________
Internal Organ/System
Disposition: Admission
Emergency Department Only
Hospital General Admission
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
Patient #3 Information
Age ________
Male
Pre-event Condition
Female
Stable
Post Event Injury Condition
Unstable
Stable
Critical
Unstable
Critical
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Exposure
Spinal Injury
Heat
Sprain/Strain
Cold
Trauma Penetrating
Exposure Hazmat
Possible Cause _____________________________________
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
____________________________________________________________________________________
Internal Organ/System
Disposition: Admission
Emergency Department Only
Hospital General Admission
DOH-4461 (2/09) Supplemental Page 2
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
SUPPLEMENTAL PAGE 3
Additional Other Emergency Service Personnel or Civilian Information
This page is intended to be used for documenting additional personnel or civilians. Photocopy as necessary.
Other Emergency Service Personnel or Civilian #2 Information
Age _________
Male
Female
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Spinal Injury
Sprain/Strain
Trauma Penetrating
Exposure
Heat
Cold
Exposure Hazmat
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
Internal Organ/System ____________________________________________________________________________________
Disposition: Admission
Emergency Department Only
Hospital General Admission
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
Other Emergency Service Personnel or Civilian #3 Information
Age _________
Male
Female
Injury/Illness Description
Respiratory
Cardiac
Cardiac Arrest
Stroke
Seizure
Death
Fracture/Dislocation
Laceration
Burn
Amputation
Head Injury
Spinal Injury
Sprain/Strain
Trauma Penetrating
Exposure
Heat
Cold
Exposure Hazmat
Specify Body Part Affected
Head
Back
Leg ( Left / Right )
Neck
Abdomen
Hand ( Left / Right )
Chest
Arm ( Left / Right )
Foot ( Left / Right )
Internal Organ/System ____________________________________________________________________________________
Disposition: Admission
Emergency Department Only
Hospital General Admission
DOH-4461 (2/09) Supplemental Page 3
Critical Care Admission
Deceased
Personal Physician
None
Time Lost ___________ (Days)
SUPPLEMENTAL PAGE 4
Additional Vehicle Information
This page is intended to be used for documenting additional vehicles involved. Photocopy as necessary.
Vehicle #3 Information
Type of Vehicle
Sedan
SUV
Pickup
Truck (Semi)
Truck (Straight)
Other ______________________________________________
Other Emergency Vehicle ______________________________
Severe
Personal Injury
Entrapment
Airbag Deployment
Truck (Semi)
Truck (Straight)
Other ______________________________________________
Other Emergency Vehicle ______________________________
Severe
Personal Injury
Entrapment
Airbag Deployment
Truck (Semi)
Truck (Straight)
Other ______________________________________________
Other Emergency Vehicle ______________________________
Severe
Personal Injury
Entrapment
Airbag Deployment
Amount of Damage
Minor
Moderate
Vehicle #4 Information
Type of Vehicle
Sedan
SUV
Pickup
Amount of Damage
Minor
Moderate
Vehicle #5 Information
Type of Vehicle
Sedan
SUV
Pickup
Amount of Damage
Minor
Moderate
DOH-4461 (2/09) Supplemental Page 4
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
09 - 07
Date: June 17, 2009
Re: Security and Safety
of EMS Response
Vehicles
Supercedes/Updates: NEW
Page 1 of 2
BACKGROUND
Each year there are approximately 3 million EMS responses in New York State.
Occasionally, across the country EMS vehicles are stolen and damaged. A study titled,
“Ambulance Snatching: How Vulnerable Are We” i identifies a sampling of 151 ambulance
arrivals observed at emergency departments in several states. The average time present at
the Emergency Department was 21.5 minutes, 23.2% of the vehicles were left with the
engine running, 26.5% were left with doors or compartments open, 90.1% were left
unattended and 84.1% were left unlocked.
Occasionally the Department receives a report that an unattended EMS vehicle has been
stolen from the scene of a call or from the parking lot of a hospital. Additionally, there has
been information distributed internationally indicating that stolen ambulances may be used to
gain access to critical areas in a terrorist attack.
EMS operations create many potential exposures for loss or theft of equipment. In many
cases, responding EMS vehicles are staffed with two EMS providers. The ambulance or nontransporting response car arrives on the scene and the providers go to the patient, leaving
the EMS vehicle unattended. Additionally, vehicles are frequently left unattended with doors
unlocked or open, cabinets unlocked, and possibly the engine running while its’ left outside of
business establishments; left outside of the Emergency Department; or on the scene of an
emergency response. EMS vehicles are also often stored in an unsecured station or other
location.
PURPOSE
This policy is intended to encourage EMS agencies to develop policies and procedures that
will improve the security and safety of their response vehicles and minimize the possibility of
unauthorized use or theft.
Some examples of common best practices, if appropriate for the situation, would include, but
not be limited to the following:
 Leaving a crew member with the vehicle,
 Shutting off the engine and removing the ignition key from any EMS vehicle,
 Locking the vehicle and its exterior storage compartments when left unattended,
 The installation of a commercial anti theft device,
 Securing of vehicles and contents when not in service or being repaired,
 The routine inspection and prompt reporting of missing equipment,
There will be times, such as during weather extremes that may require the EMS vehicle to
remain running in order to keep the patient compartment warm or cool and maintain
medications within their safe temperature range. With these considerations in mind, EMS
agencies should have in place, and implement policies for securing the vehicle.
Each agency should perform a risk analysis to evaluate their risks and vulnerabilities of
vehicle security. Policies and procedures should be developed for the identified risks that in
turn, will reduce the opportunity for their vehicles to be stolen or misused.
Should an agency experience the theft of an emergency response vehicle, after the
appropriate law enforcement and insurance notifications have been made, notification must
be made to the Department of Health, Bureau of EMS in accordance with 10 NYCRR Part
800.21(p)(11)(i).
Issued by: Operations/Disaster Preparedness Units
Approval: Bureau of EMS Director
i
Donald W. Alves, MD and Richard A Bissell, PhD, “Ambulance Snatching: How Vulnerable Are We?”, The
Journal of Emergency Medicine, Volume 25, Issue 2, Pages 211-214 (August 2003)
No.
New York State
Department of Health
Bureau of Emergency Medical Services
Date: March 6, 2009
Re:
POLICY STATEMENT
Supercedes/Updates: 98-10, 06-03, 07-04
09-03
Public Access
Defibrillation
Page 1 of 5
The purpose of this policy is to assist a person, firm, organization or other entity in understanding the
notification process for operating an automated external defibrillator pursuant to a collaborative
agreement under the provisions of Chapter 552 of the Laws of 1998 authorizing Public Access
Defibrillation. A Public Access Defibrillation (PAD) program is designed to encourage greater
acquisition, deployment and use of automatic external defibrillators (AED) in communities around the
state in an effort to reduce the numbers of deaths associated with sudden cardiac arrest. Since the
enabling legislation’s inception, there have been 4,889 PAD programs established, with over 156,167
people trained and 21,692 AED machines in public sites across the state. This program has been
successful in saving many lives all across New York State.
At present, the following facilities or organizations must have trained providers and an AED on site:
•
•
•
•
•
Public schools (§ 1 of the Education Law);
State owned public buildings (Title 9 of Executive Law Subtitle G§ 303.1);
Health clubs with a membership of greater than 500 people (General Business Law § 627-A);
Public gathering locations (PHL § 225–5(b)), and
Public surf beaches with lifeguards (PHL § 225–5(c)).
To be authorized to use an AED under this statute an individual or organization needs to make specific
notification of intent to establish a PAD program to the appropriate Regional Emergency Medical
Services Council (REMSCO) and the New York State Department of Health (DOH).
There are no approvals or certifications required.
Public Access Defibrillation Program Requirements
Original Notification Process
To be authorized to have a PAD program and utilize an AED, the following steps must be completed:
•
Identify a New York State licensed physician or New York State based hospital knowledgeable and
experienced in emergency cardiac care to serve as Emergency Health Care Provider (EHCP) to
participate in a collaborative agreement;
•
Select an AED that is in compliance with the Article 30, section 3000-B (1)(A). The AED must be
programmed to the current Emergency Cardiovascular Care (ECC) Guidelines, capable of defibrillating
both adult and pediatric patients. Please check the shaded box on the Notice of Intent to Provide PAD
(DOH-4135) if the machine is approved for pediatric use;
•
Select and use a SEMAC/DOH approved PAD training course for AED users. At present, the 12
approved programs are as follows:
American Heart Association
American Red Cross
American Safety & Health Institute
Emergency Care and Safety Institute
Emergency First Response
Emergency Services Institute
EMS Safety Service, Inc
Policy Statement 09-03
Emergency University
Medic First Aid International
National Safety Council
REMSCO of NYC, Inc
State University of NY
Wilderness Medical Associates
Page 1 of 5
•
Develop with the EHCP, a written collaborative agreement which shall include, but not be limited to
the following items:
ƒ
ƒ
Written practice protocols for the use of the AED;
Written policies and procedures which include;
¾ Training requirements for AED users;
¾ A process for the immediate notification of EMS by calling of 911;
¾ A process for identification of the location of the AED units;
¾ A process for routine inspection of the AED unit(s) as well as regular maintenance and which
meet or exceed manufacturers recommendations;
¾ Incident documentation requirements, and
¾ Participation in a regionally approved quality improvement program.
•
Provide written notice to the 911 and/or the community equivalent ambulance dispatch entity of the
availability of AED service at the organization’s location;
•
File the Notice of Intent (NOI) to Provide PAD (DOH 4135) and a signed Collaborative Agreement
with the appropriate Regional Emergency Medical Services Council (REMSCO), and
•
File a new NOI and Collaborative Agreement with the REMSCO if the EHCP changes.
Reporting a PAD AED Use
In the event that the PAD program uses the AED to defibrillate a person, the program must report
the incident to the appropriate REMSCO. The REMSCO may request additional information
regarding the incident, but the PAD must report, at a minimum, the following information:
•
•
•
•
•
•
•
•
•
Provide written notification of AED usage to the REMSCO within 48 hours of the incident;
The name of the PAD program;
Location of the incident;
The date and time of the incident;
The age and gender of the patient;
Estimated time from arrest to CPR and the 1st AED shock;
The number of shocks administered to the patient:
The name of the EMS agency that responded, and
The hospital to which the patient was transported.
A copy of the usage report should also be provided to the EHCP.
Regional EMS Council Responsibility in Public Access Defibrillation
Each REMSCO is responsible for receiving and maintaining notification and utilization
documentation. The REMSCOs must develop and implement the following policies and procedures:
•
•
•
•
•
Insure that a copy of each new or updated Notice of Intent (DOH 4135) is forwarded to the Bureau of
EMS;
Maintain a copy of the Notice of Intent and the Collaborative Agreement;
Collect utilization documentation and information;
Provide detailed quarterly reports to the DOH on PAD programs in the region, and
Develop Quality Assurance participation, data submission and documentation requirements for
participating organizations.
Data Collection Requirements
REMSCO quality improvement programs are encouraged to use the data elements from the Utstein
Guidelines for Prehospital Cardiac Arrest Research (Cumming RO, Chamberlain DA, Abramson
NS, et al, Circulation 1991; 84:960-975).
Policy Statement 09-03
Page 2 of 5
The following minimum data set is to be developed and collected as a part of the regional PAD QI
process. A copy of the data set is to be provided by each region to the DOH Bureau of EMS
quarterly:
•
•
•
•
•
•
•
•
•
•
Name of organization providing PAD;
Date of incident;
Time of Incident;
Patient age;
Patient gender;
Estimated time from arrest to 1st AED shock;
Estimated Time from arrest to CPR;
Number of shocks administered to the patient;
Transport ambulance service, and
Patient outcome at incident site (remained unresponsive, became responsive, etc).
Ambulance and ALS First Response Services
Ambulance or ALSFR services may not participate in PAD programs for emergency response.
Certified EMS agencies must apply for authority to equip and utilize AEDs through their local
Regional Emergency Medical Advisory Committee (REMAC).
Please note that the Prehospital Care Report (PCR) has a check box for EMS providers to indicate
that a patient has been defibrillated prior to EMS arrival by a community or by-stander PAD
provider. Documenting this information is required so that the DOH may monitor the effectiveness
of these community based programs
Attachments
1. Notice of Intent to Provide Public Access Defibrillation
2. Regional EMS Council Listing
Policy Statement 09-03
Page 3 of 5
Notice of Intent to Provide
Public Access Defibrillation
New York State Department of Health
Bureau of Emergency Medical Services
Original Notification
Update
Entity Providing PAD
(
)
Telephone Number
Name of Organization
Name of Primary Contact Person
Address
E-Mail Address
(
City
State
)
Fax Number
Zip
Type of Entity (please check the appropriate boxes)
Business
Construction Company
Health Club/ Gym
Recreational Facility
Industrial Setting
Retail Setting
Transportation Hub
Restaurant
Fire Department/District
Police Department
Local Municipal Government
County Government
State Government
Public Utilities
Public School K – 6
Public School 6 - 12
Private School
College/University
Physician’s Office
Dental Office or Clinic
Adult Care Facility
Mental Health Office or Clinic
Other Medical Facility (specify)
Other (specify)
PAD Training Program (Indicate the training program chosen. Only the approved programs may be used. Please see
Policy Statement 09-03 [http://www.health.state.ny.us/nysdoh/ems/policy/09-03.htm])
Automated External Defibrillator
Manufacturer of AED Unit
Model of AED
Pediatric Capable
Number of Trained
PAD Providers
Number of AEDs
Emergency Health Care Provider
Name of Emergency Health Care Provider (Hospital or Physician)
Address
City
State
Telephone Number
(
Zip
)
Fax Number
Name of Ambulance Service and 911 Dispatch Center
Name of Ambulance Service and Contact Person
Telephone Number
Name of 911 Dispatch Center and Contact Person
County
Authorization Names and Signatures
CEO or Designee (Please print)
Signature
Date
Physician or Hospital Representative (Please print)
Signature
Date
DOH-4135(4/09) Complete this form and send it with your completed Collaborative Agreement to the REMSCO for you area
Policy Statement 09-03
Page 4 of 5
REGIONAL EMS COUNCIL LISTING
Adirondack-Appalachian REMSCO
Main St. PO Box 212
Speculator, NY 12164
(518) 548-5911
(518) 548-7605 fax
Counties: Delaware, Fulton,
Hamilton, Montgomery, Otsego,
Schoharie
--------------------------------------Big Lakes Regional EMS Council
534 Main Street Suite 19
Medina, NY 14103
(585) 798-1620
Counties: Genesee, Niagara,
Orleans
--------------------------------------Central NY Regional EMS Council
Jefferson Tower - Suite LL1
50 Presidential Plaza
Syracuse, NY 13202
(315) 701-5707
(315) 701-5709 – fax
Counties: Cayuga, Cortland,
Onondaga, Oswego, Tompkins
---------------------------------------Finger Lakes Regional EMS Council
FLCC Geneva Ext. Ctr.
63 Pulteney Street
Geneva, NY 14456
(315) 789-0108
(315) 789-5638 fax
Counties: Ontario, Seneca, Wayne,
Yates
---------------------------------------Hudson-Mohawk Regional EMS
Council
C/O REMO
1653 Central Avenue
Albany, NY 12205
(518) 464-5097
(518) 464-5099 fax
Counties: Albany, Columbia,
Greene, Rensselaer, Saratoga,
Schenectady
---------------------------------------Hudson Valley Regional EMS Council
45 Academy Avenue
Cornwall on Hudson, NY 12520
(845) 534-2430
(845) 534-3070 fax
Counties: Dutchess, Orange,
Putnam, Rockland, Sullivan, Ulster,
-------------------------------------Mid-State Regional EMS Council
2521 Sunset Avenue
Utica, NY 13502
(315) 738- 8351
(315) 738- 8981 fax
(888) 225-6642
Counties: Herkimer, Madison,
Oneida
-----------------------------------------
Policy Statement 09-03
Monroe-Livingston Reg EMS Council
Office of Prehospital Care
Strong Memorial Hospital
601 Elmwood Ave. Box 4-9200
Rochester, NY 14692
585-275-3098 or
585-273-3961
Counties: Livingston, Monroe
--------------------------------------------Mountain Lakes Regional EMS
Council
365 Aviation Road
Queensbury, NY 12804
(518) 793-8200
(518) 793-6647 fax
Counties: Clinton, Essex, Franklin,
Warren, Washington
---------------------------------------Nassau Regional EMS Council
2201 Hempstead Turnpike
Bldg. A - 4th Floor
Box 78
East Meadow, NY 11554
(516) 542-0025
(516) 542-0049 fax
Counties: Nassau
--------------------------------------------North Country Regional EMS Council
SUNY Canton College of Technology
34 Cornell Drive
Canton, NY 13617
866-475-3977
315-379-3977
(315) 379-3979 fax
Counties: Jefferson, Lewis,
St. Lawrence
--------------------------------------------Regional EMS Council of NYC
475 Riverside Drive, Suite 1929
New York, NY 10115
(212) 870-2301
(212) 870-2302 fax
Suffolk Regional EMS Council
Suffolk County Dept. of Hlth. Srvcs.
Div. of Emergency Medical Services
st
Dennison Building, 1 Floor
100 Veterans Memorial Highway
Hauppauge, NY 11788-5401
(631) 853-5800
(631) 853-8307 fax
Counties: Suffolk
--------------------------------------------Susquehanna Regional EMS Council
Public Safety Building
153 Lt. Van Winkle Drive
Binghamton, NY 13905-1559
(607) 778-1178
Counties: Broome, Chenango,
Tioga
Westchester Regional EMS Council
4 Dana Road
Valhalla, NY 10595
(914) 231-1616
(914) 813-4161 fax
Counties: Westchester
-----------------------------Wyoming-Erie Regional EMS Council
PO Box 630
Clarence, NY 14031
(716) 668-9184
(716) 668-2754 fax
Counties: Erie, Wyoming
-------------------------------------------------
Listing Revised: March 12, 2009
Counties: Bronx, Kings, New York,
Queens, Richmond
--------------------------------------------Southern Tier Regional EMS Council
PO Box 3492
Elmira, NY 14905-0492
(607) 732- 2354
(607) 732-2661 fax
800-343-1311
Counties: Chemung, Schuyler,
Steuben
--------------------------------------------Southwestern Regional EMS Council
PO Box 544
Olean, NY 14760
(716) 373-2612
Counties: Allegany, Cattaraugus,
Chautauqua
---------------------------------------------
Page 5 of 5
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
09-02
Date: 01/20/2009
Re: Extension of
Certification for Military
Personnel
Supersedes/Updates: 03-10
Page 1 of 2
Purpose and Background:
It is the purpose of this policy statement to outline the procedure for military personnel being released
from active duty to have their CFR/EMT/AEMT certification extended under the provisions of Chapter 206
of the Laws of 2008 signed by Governor Paterson on July 7, 2008 and Section 3011 of Article 30 of
Public Health Law:
The text of this law as it pertains to this policy statement is as follows:
“The commissioner is hereby authorized and empowered to extend the certification for emergency
medical technicians, advanced emergency medical technicians or certified first responders who have
been ordered to active military duty, other than for training, on or after the eleventh day of September,
two thousand one and whose certification will expire during their military duty or within the six months
immediately following separation from military service. The extended certification shall be for the period of
military duty and for twelve months after they have been released from active military duty.”
If the CFR/EMT/AEMT’s certification expires more than six (6) months following separation from active
military duty, the individual is not eligible for extension of certification under the provisions of this law. In
this case, the CFR/EMT/AEMT remains eligible for a refresher course. The maximum certification
extension granted will be for the period of military duty and for 12 months effective from the date of
release from active military duty as evidenced by official military separation documentation (i.e. DD-214 or
DA Form 2-A Statement of Release from Active Duty).
Procedure:
Upon release from active military duty, the applicant for extension of certification must:
1. Complete form DOH-4281 entitled “Certification Extension for Military Personnel.” This form is also
available in downloadable PDF format on the NYS EMS website at
www.health.state.ny.us/forms/doh-4281.pdf. Additionally, it can be obtained by contacting the Bureau
of EMS at 518-402-0996 ext 1 prompt 4.
2. Return the completed form DOH-4281 and a copy of your official military separation documentation
(i.e. DD-214 or DA Form 2-A Statement of Release from Active Duty) to:
NYS DOH Bureau of EMS
Certification Unit
875 Central Avenue
Albany NY 12206
Within two weeks of receipt of the above documentation and after review and approval of same, the
Bureau of EMS will issue a new certification card bearing the extended expiration date.
Issued and authorized by Bureau of EMS Office of the Director
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
09 – 01
Date: January 6, 2009
Re: Municipal Certificate
of Need Applications
“Muni-CON”
Supersedes/Updates: 97-01, 01-06
Page 1 of 3
Under the provisions of New York State Public Health Law Article 30, section 3008(7)a, a
municipality, as defined by Article 1 of the General Municipal Law, may determine that need
exists to establish an ambulance or advanced life support service (ALS-FR). Before the
municipality may begin operation, it must make notification to the State Emergency Medical
Services Council (SEMSCO) and possess an EMS Operating Certificate. In order to obtain an
EMS operating certificate, the municipality must complete the following steps:
1-
The municipality must file a written request with the State Emergency Medical Services Council
(SEMSCO). The request must be sent to the SEMSCO in care of the Bureau of Emergency
Medical Services (BEMS). The written request must include the following items:
a) A certified copy of the local law, ordinance or resolution from the municipal legislative body
empowering the municipality to establish and operate a certified EMS service. The local law, ordinance
or resolution should include, but not be limited to, the following:




A statement of need;
A statement establishing the type of service (ie. ALS-FR or Ambulance);
A statement declaring the area to be served; and
The date the resolution is to take effect.
b) A letter from the chief executive officer of the municipality requesting Public Health Law Operating
Authority as a certified ALS-FR or ambulance service.
c) A complete Application for EMS Operating Certificate, a map identifying the area of operation
(geography to be served may not exceed the boundaries of the applying municipality) and evidence that
the service meets or exceeds all New York State Department of Health applicable standards.
d) If the municipality intends on providing Advanced Life Support, it must apply to the appropriate Regional
Emergency Medical Services Advisory Council (REMAC) and be approved to provide advanced life support
care. The approval letter from the REMAC, stating the actual level of care approved, must be included in
the submission.
e) If the municipality intends to contract with another EMS provider for service, the filing should include
copies of signed contracts or agreements.
f) If the municipality intends to operate an ALS-FR, the filing must include a transport agreement with an
appropriately authorized NYS certified ambulance service.
g) The filing for a municipal service must be sent to the following address by certified mail or other return
receipt delivery:
New York State EMS Council
c/o Bureau of Emergency Medical Services - Operations Unit
New York State Department of Health
875 Central Avenue
Albany, New York 12206-1388
09-01 Municipal CON Application
Page 1 of 3
2-
Prior to the issuance of a Certificate of Operating Authority, the ALS-FR or ambulance service
must complete and submit the following to the appropriate DOH EMS Regional Office:



The Application for EMS Operating Certificate (DOH-206) packet.
If intending to provide adjunct Basic Life Support (BLS) and ALS levels of care, include written
REMAC authorization.
Identify a physician medical director using the Medical Director Verification Form (DOH-4362).
3-
A full service inspection will then be conducted by the Department’s appropriate regional EMS
staff. The full service inspection may not take place before the filing is complete, received and
reviewed by the Bureau of EMS. The inspection establishes that the EMS service meets or
exceeds the appropriate training, staffing and equipment standards as set forth by 10NYCRR
Part 800.
4-
Upon successful completion of the inspection and receipt of the NYS DOH Operating Certificate,
the service may begin operation. The municipality shall be granted operating authority for a
period of two years starting on the date the request is received by the Bureau of EMS.
5-
In order to convert the municipal declaration to a permanent operating authority, the ALS-FR or
ambulance service must receive a determination of public need from the Regional EMS Council
(REMSCO). Prior to the expiration of the municipal ALS-FR or ambulance service (two years
from the date of the original filing with SEMSCO) a complete application for New ALS-FR or
ambulance service must be received by the REMSCO. The REMSCO must render a
determination of need pursuant to PHL 3008. The application process, filing information and
required documentation may be found in DOH Policy Statement 06-06. The policy may be found
at www.health.state.ny.us/nysdoh/ems/pdf/06-06.pdf. It is strongly recommended that the
municipality file the application for a new service at least 90 days prior to the expiration of the
original certificate.
6-
Should the municipality make notification to the SEMSCO that it wishes to operate an ALS-FR or
ambulance service and then, prior to beginning service or anytime during the two year period,
determine that it is not in the best interest of the local government and/or community, it may
rescind the declaration. As with the original declaration, this must be done by local law, ordinance
or resolution rescinding the original local law, ordinance or resolution. This must be accompanied
by a cover letter and submitted to the SEMSCO, in care of the Department by certified mail or
other return receipt delivery.
Additional Information

The municipality is responsible for this EMS agency, even if they enter into contracts with another
organization to provide the EMS response.

An operating certificate obtained under the provisions of 3008 section 7(a) for the original two
year authority and the subsequent permanent authority may not be transferred.

If the municipality fails to become operational during the initial two years and does not rescind the
declaration, it may not file another municipal declaration to establish an EMS service under the
provisions of 3008 section 7(a).

With the exception of an entire county, a municipality may only declare operating authority for the
geography over which it has direct jurisdiction (e.g. an incorporated village contained within the
borders of a town would not be included within the authority of an EMS agency established by the
town {Also see next item}).
09-01 Municipal CON Application
Page 2 of 3

Multiple municipalities, under written inter-municipal agreements, may collaborate to operate a
single EMS service to serve several municipalities as long as each participating municipality
submits a declaration to the SEMSCO.

A municipality that intends to collect fees for the provision of EMS services (patient billing) will
need to apply for provider status in accordance with Federal and State Medicare/Medicaid
regulations. While the municipality may contract for billing services, it must be the billing entity.

The failure to initiate EMS operation in a timely manner (within 60 days of notification to the
SEMSCO) may contradict the declaration of need and may work against the municipality’s ability
to transition to a permanent operating authority after the two year period.
Available Web Based Resources
Prior to filing for a Muni-CON with the SEMSCO/Department, the following documentation may
provide additional information.

Municipal Certificate of Need (Muni-CON): An Overview
www.health.state.ny.us/nysdoh/ems/operational_authority/municipal_certificate_of_need.htm

Public Health Law, Article 30, section 3008
www.health.state.ny.us/nysdoh/ems/art30.htm#BM3008

Title 10 of the NYS Codes, Rules and Regulations related to EMS
www.health.state.ny.us/nysdoh/ems/publaw.htm

GML - Article 1, Section 2 - Definitions
http://public.leginfo.state.ny.us/menugetf.cgi

06-06 EMS Operating Certificate Application Process (CON)
www.health.state.ny.us/nysdoh/ems/pdf/06-06.pdf

Application for Ambulance and ALS-FR Operating Authority
www.health.state.ny.us/nysdoh/ems/operational_authority/certified/application_instructions.htm

DOH Regional Offices – EMS Representatives
www.health.state.ny.us/nysdoh/ems/emsrep.htm

Regional EMS Council (REMSCO) Contact Information
www.health.state.ny.us/nysdoh/ems/regional.htm
Please direct requests for applications, additional information or questions to the Bureau of
EMS, Operations Unit at 518-402-0996 x2.
09-01 Municipal CON Application
Page 3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: NEW
08 - 06
Date: Sept 8, 2008
Re: Federal Worker
Visibility Act
Page 1 of 3
EMS providers, police, firefighters and all other responders will be required to
wear American National Standards Institute (ANSI) International Safety
Equipment Association (ISEA) approved High Visibility Vests effective no later
than November 24, 2008. This new federal rule (attached) requires individuals
working on or near highways to wear the high visibility vests while conducting
operations on roadways supported by federal dollars.
The purpose of the regulation is to decrease the likelihood of worker fatalities or
injuries caused by motor vehicles, construction vehicles and equipment while
working within the right-of-way on Federal-aid highways. The federal regulation
contains the following definitions:
•
Close proximity means within the highway right-of-way on Federal-aid highways.
•
High-visibility safety apparel means personal protective safety clothing that is intended
to provide conspicuity during both daytime and nighttime usage, and that meets the
Performance Class 2 or 3 requirements of the ANSI/ ISEA 107–20041
•
Workers means people on foot whose duties place them within the right-of-way of a
Federal-aid highway, such as highway construction and maintenance forces, survey
crews, utility crews, responders to incidents within the highway right-of-way, and law
enforcement personnel when directing traffic, investigating crashes, and handling lane
closures, obstructed roadways, and disasters within the right-of-way of a Federal-aid
highway.
The ANSI/ISEA 107-2004 Classes are as follows:
•
Class 1 Garments: Intended for use in activities that permit the wearer's full and
undivided attention to approaching traffic. There should be separation of the worker from
the traffic, which should be traveling no faster than 25 miles per hour.
•
Class 2 Garments: Intended for use in activities where greater visibility is necessary
during inclement weather conditions or in work environment with risks that exceed those
for Class1 Garments. This class also covers workers who perform tasks that divert their
attention from approaching traffic, or that put them in close proximity to passing vehicles
traveling at 25 miles per hour or higher.
1
The standard requires that the background fabrics must be fluorescent yellow-green, fluorescent orange-red or
fluorescent red. Apparel must provide 360º of visibility; the retro-reflective striping must encircle the torso. It must also be
at least 2” above the hem. If there are multiple bands, they have to be separated by at least the width of the band.
08-06 Federal Worker Visibility Act
1 of 3
•
Class 3 Garments: Provides the highest level of visibility, and are intended for workers
who face serious hazards and often have high task loads that require attention away from
their work. Garments for these workers should provide enhanced visibility to more of the
body, such as the arms and legs.
In an effort to better insure the safety of EMS providers on the scene of an
emergency response, it is strongly recommended that every EMS agency do,
but not limited to the following:
<
Develop policies and procedures that require the use of high
visibility/retro-reflective2 safety apparel for all EMS providers while
working on, or near local, state or interstate roadways.
<
Make available high visibility/retro-reflective safety apparel for EMS
providers for use while working on or near local, state or interstate
roadways.
Additional information maybe obtained at the following web sites:
•
International Safety Equipment Association (ISEA)
www.safetyequipment.org
•
American National Standards Institute (ANSI)
www.ansi.org
•
Burns, David M. & Dr. Lee Pavelka. 3M® website: How Fluorescence Improves Roadway
Safety.www.3m.com/us/safety/tcm/research/fluorescence.jhtml
•
The CDC’s NIOSH website Death in the line of duty…: www.cdc.gov/niosh
•
Schertz, Greg (Safety Engineer, FHWA). Roadway Safety Foundation: The Importance of
Retroreflectivity
•
3M Corporation website: www.scotchlite.com
•
ANSI/ISEA 107-2004 MADE EASY: A Quick Reference to High-Visibility Safety Apparel
www.multimedia.mmm.com/mws/mediawebserver.dyn?6666660Zjcf6lVs6EVs666NA8CO
rrrrQ-
•
Oriole, Kim (JEMS InfoMail Reporter). JEMS: Journal of Emergency Medical Services:
Fatality Study: EMS Is a Dangerous Profession,
2
Retro-reflection occurs when light rays are returned in the direction from which they came. A large amount of reflected
light is returned directly to the original light source, causing retro-reflective materials to appear brightest to an observer
located near the light source.
08-06 Federal Worker Visibility Act
2 of 3
PART 634—WORKER VISIBILITY
Sec.
634.1 Purpose.
634.2 Definitions.
634.3 Rule.
634.4 Compliance date.
AUTHORITY: 23 U.S.C. 101(a), 109(d),
114(a), 315, and 402(a); Sec. 1402 of Pub.
L. 109–59; 23 CFR 1.32; and 49 CFR 1–
48(b). SOURCE: 71 FR 67800, Nov. 24,
2006, unless otherwise noted.
EFFECTIVE DATE NOTE: At 71 FR 67800,
Nov. 24, 2006, part 634 was added,
effective Nov. 24, 2008.
§ 634.1 Purpose.
The purpose of the regulations in this part is
to decrease the likelihood of worker fatalities
or injuries caused by motor vehicles and
construction vehicles and equipment while
working within the right-of-way on Federalaid highways.
§ 634.2 Definitions.
Close proximity means within the highway
right-of-way on Federal-aid highways.
Arlington, VA 22209, http://
www.safetyequipment.org.
Workers means people on foot whose
duties place them within the right-of-way
of a Federal-aid highway, such as
highway construction and maintenance
forces, survey crews, utility crews,
responders to incidents within the highway
right-of-way, and law enforcement personnel
when directing traffic, investigating crashes,
and handling lane closures, obstructed
roadways, and disasters within the right-ofway of a Federal-aid highway.
§ 634.3 Rule.
All workers within the right-of-way of a
Federal-aid highway who are exposed either
to traffic (vehicles using the highway for
purposes of travel) or to construction
equipment within the work area shall wear
high-visibility safety apparel.
§ 634.4 Compliance date.
States and other agencies shall comply with
the provisions of this Part no later than
November 24, 2008.
High-visibility safety apparel means
personal protective safety clothing that is
intended to provide conspicuity during both
daytime and nighttime usage, and that
meets the Performance Class 2 or 3
requirements of the ANSI/ ISEA 107–2004
publication entitled ‘‘American National
Standard for High-Visibility Safety Apparel
and Headwear.’’ This publication is
incorporated by reference in accordance
with 5 U.S.C. 552(a) and 1 CFR Part 51 and
is on file at the National Archives and
Records Administration (NARA). For
information on the availability of this material
at NARA, call (202) 741– 6030, or go to
http://www.archives.gov/
federallregister/codeloflfederallregulations/
ibrllocations.html. It is available for
inspection and copying at the Federal
Highway Administration, 400 Seventh
Street, SW., Room 4232, Washington, DC,
20590, as provided in 49 CFR Part 7. This
publication is available for purchase from the
International Safety Equipment Association
(ISEA) at 1901 N. Moore Street, Suite 808,
08-06 Federal Worker Visibility Act
3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Super cedes/Updates: 88-19, 98-13
08-04
Date: July 16, 2008
Re: Passenger
Restraint Devices in
Emergency Response
Vehicles
Page 1 of 3
For the previous five (5) years, the New York State Department of Motor Vehicles
reported an annual average of 489 ambulance vehicle crashes. A growing number of
these crashes have cost the lives or seriously injured EMS providers, patients and the
general public. The NYS Vehicle & Traffic Law requires drivers and all front seat
passengers in motor vehicles to be restrained in safety seats or by safety belts. While
an exemption in the law specifically excludes those vehicles defined as an “authorized
emergency vehicle (V&T section 101)” which includes ambulances, it is vitally important
that seatbelts are used at all times by every occupant of an emergency vehicle.
National Highway Traffic Safety Administration (NHTSA) data shows that when
lap/shoulder seat belts are used properly, they reduce the risk of fatal injury to front-seat
passenger car occupants by 45 percent and the risk of moderate-to-critical injury by 50
percent. For light-truck front-seat occupants, seat belts reduce the risk of fatal injury by
60 percent and the risk of moderate-to-critical injury by 65 percent. (Light trucks,
weighing less than 10,000 lbs., also include truck-based station wagons.)1
The New York State Department of Motor Vehicles 2006 data reported a total of 506
ambulance crashes. The data indicated that 1,427 individuals were involved, of that
876 (61.4%) were wearing a lap and harness seatbelt. The injury severity is reported as
follows:
•
•
•
•
16 serious injuries
19 moderate injuries
257 minor injuries
584 reported no injuries
PURPOSE
It is the purpose of this policy to strongly remind EMS agencies and individual providers
to evaluate their overall operations and develop practices or internal controls that lead
to a safe working environment and a culture of safety in all aspects of the agency.
This policy also assists EMS agencies in reviewing or developing policies and practices
that insure safe driving habits, the appropriate use of seat belts by all crew members,
1
Excerpted from the NHTSA – Crash Outcome Data Evaluation System (CODES).
Policy Statement 08-EF
Page 1 of 3
passengers and patients as well as a review of practices in the patient care
compartment to improve safety.
RECOMMENDATIONS
New York State Emergency Medical Services Council (SEMSCO) and the Bureau of
EMS strongly recommend that all EMS agencies develop and periodically review,
service specific policies for their personnel that include the provision of appropriate
emergency driver training programs, proper driving skills and behaviors. The policies
should also include, but are not limited to the following:
•
All drivers and front seat passengers of ambulances must use seat belts at all times when the
vehicle is in motion.
•
All operators & passengers of non-ambulance response vehicle (EASV, ALSFR, etc.) must use
seat belts at all times when the vehicle is in motion.
•
All patients not located on a patient carrying device - stretcher, as well as any passengers riding
in the patient compartment must use seat belts at all times when the vehicle is in motion.
•
All EMS personnel in the patient compartment must use seat belts when they are not attending to
a patient and the vehicle is in motion. In as much as possible, EMS personnel should perform
patient care activities while restrained by a seatbelt. Only if it becomes necessary to care for the
patient, should the seat belt be removed. Examples of necessary care are CPR, artificial
ventilation, medication administration, or reassessment of unstable patients.
•
All patients on the stretcher must be secured at all times when the vehicle is in motion or the
stretcher is being carried or moved. Manufacturer recommendations often include the use of
shoulder harnesses and those restraints should be used at all times.
•
Any child transported to the hospital should be in the child’s own protective restraining device –
child safety seat - when available. He/she should be placed in the device and the device should
be belted to an ambulance seat. If the child actually is the patient, he/she should be secured onto
the stretcher and if appropriate, kept in the child safety seat.
•
If the ambulance service does not have an ambulance equipped with child safety seats, it is
recommended that the agency purchase an approved child safety seat for each ambulance.
•
Agencies should consider the acquisition of patient monitoring devices (such as automated blood
pressure cuffs) and positioning of equipment in the patient care area that would allow for
personnel to remain restrained while providing patient care.
CONCLUSION
Whether paid or volunteer, commercial, municipal, independent or fire based, the EMS
community can not afford to lose EMS providers because of death, injury or disability
when the circumstances can be prevented through education and policy improvements.
It is the responsibility of every EMS agency and prehospital care provider to establish
and/or continue the culture of safety in the emergency medical services.
Policy Statement 08-EF
Page 2 of 3
RESOURCE INFORMATION
Below is a small selection of web sites that may provide additional resource information:
National Highway Traffic Safety Administration
http://www.nhtsa.gov
Emergency Vehicle Operators Course (EVOC) Information
http://www.nhtsa.dot.gov/people/injury/ems/web%20site%20intro.htm
United State Fire Administration
http://www.usfa.dhs.gov/downloads/pdf/publications/fa-110.pdf
National Safety Council – Coaching Emergency Vehicle Operators (CEVO)
http://www2.nsc.org/onlinetraining/driving/cevo.cfm
Volunteer Fireman’s Insurance Service, Inc. (VFIS)
http://www.vfis.com/education_training.htm\
International Association of Fire Chiefs
http://www.iafc.org/displaycommon.cfm?an=1&subarticlenbr=413
New York State Department of Motor Vehicles – 2006 Crash Summary Data
http://www.nydmv.state.ny.us/Statistics/2006_NYS_Accident_Summary_Final.pdf
Policy Statement 08-EF
Page 3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Agencies
POLICY STATEMENT
Supplements/Updates: New
08-03
Date: 04/03/2008
Re: Records Retention
Page 1 of 2
Introduction:
This policy is intended to assist EMS agencies in developing a record retention policy. It must be noted
that records retention requirements differ depending upon the ownership of the EMS service. Agencies
owned by local governments are required by law to maintain records as defined in the General Retention
and Disposition Schedule (GRDS). At present there are no state laws or regulations that define how long
private organizations must maintain their patient care records and other related EMS documents.
However federal regulations do require providers being paid through Medicaid and Medicare to retain
appropriate documentation in compliance with applicable regulations. Similarly, commercial and third
party payers may have their own requirements for record retention.
It is the intention of this policy statement to provide a guideline for the retention of records by all types of
EMS Services. This policy was prepared in conjunction with the GRDS for use by miscellaneous local
governments in New York State (Section 185.14, 8NYCRR (Appendix K). The GRDS is prepared and
issued by the State Archives, within the New York State Education Department and indicates the
minimum length of time that officials must retain their records before they may be disposed of legally.
Unless otherwise required by regulation or policy: EMS Agencies, Course Sponsors and individual
provider’s are not required to create and/or use all of the following forms of documentation. However, if
the documents are created and/or used they must be retained according to the following schedule.
It is recommended that all EMS Agencies and Course Sponsors develop a policy that describes how they
will comply with all record retention requirements. This policy should include, but not be limited to:
ƒ
ƒ
ƒ
ƒ
800.21(k) - personnel files;
800.21(l) - a record of each ambulance call;
800.21(p) - written policies; and
800.21(r) - all unexpected authorized EMS response vehicle and patient care equipment failures.
Retention Schedule:
***All documents should be appraised for historical value and considered for permanent retention.***
Agency:
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Administrative documents, such as meeting minutes and financial records must be retained for
7.5 years.
Patient Care Reports (electronic or hardcopy), must be retained for 6 years or 3 years past the
patients eighteenth birthday, whichever is longer.
Patient care data files containing medical treatment and/or billing information must be retained for
6 years or 3 years past the patients eighteenth birthday, whichever is longer.
Summary record of all patients treated and/or transported must be retained for 3 years.
Ambulance run chronological log must be retained for 6 years after the last entry.
Monthly or periodic reports or listings must be retained for 3 years.
08-03 Records Retention
Page 1 of 2
ƒ
ƒ
ƒ
Reports containing information on subjects (not patient specific) such as types of medical
emergencies, types and amounts of supplies used, call frequency etc. must be retained for:
ƒ Reports containing billing information – 7 years.
ƒ Reports not containing billing information – 1 year.
All records pertaining to controlled substances must be retained for 5 years.
Rescue and Disaster Response Reports and related records, covering specific incidents must be
retained for 3 years.
Course Sponsor:
ƒ
ƒ
Documents containing information on individuals and course files must be retained for 5 years.
Documents containing information on instructors must be retained for 5 years after working
association ends.
Provider Training Records:
ƒ
ƒ
Application for training or certification must be retained for 6 months.
Training and course materials must be retained for 7 years after the course completion.
HIPAA
ƒ
ƒ
All written policies and procedures as required by the Health Insurance Portability and
Accountability Act of 1996 are required to be maintained in writing for at least six years from the
date of its creation, or the date when the document was last in effect, which ever is later.
Section § 164.530(j), states that “written” includes electronic storage. Paper records are not
required.
Conclusion:
EMS agencies should have a policy in place describing their procedures to comply with the retention of all
required records. This policy must describe the length of time each document will be retained.
Additionally, the policy should describe where the documents will be stored, how they will be protected,
and procedures for obtaining a stored record if necessary.
Other regulatory agencies such as the IRS, OSHA / PESH etc., have regulations for document retention.
It is beyond the scope of this document to address every regulation. Therefore, it is incumbent upon each
responsible party to research and maintain compliance with all document regulations.
Resources:
ƒ
New York State Archives:
™
ƒ
™
ƒ
Website: http://www.labor.state.ny.us/
Division of Safety and Health
ƒ http://www.labor.state.ny.us/workerprotection/safetyhealth/DOSH_PESH.shtm
US Department of Labor - OSHA
™
ƒ
Website: http://www.hhs.gov/ocr/hipaa/
Referenced website link: http://www.hhs.gov/ocr/part3.pdf
New York State Department of Labor
™
™
ƒ
http://www.nyhealth.gov/nysdoh/ems/part800.htm
Health Insurance Portability & Accountability Act of 1996 - HIPAA
™
™
ƒ
Website: http://www.archives.nysed.gov/aindex.shtml
10 NYCRR Part 800 State Emergency Medical Services Code
Website for New York offices: http://www.osha.gov/oshdir/ny.html
Internal Revenue Service
™
Website: http://www.irs.gov/
08-03 Records Retention
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supersedes/Updates: New
08 - 02
Date: 03/31/08
Re: Prehospital Patient
Confidentiality
Page 1 of 3
Background:
The New York State Department of Health, in accordance with State and Federal Laws, ensures that all
health care providers protect the confidentiality of those patients for whom they are caring. It is the
responsibility of each EMS provider to maintain the confidentiality of privileged information that they may
have been exposed to in the course of their duties as a health care provider.
All agencies and/or systems are encouraged to have policies that require and include:
1. Initial and as necessary, refresher training of staff regarding the importance of patient confidentiality;
and
2. Procedures for maintaining patient confidentiality.
To better understand what the role of the EMS provider is with reference to patient confidentiality, we
must first define the term. The Encyclopedia of Surgery defines confidentiality as:
“Confidentiality is the right of an individual to have personal, identifiable
medical information kept private. Such information should be available only to
the physician of record and other health care and insurance personnel as
necessary. As of 2003, patient confidentiality was protected by federal
statute.”
Laws and Regulations:
The New York State (NYS) Public Health Law (PHL) Article 30 section 3006 and Title 10NYCRR Part
800.15 require any information that may disclose patient identity to be kept confidential. The Health
Insurance Portability & Accountability Act of 1996, (HIPAA) is a federal law that protects patient
confidentiality and privacy.
PHL Article 30, Section 3006:
§ 3006. Quality Improvement Program.
2. The information required to be collected and maintained, including information from the prehospital
care reporting system which identifies an individual, shall be kept confidential and shall not be released
except to the department or pursuant to section three thousand four-a of this article.
08-02 Patient Confidentiality
Page 1 of 3
3. Notwithstanding any other provisions of law, none of the records, documentation, or committee actions
or records required pursuant to this section shall be subject to disclosure under article six of the public
officers law or article thirty-one of the civil practice law and rules, except as hereinafter provided or as
provided in any other provision of law. No person in attendance at a meeting of any such committee shall
be required to testify as to what transpired there at. The prohibition related to disclosure of testimony shall
not apply to the statements made by any person in attendance at such a meeting who is a party to an
action or proceeding the subject of which was reviewed at the meeting. The prohibition of disclosure of
information from the prehospital care reporting system shall not apply to information which does not
identify a particular ambulance service or individual.
4. Any person who in good faith and without malice provides information to further the purpose of this
section or who, in good faith and without malice, participates on the quality improvement committee shall
not be subject to any action for civil damages or other relief as a result of such activity.
Title 10NYCRR Part 800; section 800.15 REQUIRED CONDUCT:
Every person certified at any level pursuant to these regulations shall:
a) at all times maintain the confidentiality of information about the names, treatment, and conditions of
patients treated except:
(1) a prehospital care report shall be completed for each patient treated when acting as part of an
organized prehospital emergency medical service, and a copy shall be provided to the hospital
receiving the patient and to the authorized agent of the department for use in the State’s quality
assurance program;
(2) to the extent necessary and authorized by the patient or his or her representative in order to
collect insurance payments due;
(3) to the extent otherwise authorized by law;
The Health Insurance Portability & Accountability Act of 2003 (HIPAA):
In April 2003, HIPAA established a set of Federal regulations regarding confidentiality and privacy.
Though, the department does not enforce HIPAA regulations, the law does affect EMS in NYS. It
specifically relates to electronic patient billing and access to a patient’s health records. The NYS
Department of Health has information regarding HIPAA and how it affects NYS PHL. See References.
HIPAA and state laws do not necessarily preclude sharing of patient information among and between
EMS providers and other health care providers, law enforcement, regional and state quality assurance
systems, and other users of public health data. However, in the exchange of such information, EMS
providers and systems are to be vigilant in ensuring the protection of data for the purpose it is being
released.
Summary:
It is beyond the scope of this policy statement to identify all of the laws or regulations that require
confidentiality. This policy statement only identifies the most common items that pertain to the emergency
medical services. Every EMS agency and/or provider must maintain compliance with the patient’s needs
of confidentiality.
All EMS providers and other necessary agency personnel are routinely exposed to confidential patient
information. The Agency and all personnel exposed to confidential information is required to maintain
confidentiality throughout every aspect of emergency medical service operations. It is required in but not
limited to:
•
•
•
training and education;
every patient contact;
communication:
08-02 Patient Confidentiality
Page 2 of 3
•
•
• inter-agency
• intra-agency
• other necessary healthcare providers;
billing;
CQI.
Resources:
EMS services are encouraged to review the HIPAA act and the NYS PHL to determine which law will take
precedence over the other when there are similar topics and how they will affect your service and
procedures. The Department has a chart that breaks down each section and discusses which law will
take precedence. It can be found at
http://www.health.state.ny.us/nysdoh/hipaa/pdf/hipaa_preemption_charts.pdf.
Below are several links for further reference to confidentiality.
Certification – Student Reference Guide
http://www.nyhealth.gov/nysdoh/ems/pdf/srgclinical.pdf
http://www.nyhealth.gov/nysdoh/ems/pdf/srgpart63.pdf
NYS PHL Article 30 Section 3006:
http://www.health.state.ny.us/nysdoh/ems/art30.htm#BM3006
Part 800 section 800.15:
http://www.health.state.ny.us/nysdoh/ems/part800.htm#800.15
NYS Dept. of Health HIPAA advisory links:
http://www.health.state.ny.us/nysdoh/hipaa/hipaa.htm
http://www.health.state.ny.us/nysdoh/hipaa/pdf/hipaa_preemption_charts.pdf
US Dept. of Health and Human Services Office for Civil Rights – HIPAA
http://www.hhs.gov/ocr/hipaa
Surgery Encyclopedia web link:
http://www.surgeryencyclopedia.com/Pa-St/Patient-Confidentiality.html
08-02 Patient Confidentiality
Page 3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
07 - 01
Date: 07/16/07
Re: Service Animals
POLICY STATEMENT
Supercedes/Updates: NEW
Page 1 of 2
This policy is intended to provide information to EMS personnel about the rights of
patients and their service animals as well as several of the laws concerning service
animals under the Americans with Disabilities Act (ADA). This policy will assist
ambulance agencies in understanding the rights of patients who utilize service
dogs/animals, how these animals should be transported and that these animals have
rights under the law that are not granted to domestic pets.
In the United States, the idea of a service dog started with a woman named Dorothy
Harrison Eustis. In the last several decades, the concept of a service dog has
expanded greatly, with dogs helping the hearing-impaired, people who use wheelchairs
and those who have many other kinds of physical challenges. The Americans with
Disabilities Act made the rights of people who use service animals the law.
Definitions of Service Animals
•
The U.S. Department of Justice defines any guide dog, signal dog, or other
animal individually trained to provide assistance to an individual with a disability.
If the animal meets this definition, it is considered a service animal under the
Americans with Disabilities Act (ADA) regardless of whether it has been licensed
or certified by a state or local government.
•
New York State Agriculture and Markets Article 7 section 108 defines the
following:
9. "Guide dog" means any dog that is trained to aid a person who is blind and is
actually used for such purpose, or any dog owned by a recognized guide dog
training center located within the state during the period such dog is being trained
or bred for such purpose.
22. "Service dog" means any dog that has been or is being individually trained
to do work or perform tasks for the benefit of a person with a disability, provided
that the dog is or will be owned by such person or that person's parent, guardian
or other legal representative.
23. "Person with a disability" means any person with a disability as that term is
defined in subdivision twenty-one of section two hundred ninety-two of the
executive law.
Service Animals
Page 1 of 2
Identifying a Service Dog/Animal
Service animals may include dogs of any breed or size as well as other animals
including, but not limited to birds, primates and ponies. The EMS provider may ask the
following types of questions when presented with a service animal:
•
•
“Is this a service dog?” or “Does your animal have legal allowances?”
“Is the service animal required because of a disability?”
The EMS provider may NOT ask about the nature or extent of the patient’s disability
except as it relates to patient care.
Transporting the Patient and the Service Animal
When transporting a patient with a service animal, every effort should be made to do so
in a safe manner for the patient, the animal and the crew members. If possible, the
animal should be secured in some manner in order to prevent injury to either the animal
or the crew during transport. Safe transport devises may include:
•
•
•
•
Crates, cages, specialty carriers.
Seatbelts or passenger restraints using a specialized harness or seat belt
attachments.
In certain situations it may not be possible for the animal to be transported with
the patient. In that case every effort should be made to insure safe care and
transportation of the animal by alternative means (animal control personnel,
family members, etc).
EMS should notify the receiving facility of the presence of a service animal
accompanying the patient.
Additional Information and Resources
Regardless of the purpose of the animal, if the animal is a potential threat to health or
safety of anyone involved in response, the animal may be excluded from transport.
NYS has developed the Empire State Animal Response Team (ESART) and is working
with counties across the state to develop individual County Animal Response Teams
(CART’s) to assist with coordination of evacuation, shelter, and transportation of
household pets and service animals per the state and federal” P.E.T.S. Act of 2006."
The following web site provides additional information about these resources:
http://www.empiresart.com/
The following sites offer resources and Frequently Asked Questions (FAQ’s) with regard
to Service Animals:
http://www.usdoj.gov/crt/ada/archive/qasrvc.htm/
http://www.deltasociety.org/
http://www.aspca.org/site/PageServer
http://www.hsus.org/
http://www.seeingeye.org/
http://www.guidingeyes.org/
Service Animals
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 93-09, 93-10
06- 06
Date: May 26, 2006
Re: EMS Operating
Certificate Application
Process (CON)
Page 1 of 30
INTRODUCTION
This Policy Statement describes the application and consideration process, in
accordance with Article 30 of the New York State Public Health Law (PHL), when
applying for the following:
 A new ambulance or advanced life support first response service
operating certificate,
 A transfer of EMS service ownership,
 An expansion of operating territory, and/or
 A transition from a municipal declaration to permanent operating
certificate at the end of the two year initial operating period.
This policy was written in consultation with the State EMS Council’s Systems
Subcommittee and supported by the State EMS Council (SEMSCO). This
document, along with its appendices, will assist the applicant in insuring that the
application conforms to and contains the information required in the rules and
regulations promulgated pursuant to PHL.
This document, along with its appendices, defines a systematic and logical
approach and establishes a framework for Regional Emergency Medical Service
Councils (REMSCO) to use when processing EMS Service applications in
accordance with PHL.
Article 30 Section 3003 of Public Health Law states:
§ 5. The REMSCO shall have the responsibility to make determinations of public
need for the establishment of additional emergency medical services and
ambulance services and to make the determinations of public need as provided
in section three thousand eight.
06-06 EMS Operating Certificate Application Process
Page 1 of 30
Article 30 Section 3005 of Public Health Law states:
§ 5. No initial certificate (except initial certificates issued pursuant to subdivision
two of this section) shall be issued unless the commissioner finds that the
proposed operator or operators are competent and fit to operate the service and
that the ambulance service or advanced life support first response service is
staffed and equipped in accordance with rules and regulations promulgated
pursuant to this article.
§ 6. No ambulance service or advanced life support first response service shall
begin operation without prior approval of the appropriate REMSCO, or if there is
no appropriate REMSCO established such ambulance service or advanced life
support first response service shall apply for approval from the state council as to
the public need for the establishment of additional ambulance service or
advanced life support first response service, pursuant to section three thousand
eight of this article.
Article 30 Section 3008 of Public Health Law states:
§ 1. Every application for a determination of public need shall be made in writing
to the appropriate REMSCO, shall specify the primary territory within which the
applicant requests to operate, be verified under oath, and shall be in such form
and contain such information as required by the rules and regulations
promulgated pursuant to this article.
§ 2. Notice of the application shall be forwarded by registered or certified mail by
the appropriate REMSCO to the chief executive officers of all general hospitals,
ambulance services, and municipalities operating within the same county or
counties where the service seeks to operate. The notice shall provide opportunity
for comment.
§ 3. Notice pursuant to this section shall be deemed filed with the ambulance
service and municipality upon being mailed by the appropriate regional or state
council by registered or certified mail.
§ 4. The appropriate REMSCO or the state council shall make its determination
of public need within sixty days after receipt of the application.
§ 5. The applicant or any concerned party may appeal the determination of the
appropriate REMSCO to the state council within thirty days after the REMSCO
makes its determination.
06-06 EMS Operating Certificate Application Process
Page 2 of 30
TABLE OF CONTENTS
PAGE
A. Public Need
4
B. The Application
5
C. Regional EMS Council Responsibilities
9
1.
2.
3.
4.
Fitness and Competency
Public Notice
The Public Hearing
Determination of Need
9
10
11
12
D. Issuance of Operating Authority for New EMS Service or
Expansion of Operating Territory
13
E. The Appeal Process
14
F. Transfer of Ownership
16
1.
2.
3.
4.
5.
Allowable Transfer Circumstances
The Application Procedure
Fitness and Competency
The Review and Approval Process
Transferring Operating Authority to Publicly Held Entities
G. Appendices
1.
2.
3.
4.
5.
Guidelines for Establishing EMS Services
Application Work Sheet
Voting Memorandum to the SEMSCO (September 11, 2001)
Process Timeline
Definitions of Terms/Glossary
06-06 EMS Operating Certificate Application Process
16
16
17
18
19
21
21
23
24
27
29
Page 3 of 30
A.
PUBLIC NEED
The State EMS Council and the Department of Health defined public need as:
THE DEMONSTRATED ABSENCE, REDUCED AVAILABILITY
OR AN INADEQUATE LEVEL OF CARE IN AMBULANCE OR
EMERGENCY MEDICAL SERVICE AVAILABLE TO A
GEOGRAPHICAL AREA WHICH IS NOT READILY
CORRECTABLE THROUGH THE REALLOCATION OR
IMPROVEMENT OF EXISTING RESOURCES.
Variables in considering “Public Need”








Geography
Population (size, density, projections)
Level of care (existing, available)
Quality, reliability, and response patterns of existing services
Type of service (emergency, non-emergency)
Special need (i.e. Air, Industrial or Facility)
Service effectiveness, cost, and operation
Other local factors
Each REMSCO shall prepare a statement, which is reviewed annually and is
made available to each applicant that provides regional definitions and or
minimum standards, alone or in combination, for these variables and any other
local criteria that are appropriate to the development and review of an
application.
The REMSCO has an obligation to determine if the issues identified are truly
ones of public need/necessity or, as an alternative, if any improvement in existing
resource allocation or coordination within a specific time frame can resolve the
problem. Inherent in this review is a determination as to why appropriate
measures were not taken by existing providers prior to the submission of a new
application.
Every new EMS service or any service seeking to expand its primary territory
must, by statute, receive the approval of the appropriate REMSCO prior to the
issuance of an operating certificate.
Six distinctive steps are identified in the Article 30 process for determining public
need for a proposed ambulance or ALS-FR service. These steps are:
1.
2.
3.
4.
5.
6.
Application
Public Notice
The Public Hearing
REMSCO Determination
A 30 day appeal period for new, municipal and expansion applications
Certificate of Issuance or Appeal
Each step must be successfully completed in order to move to the next step.
06-06 EMS Operating Certificate Application Process
Page 4 of 30
B.
THE APPLICATION
A completed application for new EMS Service, including a transition from
municipal declaration after two years in operation, Expansion of Primary
Operating Territory or Transfer of Ownership (DOH 3777) must be submitted to
the appropriate REMSCO.
 At least two (2) original 1 applications shall be provided to the REMSCO.
All applications shall be considered complete when submitted on the
prescribed form, be notarized and affirmed, be accompanied by all
required attachments, endorsements, evidence and other supporting and
explanatory material the applicant wishes the REMSCO to consider and
any necessary fees.
 It is the applicant's responsibility to verify that, prior to submission, the
application is properly completed and that all necessary attachments and
fees, if applicable, are submitted in accordance with all policies, rules
and/or regulations.
 The application and narrative shall describe the following:
o
o
o
o
o
o
o
proposed area of service;
vehicles, equipment and supplies;
level of service;
hours of operation;
service location;
dispatch;
Other pertinent operational aspects of the proposed service to allow for a
reasonable and comprehensive review.
 The application shall describe the initial source of funds, the adequacy of
sources of future revenue and shall provide a first year budget for the
proposed service in enough detail to allow a reasonable assessment of
the financial stability of the applicant to provide the proposed service and
the financial feasibility of the proposal.
 All applications shall focus on how the proposed service will meet the
definition of public need. The narrative and endorsements shall respond
to and document issues related to this definition. Statements of want,
desire, feeling or other unsubstantiated sentiments are not
acceptable.
 The complete application is the basis for the demonstration of need. In the
public hearing the applicant may be restricted to corroborating and/or
explaining the data therein.
 The applicant bears the burden of proof for the demonstration of public
need.
1
An original may be a first generation copy in original format with original signatures.
06-06 EMS Operating Certificate Application Process
Page 5 of 30
REQUIRED ATTACHMENTS:
The attachments to the application should include, but not be limited to,
the following items:
1. Detailed narrative to support the demonstration of need, or statement of
purpose and intent for transfer, or expansion.
 The applicant, including municipalities, shall demonstrate sufficient
knowledge of the EMS system in the area to be able to describe the
positive and negative impact the proposed agency shall have on the
area and providers. The applicant shall submit a narrative to be appended
to the application detailing this impact on the following:
1. All existing ambulance and or emergency medical services within the proposed
area in terms of but not limited to:










response time (time the call was received to time on the scene);
staffing;
level of service;
call volume for the past 12 months and the anticipated call
volume for first 12 months of operation;
mutual aid;
quality assurance;
medical direction;
protocols;
ability and quality of existing services, and;
Financial impact, and any adverse impact the proposed
service will have on existing services.
2. The EMS system in the area – Provide a description of the EMS system, all
existing EMS agencies, hospitals and other institutions that generate an EMS
response. Additionally, include participation agreements, mutual aid, and actual and
projected response times for the proposed agency and the existing agencies for the
past and next 12 months. The description must also include communications system
interface, medical direction and control, proposed services impact, positive &
negative on the community, including on patient care and recruitment & retention of
EMS personnel and any possible economies and improvements in service to be
anticipated from the applicants operation.
3. Additionally, municipal EMS services, at the time of transition, may be required to
provide documentation regarding the impact their declaration has had on the existing
EMS community for the first two (2) years of operation.
 The applicant shall demonstrate the ability to meet the definition of public
need within the variables and any other standards defined by the
REMSCO. In addition, the fourteen items of evaluation, found in Appendix
1, shall be addressed in the application, and or any attachments.
 It is the intent of the public application and hearing process to obtain input
from all whom may use, provide, pay for or participate in the EMS system.
Therefore, applicants, including municipal services shall solicit letters of
endorsement from, but not limited to, the following agencies or
06-06 EMS Operating Certificate Application Process
Page 6 of 30
organizations within the proposed service area and those with service
areas or influence areas (i.e. adjacent ambulance primary service areas or
hospitals with bordering patient catchment areas, etc.):





All EMS and ALSFR agencies licensed to provide service in the area, county and
contiguous counties in the region;
EMS Medical Director(s) in the region;
The chairperson of any County EMS organization and county EMS Coordinator;
All hospital CEO's and emergency department directors, and;
The CEOs of all municipalities.
 All letters of solicitation shall include a general description of the new
service, the type and level of service to be provided, the demonstration of
public need, how the proposed service plans to impact public need and a
request for response by a specified date.
 All letters in response to the applicant's solicitation shall be signed by the
CEO of the organization or authorized designee, can be no more than six
(6) months old and shall include an acknowledgement of receipt of the
definition of public need.
 The application shall include a copy or sample of the letter of solicitation, a
list of the agencies/individuals to which it was sent and all responses
received.
 Applicants shall provide copies of the application accepted by the
REMSCO for each member, unless otherwise defined by local REMSCO
policy.
3. Affirmation of Fitness and Competence (DOH 3778)
 The application shall attest to the competency and fitness of the
applicant(s) and/or officers of the corporation. An affirmation of
Competency and Fitness (DOH 3778) shall be provided.
 For the purposes of fitness and competency review, the applicant must
include personal information to include, but not be limited to current
resume/curriculum vitae, home address, and date of birth and social
security number. This information will not be maintained in any files
or be discoverable and will be destroyed once the determination has
been made.
4. Certificate of Incorporation
 The applicant shall include the Certificates of Incorporation, d.b.a’s and
ownership from the issuing government.
 The application must include a complete listing of all shareholders,
principal owners and operators of the EMS service.
06-06 EMS Operating Certificate Application Process
Page 7 of 30
5. Financial Information
 The application shall describe the initial source of funds, the adequacy of
sources of future revenue and shall provide a first year budget for the
proposed service in enough detail to allow a reasonable assessment of
the financial stability of the applicant to provide the proposed service and
the financial feasibility of the proposal.
 The applicant shall provide taxpayer federal identification number issued
to the organization.
6. Primary Operating Territory Map
 The applicant shall include a written description of the desired territory
described within geo-political boundaries.
 A detailed map of the primary operating area.
7. Fees
 The REMSCO may establish a uniform and non-waivable fee to be
received with each application that reflects the direct and real costs of
the application review, the process of public notice and the hearing. The
fee shall be reviewed and re-approved annually by the REMSCO and be
made available at the official place of business. The fee must accompany
the completed application when submitted to the REMSCO. Within sixty
(60) days of the determination, the REMSCO shall provide the applicant
with a detailed expenditure report.
8. Application Worksheet
 Attached as Appendix 2, is an Application for Public Need Work Sheet.
This Work Sheet is intended to assist the applicant and the REMSCO in
completing the application process.
9. Submission of the Application
 Once the application and required attachments have been completed, the
completed package must be delivered to the REMSCO at their official
business address, by certified mail or personal service.
06-06 EMS Operating Certificate Application Process
Page 8 of 30
C.
REMSCO RESPONSIBILITY
Upon receipt, the application shall be reviewed for completeness by the
designated REMSCO sub-committee or program staff.
 The application shall be accepted if it is deemed to be complete in
accordance with these policies. The acceptance date must be
documented in the shaded section on the second page of the application
form (DOH-3777).
 When determined to be complete by the REMSCO, the time frame for
processing established by Article 30, 3008 begins.
 If found to be incomplete, it shall be returned by certified mail or personal
service to the applicant within ten (10) business days with a written
explanation of the grounds for the rejection.
 If requested, the applicant shall provide copies of the accepted application
and attachments for each REMSCO member.
 The designated REMSCO shall begin action immediately upon receipt and
acceptance of a complete application. This action shall include the
following:
1. scheduling a hearing date;
2. send public notice, and;
3. establish a REMSCO meeting date at which a determination will be made so as
to comply with the 60-day time limit established in PHL. Appendix 4 delineates
the time line that is to be followed in order to comply with Public Health Law,
Section 3008.
1. Fitness and Competency
One responsibility of the application process is to insure a high quality of
ownership and management of an ambulance or ALS-FR service to the degree
of attempting to identify any issues of character that would be detrimental to this
highly personal service. With this as a purpose, the REMSCO shall address
issues relative to the competency and fitness of the applicant and/or officers of
the corporation as prescribed in PHL 3005(5).
The REMSCO may request the Department to conduct the detailed review. The
review shall include multiple factors such as the individual or group of individuals
standing in the community, an evaluation of the applicants prior record as an
ambulance service operator or health care provider, and if applicable, a
statement of experience in the industry, or related industries. The REMSCO may
augment the fitness and competency review, however it must have a
documented process.
The review will also include an evaluation of past history, including computer
searches of legal filings and judgements, business ownership as well as any
convictions for a crime or crimes involving moral turpitude including, but not
06-06 EMS Operating Certificate Application Process
Page 9 of 30
limited to, murder, manslaughter, assault, sexual abuse, theft, robbery, drug
abuse, the sale of drugs or fraud. The fitness and competency review will also
include an applicant’s history with both Medicaid and Medicare programs.
In addition to original applications and municipal applications, a fitness and
competency (F&C) determination must be made by the REMSCO for all transfers
of ownership.
The applicant shall submit a completed Affirmation of Fitness and Competency
(DOH 3778) for each principal owner and/or operator. The REMSCO or upon
request, the Department shall conduct a review of the applicant's fitness and
competency in accordance with the provisions of PHL Section 3005. A current
resume for each principal owner and/or operator must be attached for each
affirmation submitted.
2. Public Notice
 The REMSCO shall establish a date, time and location for a public
hearing(s) to review the application and receive all comments.
 The hearing(s) shall be held within 30 calendar days of accepting a
complete application and the notice shall be postmarked at least 14
calendar days prior to the hearing date.
 The hearing(s) shall be established at a time and place(s) logical to the
application, preferably in the county or central to the proposed service
area. Considerations for public access must be included.
 More than one public hearing may be held if it is in the best interest of the
application and so long as the same application and information is
presented by the applicant at each hearing and they are held within the
appropriate time frames.
 One public hearing can be held to serve the needs of several REMSCOs,
if it is in the best interest of each REMSCO and applicant.
 Letters of notice shall be sent in accordance with PHL 3008, by certified
mail to:
"The chief executive officers of all general hospitals,
ambulance services, and municipalities operating
within the same county or counties where the service
seeks to operate...”
 Hospitals adjoining the proposed service area and ambulance agencies
with adjoining primary service areas and the local health systems agency
shall also be included in the notice.
06-06 EMS Operating Certificate Application Process
Page 10 of 30
 The letter of notice shall include the date, time and location of the hearing
session, the definition of public need, a solicitation of response to the
application by a specific date and provide a mechanism for any interested
party to obtain and/or review the application.
 The REMSCO shall maintain a copy of the letter of notice, a list of
recipients, and all postal receipts until final disposition of the application is
made.
 The information contained in the letter of notice shall be published in the
newspaper designated by the REMSCO to receive legal notices. As
necessary this shall include newspapers designated by the REMSCO.
3. The Public Hearing
 The REMSCO shall establish a committee to hear each application. The
Committee will usually consist of five members. Normally one member
shall be from the county or area the applicant proposes to serve, and one
member shall represent the majority of the ambulance constituency in the
proposed service area.
 The REMSCO must use a hearing officer designated by the REMSCO and
charged with finding fact and preparing a report for the REMSCO.
REMSCOs can utilize individuals who are authorized by various state
agencies (DEC, State, etc.) to act as hearing officers or other individuals
with similar training and experience. Ideally, a hearing officer should be
familiar with Public Health Law and the administrative hearing process.
The hearing officer will moderate and insure the hearing process follows
generally accepted procedures.
 The purpose of the hearing is to provide a technical review and objective
evaluation of the applicant's statement of need as well as any other
testimony presented.
 The committee may hear witnesses, receive written statements, ask
questions and accept testimony in any form that will lend credibility to the
hearing and the ultimate determination.
 The REMSCO shall complete and maintain a record of the proceedings of
any and all hearings. This shall be in stenographic or tape form. The
record must be transcribed and considered along with all other evidence in
making the determination, especially pertinent are all discussions relating
to public need.
 A written summary of the hearing shall be prepared that includes a finding
of fact and a recommendation to support or deny the motion to approve
the application and detailed justification for the recommendation made.
Any other pertinent findings for presentation to the REMSCO must also be
included. If a hearing officer's report is the principle process, the
06-06 EMS Operating Certificate Application Process
Page 11 of 30
committee should review the report and prepare the recommendation for
the REMSCO following a similar outline. It is recommended that the
committee meet at a time other than immediately prior to the REMSCO
meeting for its deliberations.
4. Determination of Need
 At the designated REMSCO meeting, the chairperson of the hearing
committee shall present the application, committee report, including the
summary, any technical review, finding of fact and a specific
recommendation.
 The recommendation of the hearing committee comes to the floor of the
REMSCO as a seconded motion for debate.
 Opportunity shall be provided for REMSCO members present to make
inquiry and ask questions prior to making a determination. As the
application and the public hearing (s) constitute the appropriate
forum to introduce/provide new information, this is not an
opportunity for REMSCO members or non-REMSCO members to
introduce/provide new information.
 The REMSCO may place binding contingencies on the approval of an
application as long as the conditions are in the best interest of the EMS
system and are not in conflict with any State law or regulation. The
applicant may amend the application so long as it is occurs prior to the
public hearing.
 Each REMSCO may establish a policy within the framework mandated by
NYS Ethics Rules and established by the State EMS Council regarding
members abstaining from voting in cases of conflict of interest.
This policy shall address members who have a pecuniary (financial)
interest in a competing service and those who serve as an officer in an
organization deemed to be in direct competition with the applicant.
 Each REMSCO has the obligation to discuss and record in the record, all
pertinent points and issues of the application relating to need, the
definition of public need, and specific reasons and rationale for and
against the application based on the application, evidence presented and
testimony from the public hearing.
 It is proper format for a motion to approve the application. The motion is
supported by a recommendation from the committee for or against the
application and shall contain rationale and justification, positive and
negative, for the recommendation presented.
 The REMSCO shall make its determination by a roll call ballot of the
members present to accept or reject the recommendation of the
06-06 EMS Operating Certificate Application Process
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committee. The motion must be made in the form of an approval of the
application. Based on the Department’s Bureau of House Counsel opinion
(Appendix 3), in order to make a determination, it must be passed by not
less than a majority of the entire members authorized to vote, not those
members present for the meeting.
 A statement shall be entered into the stenographic record that clearly
defines the authority of alternates to vote in the procedure and a
statement of the needed majority to pass the motion. A written record of
the roll call vote shall list all voting members of the REMSCO and include
at least the following information:




D.
Member name, affiliation and status as member or alternate;
Present or absent for ballot;
Voting for, against or abstaining;
Declarations and/or decisions of conflict of interest;
ISSUANCE OF OPERATING AUTHORITY
 The REMSCO shall provide written notice of its determination to the
applicant within seven (7) business days by receipted mail or delivery
method.
 The REMSCO shall provide to the Department with written notice of the
determination within seven (7) business days by receipted mail or delivery
method. Notice shall include:




An original copy of the complete, accepted application and attachments;
A written copy of the seconded motion to approve the application on which
the REMSCO vote is based;
Documentation of the roll call vote;
A copy of the document or checklist the REMSCO used to determined the
application to be complete.
 If the REMSCO(s) determination is to grant operating authority, and no
notice of appeal is filed within the 30 business days, the Department's
Regional EMS representative shall obtain additional required paperwork,
and conduct any necessary inspections.
 The Department will issue the EMS Operating Certificate.
 The REMSCO must retain all documentation and stenographic minutes in
the event of an appeal to the determination.
E. THE APPEAL PROCESS
The applicant or any other party directly involved has the right to appeal by filing
notice with the Executive Secretary of the State EMS Council at the Department.
This notice must be received by the Department, using receipted delivery,
within thirty (30) calendar days of the date of the REMSCO's determination.
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 After the REMSCO’s determination a notice of appeal may be filed within
the 30 days. The Department shall not issue the EMS operating
certificate. This shall stand until the conclusion of all appeal processes.
 In the event of an appeal the Department shall request the assignment of
an Administrative Law Judge (ALJ) to hear the appeal and make a finding
of fact and recommendation to the State EMS Council.
 SEMSCO meetings and considerations of service application appeals are
not de novo (consideration of new material or information) hearings of the
application, therefore discussion will be limited to State EMS Council
members and the record.
 The State EMS Council's Systems Committee shall review any appeal and
the recommendation of the ALJ and shall make a recommendation to the
State EMS Council. The complete application and pertinent record and the
ALJs report shall be provided to the Council prior to their consideration of
the appeal and a decision in accordance with PHL 3002(3).
 The SEMSCO meeting notice will serve to provide a date by which any
opposition to the application from certificate holders in the territory to be
served or any receiving hospital or municipality for the proposed service
must be declared.
 If no opposition is heard/received, the SEMSCO may make a
determination following an open discussion period at the next scheduled
meeting.
 If significant opposition is received, as determined by council
reviewers/staff, a public hearing should be scheduled at least two (2)
weeks prior to the scheduled SEMSCO meeting.
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F.
TRANSFER OF EMS SERVICE OPERATING AUTHORITY
Article 30, Section 3010 permits EMS services to transfer operating authority to a
new owner(s) or operator(s) following a review of the competency and fitness of
the new operator and with the approval of the appropriate REMSCO(s) and the
Department.
This approval process assumes that the original holder of certificate has been in
continuous operation and will surrender all rights to operate an EMS service
under this certificate without application and approval of the appropriate
REMSCO.
1. Allowable Transfer Circumstances
Transfers of operating authority are allowable in the following circumstances with
approval of the appropriate REMSCO and the Department:
a) Any change in the individual who is the sole proprietor (3010.2(a));
b) Any change that results in adding new partners (3010.2(b));
c) Any transfer, assignment or other disposition of ten percent (10%) or more of a
corporation's stock (3010.2(c));
d) Any transfer of all or substantially all of the assets of a corporation to a new
corporation or owner (3010.2(d));
e) A municipality that has transitioned to a permanent operating authority.
Examples: the change in an operator without changing the territory of a sole
proprietor, a sole proprietor incorporating for the first time or a fire department
service and assets being assumed by a volunteer ambulance corp.
2. The Application Procedure
The applicant shall submit to the appropriate REMSCO at least two (2) original
versions of the application, including fees as appropriate and the number of
copies as requested by the REMSCO of the following documents:
 A completed Application for New EMS Service, Expansion of Primary
Territory or Transfer of Ownership (DOH 3777).
 Completed, notarized and sworn Affirmation of Competency and Fitness
(DOH 3778) and a current resume for each proposed owner and/or operator
(example: CEO, managing partner, executive board member, operations
manager). A statement of purpose and intent, signed by both parties that
explains in common terms what is being proposed and including the end
effect on both individuals, partnerships or corporations.
 A complete resume for the new owner(s)/operator(s) that includes all health
related licenses, social security number (which will be kept confidential) and a
history of all employment and/or activities in any regulated health care facility
or activity for the past 10 years.
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 A list and/or copy of orders or deficiency notices issued within the past 10
years from any NYS Department or equivalent out of state agency listed that
have deficiencies identified (singular or repetitive) that did or could have
caused patient harm or were repetitive and uncorrected.
 A list of any malpractice actions within the past 10 years that relate to patient
care or harm and the outcome of each.
 A copy of any stock sale and/or transfer agreement or other contract or legal
agreement.
 A listing of all capital, property, plant, equipment, receivables and stock
owned by the certificate holder or involved in the transfer. Note: Disclosure of
the financial values of each is not required.
 A complete listing of the final owner(s).
3. Fitness and Competency
One responsibility of the application process is to insure a high quality of
ownership and management of an ambulance service to the degree of attempting
to identify any issues of character that would be detrimental to this highly
personal service. With this as a purpose, the REMSCO shall address issues
relative to the competency and fitness of the applicant and/or officers of the
corporation as prescribed in PHL 3005(5).
The REMSCO may request the Department to conduct the detailed review. The
review will include an evaluation of past history, including computer searches of
public documents including legal filings and judgements and business ownership.
Additionally any charges or convictions for a crime or crimes involving moral
turpitude including, but not limited to, murder, manslaughter, assault, sexual
abuse, theft, robbery, drug abuse, the sale of drugs or fraud are considered. The
fitness and competency review will also include an applicant’s history with both
Medicaid and Medicare programs.
In addition to original applications and municipal transition, a fitness and
competency (F&C) determination must be made by the REMSCO for all transfers
of ownership.
The applicant shall submit a completed Affirmation of Fitness and Competency
(DOH 3778). The REMSCO shall conduct a review of the applicant's fitness and
competency in accordance with the provisions of PHL Section 3005. A current
resume for each applicant/owner/operator must be attached for each affirmation
submitted.
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4. Review and Approval Process
 REMSCO receives the application and insures that all requirements are met
and that all documents are complete. REMSCO contacts the applicant to
acknowledge receipt, obtain any missing items, clarify any information and
inform the applicant when the application is complete and the date the
application will be considered.
 If the new owner meets any of the criteria stated in 3005(8), REMSCO
contacts the DOH Central Office for review of any history of patient harm or
uncorrected deficiencies in any regulated facility specified in the statute. If the
new owner(s) has no involvement in a specified area, such will be noted to
the REMSCO.
 REMSCO staff will forward a copy of the application and affirmations to the
DOH Central Office within five (5) working days of the application being
deemed complete. The DOH and REMSCO staff may jointly develop the
information required to determine if a new operator has provided a
consistently high level of care and therefore is competent to operate the
service. Since approval of both the REMSCO and Department are required,
joint development of all required information is essential to expedite the
process.
 A new operator may not be found to be competent if there have been
multiple, repeated or uncorrected violations of the State EMS Code or other
applicable rules and regulations that have directly threatened the health,
safety or welfare of a patient.
 Definitions for substantially consistent high level of care will be developed and
codified by the State EMS Council. In the absence of these regulations, an
operator cannot be found to have provided this level of care if the/any
Department has/had instituted license revocation proceedings for a service
the operator was a principle in within the last 10 years.
 The REMSCO and the Department have an obligation to act expediently to
review and act on an application to prevent unnecessary hardship to
individuals or corporations. The REMSCO shall render a decision at its next
scheduled meeting or no later than sixty (60) days following receipt of a
complete application and all fitness and competency review information. The
Department will make every effort to have their information available to the
REMSCO at least two (2) weeks prior to the scheduled REMSCO meeting.
 There are NO mailing, notice, hearing or time requirements imposed by the
statute. If a REMSCO sub-committee review is conducted, the committee
shall focus on reviewing fitness and competency only. There is no intent for a
hearing and a committee review to delay the process.
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 The REMSCO meeting is an open meeting and the vote for the review of
fitness and competency shall be conducted by roll call vote, using the
definition of majority from the REMSCO's by-laws.
 The REMSCO shall forward to the Department within seven (7) business
days, one complete original application and competency affirmation and the
written REMSCO decision. A complete record of the proceedings will be
maintained including the meeting's minutes and a record of the roll call vote
and any committee recommendations and vote record. The REMSCO needs
to include a detailed rationale and explanation for any negative decision.
 The Department will review the application and REMSCO decision and within
ten (10) business days of receiving the decision, confirm or deny the
REMSCO decision and notify the applicant and REMSCO accordingly.
 Approval of the application, receipt of final transaction closures and the
transfer of operating authority will be granted only upon approval of both the
REMSCO and the Department.
 Following approval of both the REMSCO and the Department an application
for EMS Operating Certificate will be completed and a site inspection
scheduled with the appropriate DOH Area Office.
5. Transferring Operating Authority to Publicly Held Entities
This section defines additional requirements needed to transfer the operating
authority of an EMS service where the new owner/operator will be a publicly
traded corporation, typically with ownership widely distributed among numerous
and constantly changing stockholders.
I.
The requirements for fitness and competency reviews will apply to:
 The Corporate entity and any parent or health related subsidiaries;
 Any/All Directors of the Corporation;
 Any/All Officers of the Corporation, and/or;
 Any/All stockholder(s) holding ten (10) or more percent of the stock of the corporate
applicant as of the filing date of the application to transfer.
The review will include any operations in other states where the service is
licensed to conduct EMS or health care related business
II.
The Application to transfer EMS Service Operating Authority shall include,
but not be limited to:
 A photocopy of the executed existing or proposed applicable corporate certificate
which shall, in all respects conform to the applicable provisions of the New York
Business law.’
 If the applicant is a foreign corporation, it shall include a photocopy of the executed
existing or proposed Application for Authority to do business in NY as a Foreign
Corporation, which in all respects conforms to the requirements for filing with the NY
Secretary of State.
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III.
The proposed new owner/operator agrees to:
 Identify and maintain current a principal location of the business within the state;
 Provide the name of the individual empowered to conduct business;
 Implement NYS DOH statutes, rules & regulations and policies relating to the
conduct of its EMS business in the state;
 Empower the individual to make routine decisions on behalf of the owner/operator
with regard to the conduct of its EMS business.
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Appendix 1 1
GUIDELINES FOR ESTABLISHING AMBULANCE SERVICES
Excerpt from EMS Management: Beyond the Street, 2ed
Joseph J. Fitch, © 1993
Many states have specific guidelines that they use to evaluate ambulanceservice license applications. Although some states license the service to operate
in any part of the state, others require separate authorization for each specific
service area. The following information was adapted from regulations, which
guide Missouri's Department of Health in granting ambulance licenses. EMS
managers throughout the nation should find this information helpful in
considering the viability of any new service area.
When considering a request for licensure of an ambulance service, the Missouri
Bureau of Emergency Medical Services employs the following 14-factor analysis
in making the difficult decision on whether or not a new service should be
licensed. Typically, a convenience and necessity hearing is held to evaluate the
14 criteria. Following the hearing, and upon further review, a formal
determination is made on the need for the service.
1.
What is the population of the jurisdiction requesting the ambulance
service, including tourism and traffic flow through the area? Does the area
have a large enough population base to support a new ambulance
service?
2.
How many calls for service and how many emergency calls are made in
the proposed area? What is the average daily rate of calls for this area?
Would the area have a large enough demand to maintain a full-time
service?
3.
What is the average response time for all calls and emergency calls during
a recent time period? Is the average response time reasonably prompt or
under response-time specifications?
4.
What is the quality of existing services and how do the present conditions
affect public convenience? Do the nearby ambulance services adequately
cover the emergency medical needs of the area? Would a newly licensed
ambulance service be an improvement to public convenience?
5.
Do mutual-aid ambulance agreements exist among the area under
consideration and the nearby ambulance, police, and fire units? Are these
agreements necessary for adequate coverage of this particular area?
6.
Would the employees of the proposed ambulance service have a sufficient
level of clinical experience for maintaining emergency care?
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7.
Would opportunities exist for personnel to maintain their level of skill? If
an additional ambulance service were added, would the dilution of service
calls between the ambulance services cause decay in skills due to
inactivity?
8.
Are the existing communications capabilities adequate for maintaining
medical control and directing paramedics? Would the proposed facilities
by an improvement?
9.
How will the ambulance service be financed? Are the financial resources
available to the proposed ambulance service sufficient for maintaining a
full-time service?
10.
How will the ambulance service be organized and administered? Does
management seem willing to support an ambulance service and is
management capable of performing its duties?
11.
What will be the total cost of the new ambulance service? Are the benefits
that the proposed area would receive worth the expense?
12.
Does public opinion in the proposed area favor the establishment of a new
ambulance service?
13.
Do the local government planning agencies favor establishment of a new
ambulance service?
14.
Are there any viable alternatives other than licensing a new ambulance
service? For example, in some cases volunteer EMTs or fire fighters can
respond in a non-licensed vehicle and call in an existing service for
transport.
Before embarking on a program of licensure, an EMS leader should review the
above questions and then objectively decide if there's a legitimate need for an
ambulance service in the area.
1
Excerpt taken from EMS Management: Beyond The Street, 2ed; written by
Joseph J. Fitch, © 1993 by JEMS Publishing Co., Inc.
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APPENDIX 2
APPLICATION FOR PUBLIC NEED WORK SHEET
To be completed and a made part of the record.
1. Required DOH Applications
YES
NO
DOH Form 3777, Application for New EMS Service, Expansion
of Primary Operating Territory or Transfer of Ownership,
completed and notarized.
DOH Form 3778, Affirmation of Fitness and Competency,
competed and notarized for each person identified as an officer,
director holder of greater than 10% of companies stock.
2. Narrative which includes the following operational aspects of the proposed
service:
YES
NO
Proposed Area of Service
Proposed level of care of the service
Proposed hours of operation
Proposed physical location(s) of the service
Proposed number of employees/members.
Number of ambulances/ALS FR vehicles.
3. The applicant has included financial information including:
YES
NO
Source of initial funds
First/next year’s proposed operating budget.
Proof of adequacy of funding sources/future revenue.
Documentation to support that the applicant has financial resources
capable of support proposed service/expansion.
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4. The narrative shall include documentation of the positive and negative impact
of the proposed new/expanded service to include (but not be limited to):
Impact on all existing ambulance/EMS relating to:
YES
NO
Response times
Staffing
Level of service
Call volume of last 12 month/proposed first 12 months of operation
Mutual Aid
Medical direction
Quality assurance
Financial impact on any existing service(s)
Any adverse impact the proposed service will have on any existing
service(s).
Prehospital care protocols
5. Narrative addendum of the application lists all segments of the EMS system
in the proposed new/expanded operating territory including:
YES
NO
All existing EMS agencies
All hospitals and other institutions generating calls (nursing homes,
adult homes, centers for independent living, community residences
for the disabled. etc)
Any/ all mutual aid agreements
Actual & projected response times for past and next 12 months
Communications system and the impact additional/expanded
service will have on the existing communications system.
Medical direction/control of system and impact additional/expanded
service will have on existing system.
Any anticipated improvements the new/expanded service intends to
make in the communications system if approved.
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6. The applicant shall include copies of letters showing they have advised
various entities of their proposal and solicit letters of support.
The letters sent by the applicant must:
YES
NO
Include a definition of public need
Include a general description of the new/expanded service.
Include the type and level of service proposed.
Request a response by a specific date and that the request be
signed by the CEO of the entity.
Letters received back in support or opposition are not more than six
months old.
7. Applicant documents letters have been sent to:
YES
NO
All Ambulance and Advanced Life First Response services within
proposed operating territory.
All EMS Medical Directors in Region
The Chairperson(s) of any county(ies) EMS organization(s)
County EMS coordinator(s)
All Hospital CEOs
All Hospital Emergency Department Directors
The CEOs of all municipalities
All ambulance services in areas adjacent to the proposed operating
territory
All hospitals in areas adjacent to the proposed operating territory
The applicant submitted proof of receipt by entity letter was sent to
(copies of registered mail receipts signed by agency letter was sent
to)
8. Required Fees
YES
NO
Applicant has submitted required REMSCO application fee.
06-06 EMS Operating Certificate Application Process
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9. Application Deemed Complete:
YES
NO
DATE
Regional Council/Program Agency Staff
Transportation/Ambulance Committee
Full Regional EMS Council
Provide Written Notification to Applicant
indicating Complete Submission
10. Dates of Action:
YES
NO
DATE
Request for F&C review from DOH
Received results of F&C review from DOH
Public Hearing Officer Assigned
Public Hearing Scheduled
Transportation/Ambulance Committee/
REMSCO Meeting
Copy of Complete Application and
Determination sent to DOH
11. Regional Council Decisions:
Agree Deny
DATE
Transportation/Ambulance Committee
Public Hearing Officer
REMSCO Determination
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06-06 EMS Operating Certificate Application
Process 5
APPENDIX
Page 28 of 30
DEFINITION OF TERMS/GLOSSARY
Advanced life support first response service: "Advanced life support first responder (ALSFR)
service" means any person or organization that provides advanced life support care, but does not
transport patients.
Ambulance Service: "Ambulance service" means an individual, partnership, association,
corporation, municipality or any legal or public entity or subdivision thereof engaged in providing
emergency medical care and the transportation of sick or injured persons by motor vehicle,
aircraft or other forms of transportation to, from, or between general hospitals or other health care
facilities.
Article 30: Is the New York State Public Health Law that specifically addresses the Emergency
Medical Services (EMS) and pre-hospital care. It is the purpose of this article to promote the
public health, safety and welfare by providing for certification of all advanced life support first
response services and ambulance services; the creation of regional emergency medical services
REMSCOs; and a New York state emergency medical services REMSCO to develop minimum
training standards for certified first responders, emergency medical technicians and advanced
emergency medical technicians and minimum equipment and communication standards for
advanced life support first response services and ambulance services.
De Novo: Anew, afresh. Considering the matter anew, the same as if it had not been heard
before and as if no decision previously had been rendered
The Department: Department means the New York State Department of Health, Bureau of
Emergency Medical Services (BEMS).
Primary Operating Territory: "Primary operating territory" means the geographic area or
subdivisions listed on an EMS certificate or within which the EMS service may receive patients for
transport.
Part 800: Part 800 is the section of Title 10 of the New York State Codes, Rules and Regulations
(10NYCRR) that pertain to EMS systems, services, providers, course sponsors and vehicle
requirements. This Chapter is known and may be cited as the State Emergency Medical
Services Code.
Public Need: Public Need means the demonstrated absence, reduced availability or an
inadequate level of care in ambulance or emergency medical service available to a geographical
area which is not readily correctable through the reallocation or improvement of existing
resources.
Regional Emergency Medical Services Council: Regional Emergency Medical Services
Council (REMSCO) means a regional emergency medical services council established pursuant
to section 3003 of article 30 of the Public Health Law.
Fitness and Competence: fit means that the operator or proposed operator (a) has not been
convicted of a crime or pleaded nolo contendere to a felony charge involving murder,
manslaughter, assault, sexual abuse, theft, robbery, fraud, embezzlement, drug abuse, or sale of
drugs and (b) is not or was not subject to a state or federal administrative order relating to fraud
or embezzlement, unless the commissioner finds that such conviction or such order does not
demonstrate a present risk or danger to patients or the public… competent means that any
proposed operator of any ambulance service or advanced life support first response service who
is already or had been within the last ten years an incorporator, director, sponsor, principal
stockholder, or operator of any ambulance service…
Municipal Operating Authority: …any municipality… or fire district acting on behalf of any such
municipality, and acting through its local legislative body, … authorized and empowered to adopt
06-06 EMS Operating Certificate Application Process
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and amend local laws, ordinances or resolutions to establish and operate advanced life support
first responder services or municipal ambulance services within the municipality, upon meeting or
exceeding all standards set by the department for appropriate training, staffing and equipment,
and upon filing with the New York State Emergency Medical Services Council, a written request
for such authorization.
06-06 EMS Operating Certificate Application Process
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No.
06 - 05
Date: June 5, 2006
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re:
National
Incident Management
System (NIMS)
Supercedes/Updates: New
Page 1
of 4
The National Incident Management System – NIMS
Introduction:
Under Homeland Security Presidential Directive #5 (February 2003), the Federal government has created
the National Incident Management System (NIMS). This system directs the creation of a comprehensive,
national approach to incident management by federal, state, territorial, Tribal and local responders. The
Presidential Directive also makes NIMS compliance a requirement for any of these entities wishing to
receive Federal funds starting with Federal fiscal year 2007.
Federal and State response agencies and any agencies receiving Federal monies, have been given
compliance guidance and are working towards educating and training their respective organizations in
becoming NIMS compliant. The Federal government has expanded the definitions of "first responder"
agencies beyond the traditional Fire, HAZMAT, Police, EMS to include public works, public health,
emergency communications, emergency management, and other agencies involved in disaster
preparedness, prevention, response and recovery activities.
This integrated system establishes a uniform set of processes, protocols, and procedures that all
emergency responders, at every level of government will use to conduct response actions.
There are six (6) components included in NIMS:
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Command and Management
Preparedness
Resource Management
Communications and Information Management
Supporting Technologies
Ongoing Management and Maintenance
Additionally, NIMS identifies a variety of Federal Preparedness programs that are available to
responders.
This policy will review the components of NIMS and some of the available guidance and requirements. It
also provides a list of resources that should be checked frequently for updated information.
06-05 NIMS
Page 1 of 4
Background:
New York State (NYS) Perspective
On March 5, 1996, Governor George Pataki signed Executive Order No. 26 establishing the National
Incident Management System (NIMS) - Incident Command System (ICS) as the State standard command
and control system that will be utilized during emergency operations. Since that time, NYS agencies have
used ICS in every response or pre-planned event operation and have trained tens of thousands of
individuals in the Incident Command System.
State response agencies have been advised that the following training requirements will need to be
completed by the basic responder:
IS 700
ICS 100
ICS 200
Effects on New York State’s EMS System:
All future preparedness grants and funding will be contingent upon NIMS compliance by the end of fiscal
year 06. Additionally, any first response agency that is independent and not part of a municipality, yet
receives funding from a municipality that is mandated to be compliant, must also be compliant. For more
information: www.fema.gov/nims/
HSPD-5 Requirements for Local governments in order to be in compliance with NIMS by September 30,
2006 include:
ƒ Institutionalizing the use of the Incident Command System (ICS). (Encourage adoption of local
resolutions that require ICS for incident management);
ƒ Formally recognizing the NIMS and adopting NIMS principals and policies. (Local resolution);
ƒ Establishing a NIMS baseline by determining which NIMS requirements are already met using the
NIMS Capability Assessment Support Tool. (NIMCAST); and
ƒ Establishing a timeframe and developing a strategy for full NIMS implementation using the NIMS
Implementation Template.
TRAINING REQUIREMENTS:
ƒ Complete the NIMS Awareness Course "IS-700 National Incident Management System (NIMS), An
Introduction." (All entry level First Responders and disaster workers);
ƒ Complete ICS 100: Introduction to ICS. (All entry level First Responders and disaster workers);
ƒ Complete ICS 200: Basic ICS. (All personnel listed above plus single resource leaders, first line
supervisors, field supervisors and other emergency management/response personnel that require a
higher level of ICS/NIMS Training);
ƒ Complete the National Response Plan Course IS-800 NRP: An Introduction. (All personnel listed
above plus middle management including strike team leaders, task force leaders, unit leaders,
division/group supervisors, branch directors and multi-agency coordination system/emergency
operations center staff);
ƒ Complete ICS 300: Intermediate ICS. (All personnel listed above plus middle management including
strike team leaders, task force leaders, unit leaders, division/group supervisors, branch directors and
multi-agency coordination system/emergency operations center staff); and
ƒ Complete ICS 400: Advanced ICS. (All personnel listed above plus Command and general staff,
select department heads with multi-agency coordination system responsibilities, area commanders,
emergency managers and multi-agency coordination system/emergency operations center
managers).
06-05 NIMS
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Training Resources:
The IS-700, IS-800, ICS-100 and ICS200 are all available as self study courses on-line. Additionally, the
ICS-200, ICS-300 and ICS-400 are available at various times throughout New York State. Contact your
county Emergency Manager or check the training calendar on the SEMO website,
http://www.nysemo.state.ny.us, for course dates and locations. Please routinely check this calendar as it is
frequently updated.
Steps to NIMS Compliance:
1. Adopt NIMS through executive order, proclamation, resolution, policy statement or legislation as the
jurisdiction’s official all-hazards, incident response system;
2. Manage all incidents and preplanned events using the Incident Command System;
3. Conduct a demo of the National Incident Management System Capability Assessment Tool
(NIMCAST): http://www.fema.gov/nimcast/index.jsp;
4. Begin the process of identifying individuals who will take the required training;
5. Have appropriate employees, (defined above), take the training’s IS-700, IS-800, ICS-100, ICS-200,
ICS-300 (FFY07) and ICS-400 (FFY07): http://www.security.state.ny.us/training/index.html;
6. Start to identify plans and procedures that require updating to include NIMS and determine who will
be responsible to update them;
7. Have the individual(s) that were identified in bullet 6 above begin to make the necessary adjustments;
8. Ensure exercise programs include NIMS principles;
9. Inventory assets using Resource typing;
http://www.fema.gov/pdf/emergency/nims/508-3_emergency_medica_%20services_%20resources.pdf
10. Coordinate and support emergency incident and planned event management through the
development and use of integrated Multi-Agency Coordination Systems – (develop and maintain
communications between local Incident Command Posts (ICPs), local 911 centers, local Emergency
Operating Centers (EOCs) and the state EOC); and
11. Implement processes, procedures and plans to communicate timely, accurate information to the
public during an incident using a Joint Information System and Joint Information Center.
Summary:
NIMS is still an evolving plan and process. This policy is intended to introduce NIMS and list basic
requirements. It is not all inclusive, nor will it be capable of always being a complete document. Agencies
and Municipalities are strongly encouraged to use the additional resources and review updates, as they
are available.
06-05 NIMS
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Additional Resources
1.
Training:
http://www.security.state.ny.us/training/nims_documents.html
http://www.security.state.ny.us/training/training_calendar.html
http://www.nysemo.state.ny.us/training/semotraining.asp
http://training.fema.gov/EMIWeb/
http://training.fema.gov/emiweb/ntc/
2.
NYS Office of Homeland Security NIMS Information Center:
http://www.security.state.ny.us/training/nims_documents.html
http://www.security.state.ny.us/training/training_calendar.html
ƒ
NYS Point of Contact
ƒ
NYS Office of Homeland Security NIMS Information Coordinator (NIC)
Training Guidance:
ƒ
Telephone: (866) 837-9133
Email questions: [email protected]
3.
NYS Emergency Management Office (SEMO):
ƒ
SEMO Training Guidance/Assistance
http://www.nysemo.state.ny.us/training/semotraining.asp
4.
FEMA
http://www.fema.gov/emergency/nims/index.shtm
ƒ
NIMS Integration Center (NIC):
http://www.fema.gov/nims/
ƒ
NIMS Mutual Aid Ambulance Typing:
http://www.fema.gov/pdf/emergency/nims/508-3_emergency_medica_%20services_%20resources.pdf
ƒ
NIMS Glossary:
http://www.fema.gov/pdf/emergency/nims/507_Mutual_Aid_Glossary.pdf
ƒ
NIMSCAST Access:
http://www.fema.gov/nimcast/index.jsp
06-05 NIMS
Page 4 of 4
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 99-07
06 – 04
Date: May 22, 2006
Re:
BLS-FR Services
Information
Page 1 of 5
The following policy for Basic Life Support First Response (BLS-FR) agencies was
developed by the Bureau of Emergency Medical Services (BEMS), in cooperation with
the New York State EMS Council’s EMS Systems committee. This policy is intended to
provide guidance to the managers of agencies that provide BLS first response service to
their community. While BLS-FR services are not defined or regulated by Public Health
Law, it is vitally important that BLS-FR agencies are integrated into the local EMS
systems.
Purpose
The overall intent of providing BLSFR is to ensure adequate, or where possible enhance,
the delivery of emergency medical care to the community. This may include, but not be
limited to the following:
•
•
•
•
•
•
Improve overall response times to medical emergencies;
The delivery of quality prehospital patient care;
Provide additional BLS treatments such as Public Access Defibrillation (PAD);
Provide personnel support to transporting agencies by supplementing
availability of drivers and care providers;
Increase availability of personnel for large scale incidents, and
Improve public awareness of EMS issues in the community and the value of
personnel trained in First Aid, CPR and PAD
NYS EMS Agency Code
In order for a BLS-FR agency participating in a local EMS system to obtain an agency
code number, the agency needs to provide documentation indicating the following:
•
Support from the Executive of the municipality (village, city, town, county) for
the territory covered. This may be a mayor, supervisor, board of
commissioners or the chairman of a fire district and must be documented in
writing.
AND
•
Document being publicly dispatched and providing primary EMS response on
a regular and ongoing basis to public emergency medical needs, as defined
by 3001(l) of the Public Health Law.
NYS-EMS Policy 06-04 (5/22/06)
Pg. 1 of 5
EMS System Participation
The following information must be documented by the BLSFR agency as part of its
participation in the local EMS system:
•
•
•
•
Description of response plan, including territory served,
Method of dispatch / activation / radio communications resources used,
Adherence to state and regional BLS patient treatment protocols,
A written participation agreement with transporting service(s) to include, but
not limited to:
•
•
•
•
•
•
•
•
Appropriate transfer of patient to insure continuity of care;
Agreement with the local ambulance service to transport patients received
from the BLSFR agency;
Appropriate, timely documentation of patient care (i.e. PCR or equivalent, see NYSEMS Policy 02-05);
Participation in unified incident command;
Participation in QA/QI activities;
Adherence to State and Regional BLS Treatment protocols, and
Management of supply, resupply/retrieval of medical equipment and supplies used, and
Identify resources to be used:
•
•
•
Number and type of vehicle(s);
Number and level of EMS certification of the personnel, and
Medical equipment and supplies used to deliver patient care. (i.e.: equipment, and
supplies such as identified in Part 800.26) coordinated with the transporting
ambulance service.
Agencies making application to NYS DOH for recognition as a BLS-FR agency will be
required to submit proof of local EMS system participation to their Regional Emergency
Medical Services Council for evaluation and written endorsement.
Operations
Operational issues for BLS-FR agencies to consider should include, but not be limited to:
• Written Standard Operating Policies-Guidelines (SOPs / SOGs) that ensure
use of state / regional BLS treatment protocols;
•
Policies to insure the use of appropriately trained personnel to render patient
care. Appropriately trained personnel include Certified First Responder,
Emergency Medical Technician1, Nationally recognized First Aid and/or CPR
and Public Access Defibrillation (PAD);
1
Personnel certified at Advanced EMT levels may NOT render care beyond the scope of practice of an
EMT when providing care for a BLS-FR service. Defibrillation may only be provided by agencies with
either PAD authority or BLS-Defibrillation authority as granted by a Regional Emergency Medical Advisory
Committee.
NYS-EMS Policy 06-04 (5/22/06)
Pg. 2 of 5
•
•
•
•
•
•
•
•
•
Policies that insure patient care rendered is by the individuals with the
highest present level of EMS training/certification;
Documentation of patient care rendered and secure storage of medical
records;
Training and Continuing Education;
Policies regarding infection control, confidentiality, liability, minors, psychiatric
patients, mandatory reporting of child abuse or Methamphetamine
Laboratories, refusal of medical aid (RMA) and other special situations;
Mutual Aid / MCI / Haz-Mat planning;
Periodic review and renewal of participation agreements with transporting
agency(s);
Communications method used to talk to both dispatch and the arriving
ambulance to report patient status and scene information. Such
communications needs to include ability to contact medical control if required;
A detailed list of equipment provided by the BLSFR agency. All equipment
needs to be compatible with the equipment and vehicles used by the
ambulance service(s). The attached list from Part 800.26 is a reasonable
reference for developing an equipment list; and
Incident management training / National Incident Management System
(NIMS) Compliance.
Defibrillation
BLSFR agencies are encouraged to provide defibrillation by being a Public Access
provider. Contact your Regional EMS Council or the Bureau of EMS for current
information on providing PAD or see DOH Policy Statement #06-03, Public Access
Defibrillation.
Additional Resources
Additional resource information may be found at the NYS DOH web site.
www.health.state.ny.us/nysdoh/ems/main.htm
NYS-EMS Policy 06-04 (5/22/06)
Pg. 3 of 5
800.26 EMERGENCY AMBULANCE SERVICE VEHICLE EQUIPMENT REQUIREMENTS
The governing authority of any ambulance service, which, as a part of its
response system, utilizes emergency ambulance service vehicles, other than an
ambulance to bring personnel and equipment to the scene, must have policies in effect
for equipment, staffing, individual authorization, dispatch and response criteria and
appropriate insurance.
(a) A waiver of the equipment for emergency ambulance service vehicles may be
considered when the service provides an acceptable plan to the Department
demonstrating how appropriate staff, equipment and vehicles will respond to a call for
emergency medical assistance. The Regional EMS Councils will be solicited for
comment.
(b) Any emergency ambulance service vehicle shall be equipped and supplied with
emergency care equipment consisting of:
(1) 12 sterile 4 inches x 4 inches gauze pads;
(2) adhesive tape, three rolls assorted sizes;
(3) six rolls conforming gauge bandage, assorted sizes;
(4) two universal dressings, minimum 10 inches x 30 inches;
(5) six 5 inches x 9 inches (minimum size) sterile dressings or equivalent;
(6) one pair of bandage shears;
(7) six triangular bandages;
(8) sterile normal saline in plastic container (1/2 liter minimum) within the
manufacturer's expiration date;
(9) one air occlusive dressing;
(10) one liquid glucose or equivalent;
(11) disposable sterile burn sheet;
(12) sterile obstetric [O.B.] kit;
(13) blood pressure sphygmomanometers cuff in adult and pediatric sizes and
stethoscope;
(14) three rigid extrication collars capable of limiting movement of the cervical
spine. These collars shall include small, medium and large adult sizes; and
(15) carrying case for essential equipment and supplies.
(c) Oxygen and resuscitation equipment consisting of:
(1) portable oxygen with a minimum 350 liter capacity with pressure gauge,
regulator and flow meter medical "D" size or larger. The oxygen cylinder must
contain a minimum of 1000 pounds per square inch.
(2) manually operated self-refilling bag valve mask ventilation devices in pediatric
and adult sizes with a system capable of operating with oxygen enrichment and
clear adult, and clear pediatric size masks with air cushion;
(3) four individually wrapped or boxed oropharyngeal airways in a range of sizes
NYS-EMS Policy 06-04 (5/22/06)
Pg. 4 of 5
for pediatric and adult patients;
(4) two each: disposable non-rebreather oxygen masks, and disposable nasal
cannula individually wrapped;
(5) portable suction equipment capable, according to the manufacturer's
specifications, of producing a vacuum of over 300 mmHg when the suction tube
is clamped and including two plastic large bore rigid pharyngeal suction tips,
individually wrapped; and
(6) pen light or flashlight.
(d) A two-way voice communications enabling direct communication with the agency
dispatcher and the responding ambulance vehicle on frequencies other than citizens
band.
(e) Safety equipment consisting of:
(1) six flares or three U.S. Department of Transportation approved reflective road
triangles;
(2) one battery lantern in operable condition; and
(3) one Underwriters' Laboratory rated five-pound ABC fire extinguisher or any
extinguisher having a UL rating of 10BC.
(f) Extrication equipment consisting of:
(1) one short backboard or equivalent capable of immobilizing the cervical spine
of a [sitting] seated patient. The short backboard shall have at least two 2 inches
x 9 foot long web straps with fasteners unless straps are affixed to the device;
and
(2) one blanket.
NYS-EMS Policy 06-04 (5/22/06)
Pg. 5 of 5
No.
06-01
Date: January 11, 2006
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Emergency Patient
Destinations and
Hospital Diversion
Supercedes/Updates: 98-15
Page 1 of 2
As prehospital care becomes more sophisticated and hospital care more
specialized, it is important to clarify the responsibilities of ambulance services to
transport their patients to the appropriate medical facility destination. EMS
services are required by either state or regional EMS medical advisory
committees to transport patients to hospitals with special designations.
BACKGROUND
While Article 30 of the New York State Public Health Law defines ambulance
service, it does not require ambulances to transport patients to specific hospital
destinations. However, the New York State Emergency Medical Services
Council has made the following statements concerning the transport of
emergency patients:
•
All ambulance patients can expect to be informed of the need to be taken to a medical
facility capable of providing appropriate emergency medical care1.
•
The triage and transport of out of hospital patients must be based upon established
principles of emergency medical practice, including pre-established state and regional
medical protocols and guidelines. For any given patient, the appropriateness of the
receiving facility to provide emergency care is a medical decision. Therefore, the direction
or redirection of a transporting vehicle cannot be made without medical approval based
upon established Regional Emergency Medical Services System protocols2.
Also, the NYS Basic Life Support Protocols, which Part 800 regulations require
all Emergency Medical Technicians to comply with specify:
•
Major Trauma Protocols – If the patient meets any one of the criteria delineated in the
protocols, they must be transported to a regional trauma center3.
•
Suspected Stroke – A. Transport the patient to the closest New York State Department
of Health designated Stroke Center if the total prehospital time is less than two hours4.
Additionally, a Regional Medical Advisory Committee (REMAC) may have
developed treatment and transport protocols that address local conditions and
require that patients be transported to specific facilities in certain situations.
06-01 Emergency Patient Destinations and Hospital Diversion
Page 1 of 2
POLICY
Based on the mechanism of injury, assessment findings, treatment, state and
local protocol, a patient, in need of emergency medical care must be taken to the
nearest appropriate health care facility capable of treating the illness, disability or
injury of the patient. Ambulance services are under no obligation to transport
patients to medical facilities not licensed under Article 28 of the Public Health
Law. It is expected that the EMS provider will consult with a medical control
physician, should there be questions of protocol, policies, procedures and
transport destinations.
In non-emergency situations, ambulance services may make transports to
facilities such as physician’s offices, diagnostic and treatment centers (DT&C),
free standing emergency clinics or other destinations. However, the ambulance
crew must be aware of the emergency care capabilities of such facilities at the
time of the patient request.
A patient's choice of hospital or other facility should be complied with unless
contraindicated by state, regional or system/service protocol or the assessment
by a certified EMS provider shows that complying with the patient's request
would be injurious or cause further harm to the patient. Patient transfer can be
arranged following emergency care and stabilization. In such cases, the EMT
should fully document the patient's request and the reasons for the alternate
destination decision, including any medical control consultation.
HOSPITAL DIVERSION REQUESTS
A hospital may notify the EMS system of a temporary inability to provide care in
the emergency department (ED) and request ambulances divert patients to an
alternate hospital facility. A request to divert to another facility may be honored
by EMS providers. A diversion request does not mean the hospital ED is closed,
but usually means the current emergency patient load exceeds the Emergency
Department's ability to treat additional patients promptly. If the patient's condition
is unstable and the hospital requesting diversion is the closest appropriate
hospital, ambulance service personnel should notify the hospital of the patient's
condition and to expect the patient’s arrival. This procedure should also be
followed when a patient demands transport to a facility on diversion. The hospital
may not refuse care for a patient presented. Should an issue arise, the EMS
provider should consult with a medical control physician.
Endnote:
1. Ambulance Patient's Bill of Rights, NYSEMS Council, 1998 Emergency Medical Services Plan
2. Access to Emergency Care in a Managed Care Environment, NYSEMS Council, 1998 Emergency Medical Services
Plan
3. Adult and Pediatric Major Trauma Protocols, T-6, T-7, May, 2004
4. Suspected Stroke Protocol, M-17, January, 2005
06-01 Emergency Patient Destinations and Hospital Diversion
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
05-05
Date: 9/12/05
Re: Guidelines for
Helicopter Utilization
Criteria for Scene
Response
Supercedes/Updates: New
Page 1 of 3
Purpose:
Air Medical Services (AMS) are a valuable, yet limited resource in New York State. It is
important that Emergency Medical Service Personnel utilize consistent and appropriate criteria
when requesting an air medical service for assistance with patient care and transport. The
following represents a combination of the current criteria in use throughout the state. These
criteria are consistent with national AMS utilization criteria. It is important that review of
appropriate helicopter utilization be a part of EMS training, as well as a component of the
agency and regional level retrospective quality assurance process.
Criteria:
1. The helicopter is an air ambulance and an essential part of the EMS system. It may be
considered in situations wherein:
• The use of the helicopter would speed a patient’s arrival to the hospital capable of
providing definitive care and this is felt to be significant to the patient’s condition, or;
• If specialized services offered by the air medical service would benefit the patient prior to
arrival at the hospital.
2. The following criteria should be used when considering use of an air medical service:
• The patient’s condition is a “life or limb” threatening situation demanding intensive
multidisciplinary treatment and care. This may include but not be limited to:
‰ Patients with physical findings defined in the adult and pediatric major trauma
protocols (see attached)
‰ Critical burn patients (see attached)
‰ Critically ill medical patients requiring care at a specialized center to include, but not
be limited to: acute stroke or ST elevation MI as defined by NYS protocol (see
attached); and/or
‰ Patients in cardiac arrest who are not hypothermic should be excluded from
these criteria
3. Dispatch, Police, Fire or EMS will evaluate the situation/condition and if necessary, may
place the helicopter on standby.
1
4. The helicopter may be requested to respond to the scene when:
• ALS personnel request the helicopter.
• BLS personnel request the helicopter, when ALS is delayed or unavailable.
• In the absence of an EMS agency, any emergency service may request the helicopter, if
it is felt to be medically necessary.
5. When EMS arrive, they should assess the situation. If the MOST HIGHLY TRAINED EMS
PERSONNEL ON THE SCENE determine, that the helicopter is not needed, it should be
cancelled as soon as possible.
6. When use of air medical services is not specifically defined by the protocol, the on scene
EMS provider should establish communication with medical control to discuss the situation with
the on line physician.
7. Air medical services may be considered in situations where the patient is inaccessible by
other means or, if utilization of existing ground transport services threatens to overwhelm the
local EMS system.
8. The destination facility will be determined by the AMS crew based upon medical
appropriateness with consideration for patient preference and on line medical direction, in
compliance with regional protocols.
9. An EMS service should not wait on the scene or delay transport waiting for the helicopter to
arrive. If the patient is packaged and ready for transport, the EMS service should initiate
transport to the hospital and reassign the landing zone. The helicopter may intercept with an
ambulance during transport at an alternate-landing site.
THIS IS A GUIDELINE AND IS NOT INTENDED TO SPECIFICALLY
DEFINE EVERY CONDITION IN WHICH AIR MEDICAL SERVICES
SHOULD BE REQUESTED. EMS PERSONNEL SHOULD USE GOOD
CLINICAL JUDGEMENT SHOULD BE USED AT ALL TIMES
Transfer of Patient Care, Documentation and Quality Assurance:
•
•
•
As with other instances where care of a patient is transferred, it is expected that all patient
related information, assessment findings and treatment will be communicated to the flight
crew.
At the completion of the EMS call, all of the details of the response, including, but not limited
to all patient related information, assessment findings and treatment must be documented
on a Department approved Patient Care Report (PCR).
As with all EMS responses, helicopter utilization, the treatment and transportation of patients
will be reviewed as a part of a Quality Assurance process.
2
05-05
Guidelines for Helicopter Utilization Criteria for Scene Response
ADULT MAJOR TRAUMA
PEDIATRIC MAJOR TRAUMA
1. GCS less than or equal to 13
2. Respiratory Rate less than 10 or more than
29 breaths per minute
3. Pulse rate is less than 50 or more than 120
beats per minute
4. Systolic blood pressure is less than
90mmHg
5. Penetrating injuries to head, neck, torso or
proximal extremities
6. Two or more suspected proximal long bone
fractures
7. Suspected flail chest
8. Suspected spinal cord injury or limb
paralysis
9. Amputation (except digits)
10. Suspected pelvic fracture
11. Open or depressed skull fracture
1. Pulse greater than normal range for patient’s
age
2. Systolic blood pressure below normal range
3. Respiratory status inadequate (central
cyanosis, respiratory rate low for the child’s
age, capillary refill time greater than two
seconds)
4. Glasgow coma scale less than 14
5. Penetrating injuries of the trunk, head, neck,
chest, abdomen or groin.
6. two or more proximal long bone fractures
7. flail chest
8. combined system trauma that involves two or
more body systems, injuries or major blunt
trauma to the chest or abdomen
9. spinal cord injury or limb paralysis
10. amputation (except digits)
CRITICAL BURNS
1. Greater than 20% Body Surface Area (BSA)
second or third degree burns
2. Evidence of airway/facial burns
3. Circumferential extremity burns
**Note that for patients with burns and
coexisting trauma, the traumatic injury should
be considered the first priority and the patient
should be triaged to the closest appropriate
trauma center for initial stabilization.
CRITICAL MEDICAL CONDITIONS
1. Suspected acute stroke
•
Positive Cincinnati Pre-hospital Stroke
Scale
•
Total prehospital time (time from when the
patient’s symptoms and/or signs first began
to when the patient is expected to arrive at
the Stroke Center) is less than two (2)
hours.
2. Suspected Acute Myocardial Infarction
•
•
Chest pain, Shortness of breath or other
symptoms typical of a cardiac event
EKG findings of
¾ ST elevation 1mm or more in 2 or more
contiguous leads
OR
¾ LBBB (QRS duration >.12msec and Q
wave in V1 or V2)
3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: New
05-04
Date: Sept. 23, 2005
Re: Blood Glucometry
for Basic Life Support
EMS Agencies
Page 1 of 2
BACKGROUND
At the January, 2005 meeting of the New York State Emergency Medical Advisory
Committee (SEMAC), the use of glucometers by Emergency Medical Technicians
(EMT) in Basic Life Support (BLS) EMS agencies was approved. The SEMAC approval
was granted with the specific condition that the EMS service wishing to use a
glucometer at the BLS level, be granted approval by the local Regional Emergency
Medical Advisory Committee (REMAC), each EMT complete an approved training
program and the service apply and be granted a Limited Laboratory Registration.
The purpose of this policy is to explain the approval process for agencies wishing to
implement a glucometry program. The addition of prehospital blood sugar evaluation is
intended to assist in the recognition of hypoglycemia and improve the speed with which
proper treatment is received.
AUTHORIZATION
Each REMAC, interested in allowing their BLS EMS agencies to participate, will adopt
protocols which will allow a basic EMT to obtain a blood sample, using a lancet device,
or equivalent and test the blood sample in a commercially manufactured electronic
glucometer. The REMAC will also determine the type and level of record keeping and
quality assurance required for this procedure.
To be authorized to use an electronic glucometer, the EMS agency must make written
request to the local Regional Emergency Medical Advisory Committee (REMAC). The
request must include, but not be limited to the following items and possess the
necessary Clinical Laboratory authorizations required by Public Health Law.
• Include a letter from the service medical director supporting the request and
indicating an understanding of their role in the Clinical Laboratory requirements and
quality assurance process.
05-04 Blood Glucometry for BLS EMS Agencies
Page 1 of 2
• Complete the NYS Department of Health Clinical Laboratory Limited Laboratory
Registration application (DOH-4081) for blood testing licensure.
• Develop written policies and procedures for the operation of the glucometer that are
consistent with local protocol. This shall include at least the following:
•
•
•
•
written policies and procedures for the training and documentation of authorized users;
a defined quality assurance program, including appropriateness review by the medical
director;
documentation of control testing process; and
written policies and procedures for storage of electronic glucometer, and proper disposal
of sharps devices.
LIMITED LABORATORY REGISTRATION
The law requires that any EMS service testing blood glucose, whether by electronic
glucometer or chemstrip, be required to possess a Limited Laboratory Registration.
In order to obtain the Registration, EMS agencies must complete and submit the
following documents:
•
•
Limited Service Laboratory Registration (DOH-4081)
Disclosure of Ownership and Controlling Interest Statement (DOH-3486)
The information and appropriate application paperwork is available at:
http://www.wadsworth.org/labcert/clep/Administrative/ChangeForms.htm
No EMS service may engage in the testing of
blood glucose without a registration permit.
NOTIFICATION
Once the EMS service has received written approval from the REMAC, the EMS
Service must provide the Bureau of EMS with a new Medical Director Verification
Form (DOH-4362), indicating the Limited Laboratory Registration permit number and
authorization by the service medical director.
05-04 Blood Glucometry for BLS EMS Agencies
Page 2 of 2
No.
05 - 02
Date: 03/10/05
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Amendment to
10NYCRR Part 800.26
Emergency Ambulance
Service Vehicles
Supercedes/Updates: New
Page 1 of 2
10NYCRR Part 800.26 – Emergency Ambulance Service Vehicles
In November of 2004, amendments to the Part 800.26, which address
Emergency Ambulance Service Vehicles (EASV) went into effect. The proposed
amendments are intended to allow local EMS systems and agencies an
increased flexibility in determining the best and most appropriate configuration for
assigning vehicles to emergency response in order to meet system, local EMS
personnel, deployment and patient needs.
The new sections of the regulation are as follows:
The governing authority of any ambulance service, which, as a part of its response system,
utilizes emergency ambulance service vehicles, other than an ambulance to bring personnel and
equipment to the scene, must have policies in effect for equipment, staffing, individual
authorization, dispatch and response criteria and appropriate insurance.
(a) A waiver of the equipment for emergency ambulance service vehicles may be considered
when the service provides an acceptable plan to the Department demonstrating how appropriate
staff, equipment and vehicles will respond to a call for emergency medical assistance. The
Regional EMS Councils will be solicited for comment.…
Policy
The purpose of an EASV, which remains unchanged by this amendment and
policy, is to deliver personnel and/or equipment to the scene of a medical
emergency. Ambulance services must still address and document how this
purpose is met whenever an EASV equipment waiver is requested.
Part 800.26(b) is the list of equipment required for all EASVs. This list represents
the minimum amount of equipment and supplies necessary for an EMS
provider to respond to a scene to care for a sick or injured patient. The
amendment to the regulation specifically allows for an ambulance service to
request that the Department of Health, Bureau of EMS (BEMS), in consultation
with the Regional EMS Council (REMSCO), waive some, or all of the equipment
requirements listed in Part 800.26(b). In order for a waiver to be considered, the
05-02 Part 800.26
Page 1 of 2
following criteria must be met.
•
•
A request for an equipment waiver must be made in writing to BEMS.
•
The letter must be on the EMS agency’s official letterhead.
•
The letter must detail what specific equipment and/or supplies are to be waived .
•
The letter must include the reason the waiver is being requested.
•
The letter must include the agency’s EASV policies and procedures addressing
equipment, staffing, individual authorizations, dispatch, response criteria and appropriate
insurance.
•
The letter must be signed by the agency’s chief executive officer (CEO), or the head of
the governing body (i.e. Chairman of the board of commissioners, president or mayor)
•
The ambulance service must submit a complete and executed Affirmation of Compliance
(DOH-1881) identifying each EASV.
A copy must be provided to the REMSCO(s).
The complete regulation, including the equipment list is available on the
Department’s web site at www.health.state.ny.us/nysdoh/ems/part800.htm#800.26
Important Notes
In addition to the Part 800 requirements, the operation of any EASV must be in
compliance with all applicable New York State Vehicle and Traffic Laws.
Additionally, when equipped with red lights and siren, the EASV must be insured
with the appropriate coverage as an emergency vehicle. No waivers for
appropriate policies and procedures or vehicle insurance will be granted.
This policy statement DOES NOT SUPERCEDE DOH EMS Policy Statement 0101. Policy Statement 01-01 is intended to clarify the requirements and
procedures for authorization of Emergency Ambulance Service Vehicles (EASV).
Authorization as an EASV involves more than just the use of red lights and a
siren on a vehicle. It is expected that every EASV be in compliance with all of the
provisions of 10 NYCRR Part 800.21 & .26. This includes proper agency
identification; vehicle marking and patient care equipment. All vehicles authorized
by the service as EASVs may be subject to inspection. In the event violations to
the code are found, the violations will be charged against the service authorizing
the vehicle.
05-02 Part 800.26
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
05 - 01
Date: 02/14/05
Re: Idling of
Emergency Vehicles
Supercedes/Updates: New
Page 1 of 2
In an effort to improve response times, provide the correct resources to patients,
Emergency Medical Services agencies are more frequently posting their vehicles
in designated locations within their response areas. As a result many emergency
vehicles engines sit idling for extended periods of time to facilitate proper climate
controls. Because of the associated health and environmental risks, excessive
idling of trucks and buses is a violation of Federal, New York State and New York
City environmental laws.
Based on these laws, it is expected that EMS agencies will examine their general
operating procedures regarding posting EMS vehicles and system status
management and develop polices that will insure proper compliance. While
ambulances are considered emergency vehicles under the Vehicle and Traffic
Law, allowing these vehicles to idle for excessive periods of time in nonemergency operation is not permitted.
The Department of Health, Bureau of EMS considers on-scene operations,
or the positioning of an ambulance/EMS response vehicle in designated
locations within a community, as a component of a planned emergency
response system, to be emergency operation. However, when EMS agencies
position vehicles, consideration must be given to the impact on the community.
The EMS agency must be flexible in re-positioning vehicles to limit the
environmental impact on the community.
The New York State and New York City laws limit the amount of time a truck or
bus may idle. Vehicle owners and operators, and in some cases people who
control buildings or land, are subject to fines and legal actions for violations. All
truck and bus drivers should insure that vehicle idling is minimized, and that
engine idling times are within the legal limits prescribed by law.
05-01 Idling of Emergency Vehicles
Page 1 of 2
The following are sections of both the State law as well as the New York City law.
Under New York State Environmental Conservation Law, heavy duty trucks and
buses may not idle for more than five (5) consecutive minutes.
The exceptions to the law include:
•
•
•
When the engine is powering an auxiliary function, such as loading or
unloading cargo, or mixing concrete;
When running the engine is required for maintenance; or
When fire, police, utility or other vehicles are performing emergency services.
Under New York City Environmental Protection Law, trucks and buses may not
idle for more than 3 consecutive minutes.
The law provides for two exceptions:
•
•
When the engine is powering a loading, unloading, or processing device; or
When the vehicle is a legally authorized emergency vehicle.
Unless in emergency operation, ambulances and first response vehicles
ARE NOT exempt from the provisions of these environment conservation
laws. The penalties for violation of these laws may include fines ranging from
$250 to $15,000.
For more information:
•
•
•
•
•
•
New York State’s idling regulation is found at 6 NYCRR § 217-3.2.
New York City’s idling regulation is found at NYC Administrative Code § 24-163.
The American Lung Association - www.alanys.org
The US Environmental Protection Agency – www.epa.gov/otaq
The NYS Attorney General – www.oag.state.ny.us
The NYS Department of Environmental Conservation – www.dec.state.ny.us
05-01 Idling of Emergency Vehicles
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 84-22 Bee Sting Policy,
99-01 EMT-B Assisted Medications
04-07
Date: 7/28/04
Re: EMT-Basic
Assisted Medication
Administration
Page 1 of 2
EMT-Basic Assisted Medication Administration
This policy is intended to delineate the role of the EMT-B in assisting a patient in
taking his or her own pre-prescribed medication(s). The only medications
included in the training curriculum and protocols are Nitroglycerin (tablet or
spray), Bronchodilator (metered dose inhaler) and epinephrine in an autoinjector.
Definitions:
1. Pre-prescribed medications are those medications that are prescribed by a
physician for a specific patient prior to an emergency and are present at the
scene of the emergency.
2. "Assisting" means delivering a patient's pre-prescribed medication, regardless
of who delivers the medication.
3. “Contraindication” or “contraindicated” means that the condition of the patient
does not require, or may be dangerous to the patient if administered or the
patient does not meet the criteria set forth by the published protocols.
Procedure:
1. A certified EMT-B should deliver pre-prescribed nitroglycerin or a
brochodilator to a patient if the patient indicates (verbally, by gesture, etc.)
their desire to take their medication and the delivery of such medication is not
contraindicated by protocol or the EMT-B's training. If there is any question,
contact Medical Control.
NOTE: There is no circumstance when it would be proper to deliver
either nitroglycerin or a bronchodilator to a patient who can not
indicate their desire to take their pre-prescribed medication.
NOTE: As stated, this procedure prevents an EMT-B from delivering
either of these medications to an unconscious or unwilling patient.
The contraindication statement is added for cases where the patient
indicates their desire to take their medication but it is contraindicated
by the patient’s presentation or condition.
2. A certified EMT-B should deliver pre-prescribed epinephrine by auto-injector
to a patient who exhibits signs/symptoms consistent with the indications for
the medication and protocol or the EMT-B’s training does not contraindicate
the medication. If there is any question, contact Medical Control.
NOTE: There are many scenarios in which the patient may not be able
to indicate their desire to take their pre-prescribed epinephrine and
the EMT-B must make the decision to do so. The EMT-B is trained to
recognize the signs and symptoms of anaphylaxis and the
contraindications for epinephrine. In cases of an allergic reaction,
where the patient is conscious and alert, the patient should be able to
participate in the decision and the delivery of the epinephrine autoinjector.
Special Circumstances:
Experience has shown that "assisted medications" may not be labeled with the
patient's name on the container, inhaler or auto-injector carried by the patient. In
this circumstance, if the patient indicates a desire to take the medication, the
following should be considered:
ƒ
ƒ
ƒ
The medication has been identified as being the patient's pre-prescribed
medication by a claim (the patient or family member states that it belongs to
the patient) or an appearance (is in the patient's pocket or purse, etc).
The patient exhibits signs/symptoms consistent with the indications for the
medication.
Protocol or the EMT-B’s training does not contraindicate the medication.
Only then should the EMT-B assist in delivering the medication. In addition, the
container, inhaler or auto-injector may not be labeled with the name of the
medication.
ƒ
ƒ
In no case should an EMT-B assist in the delivery of a medication from a
container, inhaler, or auto-injector that is not labeled with the name of
the medication.
In cases where the label indicates that the medication is outdated, the EMT-B
must contact Medical Control for direction. If there is any question,
contact Medical Control.
NOTE: Signs/symptoms and indications for the assisted medication are
included in the New York State EMT-B curricula.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: NEW
04-02
Date: 02/26/04
Re: Maintenance of IVs
by EMTs
Page
1 of 2
MAINTENANCE OF IVs BY EMERGENCY MEDICAL TECHINICIANS - BASICS
This policy is intended to clarify that an Emergency Medical Technician–Basic
(EMT-B) may not transport a patient with an intravenous line (IV) in place. The
Department of Health, Bureau of Emergency Medical Services (BEMS) at the
request of the State Emergency Medical Advisory Council (SEMAC) was asked
to clarify the role of an EMT-B in providing care to patients who require IV
therapy.
This issue has been addressed previously by the Department of Health and the
SEMAC. A former opinion provided by the Bureau of Emergency Medical
Services (EMS) in September 1991, indicated that a non-medicated IV could be
maintained and discontinued by a basic EMT if special training were provided to
the EMT, and the training was documented by the ambulance service. This
opinion is now rescinded in part due to the changing composition of prehospital care providers. In the mid-1980s, there were a minimal number of
advanced EMS providers who were able to respond to the demands of facilities
requiring the transportation of patients requiring IV maintenance. Currently, there
are significantly more ALS providers who can appropriately care for patients that
require advanced EMS care and IV therapy.
Policy
The SEMAC has determined that it is no longer permissible for a BLS
ambulance service, staffed by EMT-Bs to transport a patient with an IV line
in place.
This applies to the following situations:
1. Intravenous lines with fluid.
2. Intravenous lines with medication.
3. Central and peripheral vascular access devices with medication.
It is allowable for an EMT-B to transport a patient with a secured saline lock
device in place as long as no fluids or medication are attached to the port.
However, the EMT-B must insure that the venous access site is secured and
dressed prior to leaving the health care facility.
Policy Statement 04-02
1 of 2
Summary
Hospitals and long term care facilities are responsible under state and federal
regulations to assure a patient is transported with the appropriate level of medical
care necessary to the patient’s medical condition. The transport of a patient with
an IV, medicated or non-medicated, requires the presence of an advanced
emergency medical technician or a licensed health care provider with the
appropriate skills. A basic level ambulance may transport a patient with an IV
only if the hospital or nursing home provides appropriate medical staff to
accompany the patient to maintain the IV. If the hospital or nursing home cannot
provide medical staff during the transport of the patient, then an advanced life
support ambulance service must provide the service. In order for an EMT-B to
care for the patient, the IV must be discontinued or secured with a nonmedicated saline lock device during transport
Issued By:
Edward G. Wronski, Bureau Director
In conjunction with the SEMAC
Policy Statement 04-02
2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supplements/Updates: 03-11
04 - 01
Date: 02/10/04
Re: SARS Advisory
Page 1 of 4
Introduction:
This policy was prepared in conjunction with the Department’s Planning Work Group for Disease
Prevention. The Bureau of Emergency Medical Services (BEMS) strongly recommends that all EMS
services review this guidance document, along with other state and county public health
recommendations to prepare your EMS agency’s response to a patient with an infectious respiratory
illness suspected of being SARS. BEMS is sharing this Policy Statement with County EMS Coordinators,
Public Health Directors, REMACs, Regional EMS Councils, Program Agencies and Dispatch Centers.
EMS providers should be aware of the signs and symptoms of infectious respiratory diseases, SARS-CoV
(SARS) and the procedures necessary for protecting themselves. Not all respiratory infections are
transmitted in the same way. Transmission can occur from direct or indirect contact, large droplets, or
small droplet nuclei. The mode of transmission will depend on the etiological agent. Certain procedures
can also impact transmission of infectious agents by producing aerosols. These are deemed “high risk
respiratory procedures” and include intubation, extubation, deep tracheal suctioning, nebulized respiratory
treatments and bronchoscopy. More often in the field of emergency medicine, the etiologic agents of
infections are unknown. Given this, it is paramount that good infection control practices be followed for
contact with all patients.
SARS – Background:
A new emerging infection, Severe Acute Respiratory Syndrome (SARS), has heightened awareness of
the importance of utilizing good infection control practices to prevent the transmission of respiratory
diseases. Information from the SARS outbreaks worldwide during the spring of 2003 suggests that SARS
is transmitted through close contact with infected persons. SARS is most likely spread by droplet
transmission, however, the possibility of airborne transmission and spread through inanimate objects
cannot be ruled out. Healthcare procedures that produce aerosols (e.g. nebulized respiratory treatments,
intubation/extubation and deep tracheal suctioning) appear to have an impact on the transmissibility of
SARS.
In discussion with Ontario EMS recently we learned about the dramatic effect a SARS outbreak can have
on a community and specifically its prehospital health care community. However, we also learned from
our Canadian EMS neighbors that three prehospital care providers acquired the disease with their first
SARS contact at the beginning of the outbreak. The infected EMS providers were those who did not use
PPE (i.e. N95 mask) or used it late. Once the infective nature of the disease was realized, all EMS
personnel were required to don PPE including an N95 mask, eye protection, gowns, gloves and practice
good hand hygiene. There were no additional infections of EMS personnel after this policy was
implemented. NYS EMS should learn from this, follow appropriate protective procedures and prevent the
spread of infection.
In the absence of identified SARS cases in the world, implementing the infection control strategies of
Standard and Droplet Precautions for respiratory infections of unknown etiology with the additional
incorporation of Respiratory Etiquette principles will control transmission without overburdening the
healthcare system. Implementation of this strategy will likely impact the transmission of seasonal
circulating infections that are transmitted by respiratory spread (e.g. influenza, adenovirus, respiratory
syncytial virus, and Mycoplasma pneumoniae).
Policy Statement 04-01
1 of 4
Purpose:
Guidance for infection control and prevention for SARS will be dependant on the emergence of SARS
worldwide, nationwide, statewide, and/or locally. Approaching infection control measures according to
the level of known SARS activity will enable healthcare programs to maintain an environment that is safe
for the prevention of communicable disease outbreaks, while not overtaxing the healthcare system with
intensive isolation procedures and public health notifications. The intention of this document is to assist
EMS Agencies in the planning for SARS cases and to provide specific infection control guidance for the
following scenarios: no SARS transmission has been identified in the world; SARS transmission identified
in the world, but no transmission locally; and SARS transmission identified locally.
Infection Control Guidance
Preparedness Planning for the Re-emergence of SARS:
1. BEMS strongly recommends the following for EMS services and providers:
a) Fit testing for an N-95 or higher respirator mask
b) Education on performing a “fit check” (conforming the mask to the face and checking for air
leaks) after donning N95 respirators
c) Frequent and on-going education including, but not limited to infection control measures, PPE as
well as proper personal/hand hygiene.
d) Routine flu vaccinations and other preventative health measures
2. EMS services should monitor their crews for any type of infectious illness:
a) EMS management should monitor any provider that presents with signs and symptoms of a
respiratory illness. Services should consider the following (in order of preference):
¾ Release staff from duty until they have sought medical attention and have sufficiently
recovered.
¾ Assigning staff to non-patient care related duties for the duration of their illness.
¾ Require EMS providers to don surgical masks to protect their patients while providing
care.
¾ The EMS medical director and the County Public Health Office should be advised of any
EMS healthcare provider who is hospitalized with pneumonia.
No SARS Identified Worldwide:
1. Practice Body Substance Isolation (BSI) or Standard Precautions. Utilize personal protective
equipment (PPE -e.g. use of gown, gloves and eye protection/face shield) based on the contact with
bodily substances that is anticipated. More information on Standard Precautions can be found on the
following Centers for disease Control and Prevention (CDC) Website:
http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm.
2. Utilize the Standard Respiratory Precautions below for all patients presenting with respiratory
symptoms. This includes wearing a surgical mask within 3 feet of the patient.
3. Prior to transporting a patient with respiratory symptoms, the door between the driver and the patient
compartment should be closed. If the vehicle does not have a barrier between the cab and the
patient compartment, the driver and front seat passenger should also wear surgical masks.
4. Hands must be properly washed or disinfected with a waterless hand sanitizer immediately after
removal of gloves. Do not wait until you return to the ambulance station to practice hand hygiene.
5. Assure adequate cleaning of the equipment and vehicles between transports. This cleaning should
minimally include:
a. Use of an Environmental Protection Agency (EPA) approved disinfectant;
b. Disinfection of any reusable equipment used on the patient as per the manufacturer’s
instructions;
c. Frequently touched surfaces of the vehicle;
d. Visibly soiled surfaces.
Policy Statement 04-01
2 of 4
6. Medical procedures, such as nebulized respiratory treatments, that may re-aerosolize infectious
material should only be done if medically necessary. It is recommended that mechanical ventilators,
including BVM devices and suction equipment, should be fitted with a HEPA filter, if available, to
prevent re-aerosolization. EMS services should contact equipment manufacturers for
recommendations on a HEPA filter.
7. Humidified oxygen use should be suspended for the treatment of a suspected SARS patient unless
otherwise directed by medical control.
Standard Respiratory Precautions
¾
¾
¾
¾
Provide surgical masks to all patients with symptoms of a respiratory illness. Provide
instructions on the proper use and disposal of masks.
For patients who cannot wear a surgical mask, provide tissues and instructions on when to
use them (i.e., when coughing, sneezing, or controlling nasal secretions), how and where
to dispose of them, and the importance of hand hygiene after handling this material.
Implement use of surgical or procedure masks by healthcare personnel during the evaluation
of patients with respiratory symptoms.
Continue to use droplet precautions to manage patients with respiratory symptoms until it is
determined that the cause of symptoms is not an infectious agent that requires precautions
beyond standard precautions.
SARS Re-emerges in the World without Local Transmission:
1. Follow the recommendations in Specific Infection Control Guidance – No SARS Transmission
Identified Worldwide.
2. Assign a point person to regularly access CDC Website http://www.cdc.gov/ncidod/sars/ to obtain
updated information on the epidemiology of SARS, and to share the up to date case definition with
EMS personnel.
3. Screen all patients for fever, respiratory symptoms, and SARS risk factors.
SARS risk factors include:
• Travel within 10 days of illness onset to a foreign or domestic location with documented or
suspected recent local transmission of SARS, or
• Persons who had close contact within the last 10 days of illness onset with an ill traveler who had
recently returned from an area with documented or suspected recent local transmission of SARS,
or
• Employment as a healthcare worker, or
• Close contact within 10 days of illness onset, with a person with confirmed or probable SARS or
SARS report under investigation.
3.
For Patients meeting the established SARS case definition, Temperature of >100.4º F (>38º C) and
one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty
breathing, or hypoxia):
a. Utilize Airborne, Contact, and Standard Precautions, including a fit-tested N95 respirator, gloves,
gown and approved eye protection (e.g. face shield or goggles).
b. Prior to transporting the patient, the door between the driver and the patient compartment should
be closed. If the vehicle does not have a barrier between the cab and the patient compartment,
the driver and front seat passenger should also wear fit-tested N95 respirators. Do not use any
air-recirculating mechanisms in the vehicle, and consider opening a window for fresh air
exchanges.
c. Perform high-risk procedures that increase aerosolization (nebulized treatments, deep tracheal
suctioning, intubation/extubation), only if medically necessary; do not use humidified oxygen.
d. After treating and transporting any patient with a infectious respiratory illness or a suspected
SARS case, decontamination and waste disposal procedures should be followed:
Policy Statement 04-01
3 of 4
¾
The ambulance patient compartment, including stretchers, railings, medical equipment,
control panels and adjacent flooring, counter tops should be cleaned using a recommended
EPA approved disinfectant in accordance with manufacturer’s specifications.
¾ All PPE as well as disposable equipment and supplies used while treating patients should be
disposed as regulated medical waste.
¾ Spills of body fluids should be cleaned by placing absorbent material over the spill and
collecting the material in a biohazard bag for disposal.
¾ Personnel cleaning the vehicles should be appropriately protected.
e. If treating and transporting a patient suspected to have SARS, the EMS service must immediately
notify:
¾ The destination hospital prior to arrival of the suspected case of SARS and the possible need
for an airborne infection isolation room and proper precautions. Do not identify the patient as
a suspected SARS patient over the radio. Please utilize either a cellular or landline
telephone.
¾ The County Public Health Officer
SARS Re-emerges in the World with Local Transmission:
1. Follow the recommendations above for Specific Infection Control Guidance – No SARS Transmission
Identified Worldwide and SARS Re-emerges in the World without Local Transmission.
2. Actively screen all patients for fever or respiratory symptoms.
3. Utilize Airborne, Contact, and Standard Precautions, including a fit-tested N95 respirator, gloves,
gown and approved eye protection (e.g. face shield or goggles) for all patients presenting with
respiratory symptoms.
4. Notify the receiving hospital of the need for an Airborne Isolation room or SARS designated unit.
Conclusion:
It is vitally important that the EMS community regularly utilize Standard Precautions and Personal
Protective Equipment when treating all patients with a suspected infectious disease. Changing routine
habits to include these measures will allow EMS providers to protect themselves against known infectious
diseases as well as SARS - CoV or other new emerging diseases.
In addition to changing habits, providing initial and on going education on disease prevention, personal
hygiene and hand washing techniques, equipment and vehicle cleaning will allow the EMS community to
protect patients and itself against all types of infectious diseases.
For Additional Resources:
Please review the information provided at the following web sites;
1. www.health.state.ny.us
2. www.cdc.gov
References:
1. CDC Public Health Guidance for Community-Level Preparedness and Response to Severe Acute
Respiratory Syndrome (SARS), IV - Infection Control for Prehospital Emergency Medical Services,
January 8, 2004
2. Policy Statement 03-11, Respiratory Disease Precautions
Issued By:
Edward Wronski, Bureau Director
With the participation of the DOH Infectious Disease Clinical Workgroup
Policy Statement 04-01
4 of 4
No.
New York State
Department of Health
Bureau of Emergency Medical Agencies
POLICY STATEMENT
Supplements/Updates: 92–02 and 03-02
03 - 11
Date: 12/10/03
Re: Respiratory Disease
Precautions
Page 1 of 3
Introduction:
It is the intention of this Policy Statement to provide information and recommendations
for the transport of patients with potentially infectious respiratory illnesses. This policy
will also provide updated guidelines for “respiratory etiquette” and the use of Personal
Protection Equipment (PPE) as well as recommendations for preventive health care
measures for EMS providers.
This policy was prepared in conjunction with the Department’s Planning Work Group for
Disease Prevention. The Bureau of Emergency Medical Services (BEMS) strongly
recommends that all EMS agencies review this guidance document, along with other
state and county public health recommendations to prepare your EMS agency response
to a patient with an infectious respiratory illness. BEMS is sharing this Policy Statement
with County EMS Coordinators, Public Health Directors, REMAC, Regional EMS
Councils, Program Agencies and Dispatch Centers.
A new emerging infection, Severe Acute Respiratory Syndrome (SARS), has
heightened awareness of the importance of utilizing good infection control practices to
prevent the transmission of respiratory diseases. Information from the SARS outbreaks
worldwide during the spring of 2003 suggests that SARS is transmitted through close
contact with infected persons. SARS is most likely spread by droplet transmission.
However, the possibility of airborne transmission and spread through contaminated or
inanimate objects has not been ruled out. Healthcare procedures that produce aerosols
(e.g. nebulized respiratory treatments, intubation/extubation and deep tracheal
suctioning) appear to have an impact on the transmissibility of SARS.
EMS providers should be aware of the signs and symptoms of infectious respiratory
diseases and the procedures necessary for protecting themselves. Not all respiratory
infections are transmitted in the same way. Transmission can occur from direct or
indirect contact, large droplets, or small droplet nuclei. The mode of transmission will
depend on the etiological agent. Certain procedures can also impact transmission of
infectious agents by producing aerosols. These are deemed “high risk respiratory
procedures” and include intubation, extubation, deep tracheal suctioning, nebulized
respiratory treatments and bronchoscopy. More often in the field of emergency
medicine, the etiologic agents of infections are unknown. Given this, it is paramount
that good infection control practices be followed for contact with all patients.
1
Respiratory Etiquette Strategy
¾
¾
¾
¾
Implement the use of surgical masks by healthcare personnel, during the evaluation of
patients with respiratory symptoms.
Provide surgical masks to all patients with symptoms of a respiratory illness. Provide
instructions on the proper use and disposal of masks.
For patients who cannot wear a surgical mask in addition to any medical treatment being
provided, provide tissues and instructions on when to use them (i.e., when coughing,
sneezing, or controlling nasal secretions), how and where to dispose of them, and the
importance of hand hygiene after handling this material.
Continue to use droplet precautions to manage patients with respiratory symptoms until it is
determined that the cause of symptoms is not an infectious agent that requires precautions
beyond standard precautions.
Recommendations:
1. Personal Protection
•
•
•
•
•
•
When assessing a patient with symptoms of a febrile respiratory illness, a surgical mask is
usually adequate protection. When directed by a BEMS Advisory, the REMAC or the service
medical director, use the highest level of respiratory protection available. A fit-tested N-95
respirator or higher is preferred.
Adhere to Standard Precautions - the use of gown, gloves and eye protection if contact with
bodily secretions or a contaminated environment is anticipated. Additionally, EMS providers must
be familiar with PPE application (donning) and removal (doffing) procedures.
Place a surgical mask on the patient if not medically contraindicated.
Prior to transporting a patient with an infectious respiratory symptom, the door between the driver
and the patient compartment should be closed. If the vehicle does not have a barrier between
the cab and the patient compartment, the driver and front seat passenger should, if so directed,
wear a surgical mask or higher.
Practice good hand hygiene. Hands must be properly washed before and after removal of gloves
with warm soapy water or disinfected with a waterless hand sanitizer if a sink is not immediately
available. Do not wait until you return to the ambulance station to practice hand hygiene.
Assure adequate cleaning of the equipment and vehicles between transports. This cleaning
should minimally include:
a. Use of Environmental Protection Agency (EPA) approved disinfectant;
b. Disinfecting any reusable equipment used on the patient as per the manufacturer’s
instructions;
c. Frequently touched surfaces of the vehicle;
d. Visibly soiled surfaces.
2. Medical procedures, such as nebulized respiratory treatments, that may reaerosolize infectious material should only be done if medically necessary. It is
recommended that mechanical ventilators, including BVM devices and suction
equipment, should be fitted with a HEPA filter, if available, to prevent reaerosolization. EMS agencies should contact equipment manufacturers for
recommendations on a HEPA filter. The highest level of respiratory protection should
be worn during these procedures.
EMS Provider Health Precautions
1. BEMS strongly recommends providing the following to EMS agencies and providers:
a. Fit testing for an N-95 or higher respirator masks and insuring that each provider knows the
manufacturer and model of the N-95 mask for which they were fit tested.
b. Education on performing a “fit check” (conforming the mask to the face and checking for air
leaks) after donning N95 respirators.
c. Frequent and on-going education including, but not limited to infection control measures, PPE as
well as proper personal/hand hygiene.
d. Annual flu vaccinations and other preventive health measures.
2
2. EMS agencies should monitor their crews for any type of infectious illness. EMS
management should monitor any provider that presents with signs and symptoms of
a febrile respiratory illness. Agencies should consider the following (in order of
preference):
¾
¾
¾
¾
Release staff from duty until they have sought medical attention and have sufficiently recovered.
Assigning staff to non-patient care related duties for the duration of their illness.
Require EMS providers to don surgical masks to protect their patients while providing care.
The EMS agency medical director and the County Public Health Office should be advised of any
EMS healthcare provider who is hospitalized with pneumonia.
Conclusion:
It is vitally important that the EMS community get in the habit of using Standard
Precautions, such as donning Personal Protective Equipment and placing a surgical
mask on the patient when appropriate, while treating all patients with a suspected
infectious disease. Changing routine habits to include these measures will allow EMS
providers to protect themselves and their patients against known infectious diseases as
well as SARS or other new emerging diseases.
In addition to changing habits, providing initial and on going education on disease
prevention, proper donning and removing of PPE, hand hygiene and hand washing
techniques as well as equipment and vehicle cleaning will allow the EMS community to
protect patients and itself against all types of infectious diseases.
For Additional Resources:
Please review the information provided at the following web sites;
¾ www.health.state.ny.us
¾ www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm
¾ http://www.nyc.gov/html/doh/home.html
References:
1. CDC Interim Guidance: Ground Emergency Medical Transport for Severe Acute
Respiratory Syndrome Patients
2. CDC Updated Interim Guidance - Pre-Hospital Emergency Medical Care and
Ground Transport of suspected Severe Acute Respiratory Syndrome Patients.
3. NYS DOH - ADVISORY AND UPDATE SUBJECT: Severe Acute Respiratory
Syndrome (SARS) - EMS Update
Issued by:
Edward G. Wronski, Director
Bureau of EMS
3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
03 – 06
Date: 02/18/03
Re: Radiological
Terrorism Rapid
Response Card
Supercedes/Updates: New
Pages: 8
Introduction:
The New York State Department of Health distributed the Radiological Terrorism Rapid
Response Card to all organizations involved in emergency response. The card is
designed to serve as a quick reference to providers when faced with a potential act of
radiological terrorism.
Emergency Medical Services (EMS) agencies are encouraged to have all responders
review this document and understand what capabilities exist within their agency in
complying with the recommendations.
These guidelines are provided to give you basic information to manage care at the scene
of a possible radiologically contaminated patient or patients, who received a large dose of
radiation while protecting yourself as well. The guidelines are applicable to any incident
where a person may have been exposed to a radiological hazard including acts of
terrorism.
The attached pages of this policy statement contain the Radiological Terrorism Rapid
Response Card in its entirety. Should you desire additional copies, it is available in
several electronic formats on the Bureau of EMS’ WMD and Disaster Preparedness
Website, which can be located at:
http://www.health.state.ny.us/nysdoh/ems/main.htm
RADIOLOGICAL TERRORISM
Rapid Response Card for EMS Personnel
This guide provides Emergency Medical Services (EMS) staff and other health
care providers with basic information to manage radiologically contaminated
patients, or patients who received a large dose of radiation from an external
radiation source. This guidance is applicable in all radiological incidents,
including terrorism. The format is designed to be a quick reference guide for use
during emergencies, but it is important to become familiar with the information in
advance. While this rapid response card is directed at those who would provide
medical management, the concepts discussed will be of practical use by all first
responders.
PHONE NUMBERS:
New York State Department of Health (NYSDOH)
Bureau of Environmental Radiation Protection
Wadsworth Center Laboratory
After hours: NYSDOH Duty Officer
After hours: SEMO State Warning Point
(SEMO – State Emergency Management Office)
New York City Department of Health
Bureau of Radiological Health
After hours:
518-402-7550
518-473-4854
1-866-881-2809
518-457-2200
212-676-1572
212-764-7667
Your County Health Department
Consult phone book blue pages under “County Offices”
Poison Control Centers
1-800-222-1222
MEDICAL PREPAREDNESS REFERENCES AND RESOURCES
http://www.orau.gov/reacts/guidance.htm
http://www.afrri.usuhs.mil/
Management of Persons Accidentally Contaminated with Radionuclides.
National Council on Radiation Protection. NCRP Report No. 65 (1980).
Management of Terrorist Events Involving
Radioactive Materials. National Council on Radiation Protection.
NCRP Report No. 138 (2001).
EXPOSURE VS. CONTAMINATION
External Radiation Exposure: Radiation exposure occurs when a person is
near a radiation source. Persons exposed to a radiation source do not become
radioactive. For example, an x-ray machine is a source of radiation exposure.
However, you do not become radioactive when you have an x-ray taken.
Contamination: Radioactive contamination results when loose particles of
radioactive material settle on surfaces, skin, or clothing. Internal contamination
may result if these loose particles are inhaled, ingested, or lodged in an open
wound. Contaminated people are radioactive and should be decontaminated as
quickly as possible. However, the level of radioactive contamination is unlikely to
cause a health risk to another individual.
RADIATION EXPOSURE AND CONTAMINATION EVENTS
There are four types of radiation accident victims:
1. A person who has received a significant dose from an external
source(s).
This includes an exposure to a large radiation source over a short period of
time or exposure to a smaller radioactive source over a longer time frame.
Such exposure will cause symptoms that depend on the amount of exposure.
This includes nausea, reddening of the skin and fatigue. An extremely high
exposure may result in death of the victim. These symptoms may not appear
immediately; it may take several days or weeks before symptoms are
observed. (See Recognizing Radiation-Related Illnesses) Externally
exposed patients do not become radioactive and therefore they do not
pose a risk to EMS or other first responders. Do not delay medical
attention.
2. Internal contamination from inhalation and/or ingestion of radioactive
material.
Patients are not likely to exhibit any symptoms related to radiological
contamination. Internal contamination needs to be assessed and treated in a
clinical setting (emergency department). It is extremely unlikely that the level
of internal contamination would be sufficient to cause an external exposure
hazard from the patient to EMS and other first responders. A person who has
inhaled and/or ingested radioactive material is very likely to also have
external contamination (see the next item).
3. External contamination of the body surface and/or clothing by liquids or
particles.
Patients are not likely to exhibit any symptoms related to radiological
contamination. A person who is externally contaminated is likely to also have
internal contamination from breathing contaminated dust/dirt/air. (Internal
contamination needs to be assessed and treated in a clinical setting). The
amount of radioactive material expected to be on the surface of the victim is
not likely to cause a radiation hazard to EMS or any first responder. In most
cases, external skin contamination is not life threatening and can be removed
with soap and water.
Use of Universal Precautions will help prevent the spread of
contamination to emergency responders. Emergency responders
should not delay treatment of victims due to fear of becoming
contaminated with radioactive materials.
The victim should be handled in a manner that will reduce the potential
spread of contamination to other individuals and medical equipment (e.g.,
stretcher, ambulance). External contamination is likely in the situation with a
radiological dispersal device – a so-called “dirty bomb.” In a dirty bomb event,
the major hazard to health and safety is the explosion itself and/or injury from
shrapnel. An exception would be when a fragment of a high activity
radiation source pierces the victim. In that situation, an external exposure
hazard may exist.
4. A combination of the above.
In this situation, using the guidance for external contamination is warranted.
PRECAUTIONS
Contamination: UNIVERSAL PRECAUTIONS should be used in any situation
where the presence of radioactive materials is suspected. Persons entering a
radiological area, sometimes referred to as a “Hot Zone”, may be directed to
wear overshoes and a dust mask. Rescuers (i.e., fire department) should move
victims out of the hazard area (for example a fire, compromised structure or
vehicle) to a location where EMS can attend to the victim’s medical needs.
External Radiation Exposure: The three cardinal rules of radiation protection
for external radiation exposure (not contamination) from a radiation source are
time, distance and shielding.
• TIME – The less time you spend near the radiation source, the lower your
exposure will be.
• DISTANCE – The greater your distance from the source, the less your
exposure will be. Radiation exposure decreases with distance according to the
inverse-square law. That is, if you triple your distance from the radiation
source, your exposure will decrease by a factor of 9 (three squared).
• SHIELDING – External exposure to radiation can be partially blocked by the
use of shielding. Traditionally, shielding is made of lead or concrete. However,
staying behind vehicles, buildings, or other objects will also decrease exposure.
HEALTH AND SAFETY RISK TO EMS
It is important to understand that a person who has been exposed to radiation is
unlikely to pose a radiological health risk to any other person. However, if a
relatively high activity gamma source (external exposure) is present at the
emergency site, it is possible for an individual to receive a radiation dose that
could pose a health risk. It is anticipated that hazardous materials (HAZMAT)
personnel will have made an initial radiological assessment, and specific safety
precautions will be given.
RADIOLOGICAL ASSESSMENT
First responders, fire fighters, or HAZMAT, may have performed an initial
assessment or screening for the involvement of radioactive materials. Ask the
incident commander (IC), or fire/HAZMAT Chief, if radioactive materials have
been identified or are suspected. If contamination is identified or suspected,
assume that the victim has external contamination. The IC will likely have set up
a “Hot Zone” to limit access to a contaminated area. Responders working in the
hot zone should limit their time in this zone to what is necessary to assist victims.
The incident commander should position EMS outside of the hot zone so that
patient triage/treatment can be done safely. Patients should be decontaminated
prior to delivery to EMS, if possible.
RECOGNIZING RADIATION-RELATED ILLNESSES
Determining that someone has been exposed to radiation can be difficult in
situations other than catastrophic events (nuclear detonations and severe
nuclear power plant accidents). Effects of exposure and/or contamination will not
appear immediately following exposure. It can take days or weeks to see
symptoms. Some symptoms can be similar to those for chemical exposure. In
most cases, there will be no immediate symptoms of radiation exposure or
contamination. The following clinical clues suggest a possible radiological
terrorist event:
•
The acute radiation syndrome follows a predictable pattern that unfolds over
several days or weeks after substantial exposure or catastrophic events. See
below for specific symptom clusters.
•
Victims may present individually over a longer period of time after exposure to
unknown radiation sources.
Specific symptoms of concern, especially following a 2-3 week period with
nausea and vomiting, are:
 thermal burn-like skin lesions without documented heat exposure;
 a tendency to bleed (nosebleeds, gingival (gum) bleeding, bruising);
 hair loss.
•
•
Symptom clusters as delayed effects after radiation exposure:
 Headache, fatigue, weakness
 Partial and full thickness skin damage, epilation (hair loss), ulceration
 Anorexia, nausea, vomiting, diarrhea
 Reduced levels of white blood cells, bruising, infections
GUIDELINES FOR EMERGENCY MEDICAL MANAGEMENT
1. USE UNIVERSAL PRECAUTIONS to help prevent the spread of
contamination from injured victims to emergency personnel.
2. Assess and treat life-threatening injuries immediately. Treatment of such
patients takes priority over all other activities, including decontamination. Do
not delay advanced life support if victims cannot be moved, or to assess
contamination status. Perform routine emergency care during extrication
procedures. Do not delay medical attention for victims with life-threatening
injuries.
3. Move victims away from the radiation hazard area, using proper patient
transfer techniques to prevent further injury. Stay within the controlled
zone if contamination is suspected.
4. Expose wounds and cover with sterile dressings. Priority efforts should be
directed to decontamination of open wounds.
5. Victims should be monitored at the control line for possible
contamination only after they are medically stable. Radiation levels above
background indicate the presence of contamination. Remove the
contaminated person’s clothing, provided removal can be accomplished
without causing further injury.
6. Contaminated patients who do not have life-threatening or serious
injuries may be decontaminated on site. Removal of the patient’s clothing
may reduce the contamination by up to 90%. Place such items in a plastic
bag (double bag if possible) and label with the person’s name and location
(incident site). These items may be analyzed later to determine the specific
isotope and extent of contamination. These items may also be legal evidence.
7. Flush eyes with water or sterile saline. Irrigation or washing of skin with
tepid water and a mild soap is effective for initial decontamination. Do
not use irritants or methods that may abrade the skin, as this could cause
internal contamination. It is not necessary to collect the water that was used
for decontamination. However, do not let that water contaminate other
persons or equipment.
8. Move the ambulance cot to the clean side of the control line and unfold
a clean sheet or blanket over it. Place the victim on the covered cot and
package for transport. Do not remove the victim from the backboard if one
was used.
9. Package the victim by folding the stretcher sheet over and securing the
patient in the appropriate manner. This prevents spread of contamination
to the ambulance.
10. Before leaving the controlled area, rescuers should remove protective
clothing at the control line. If possible, the victim should be transported by
personnel who have not entered the controlled area. Ambulance personnel
attending victims should wear gloves.
11. Notify proper authorities and hospital. Let the hospital know that you are
dealing with radiological victims, and provide an estimate of how many
persons, their medical conditions, any known radiological information and an
estimate of your arrival time. Ask for any special instructions the hospital may
have. You may be directed to an entrance other than the routine emergency
department entrance for the purposes of radiological contamination control.
12. Transport the victim to the hospital. Follow the hospital’s radiological
protocol upon arrival. Hand-off patients in a manner which reduces the
likelihood of spreading contamination. Wrap the patient in a second clean
sheet for transfer at the hospital.
13. The ambulance is considered contaminated until proven otherwise or
decontaminated. However, you may be directed to use the same ambulance
for additional trips to the same event site prior to being “clean-released.”
14. Have yourself surveyed and decontaminated as necessary.
DECONTAMINATION GUIDELINES
Proper decontamination of patients is important to prevent contamination of
facilities and equipment and to prevent exposure to other individuals. Immediate
removal of the patient’s clothing can remove up to 90% of the contaminant.
Removed clothing, bagged and sealed to prevent spread of contamination,
should be retained as possible evidence. After clothing is removed, the patient’s
skin and eyes may need to be decontaminated. In most cases, decontamination
of the skin can be accomplished by gently washing with soap and water followed
by a thorough water rinse. It is important not to abrade the skin during washing or
rinsing, as this can lead to internal radioactive contamination of the patient. For
eyes, flush with plenty of water.
TREATMENT AND DECONTAMINATION RULES
•
Patient with life-threatening condition: treat, then decontaminate.
•
Patient with non-life-threatening condition: decontaminate, then treat.
•
Uninjured contaminated persons should NOT be directed to medical
facility; they should be decontaminated on site.
•
Externally irradiated patients are not contaminated.
•
•
Exposure without contamination requires no decontamination.
Treating contaminated patients before decontamination may contaminate
equipment, vehicles and the facility. Plan for patient decontamination
before arrival if not medically contraindicated.
•
For contaminated patients, use Universal Precautions, remove patient’s
clothing, and decontaminate with soap and water.
•
For internal contamination, contact the Radiation Safety Officer and/or a
Nuclear Medicine Physician at the hospital. Internal contamination will
have to be assessed and treated at a hospital.
USE OF POTASSIM IODIDE
In the event of a severe nuclear power plant accident, health officials may direct
the use of potassium iodide (KI) tablets to protect the thyroid from exposure to
radioactive iodine. KI saturates the thyroid with non-radioactive iodine to
minimize the uptake of radioactive iodine isotopes. It must be taken within the
first few hours after exposure to be effective. Persons allergic to iodine or
shellfish should not take KI.
Note: KI is only effective for protecting the thyroid gland from radioiodine
exposure.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
03-05
Date: 02/13/03
Re: Mark I Kits
POLICY STATEMENT
Supercedes/Updates: 02-08
Pages: 10
Use of “Mark I Kits” (AtroPen® Auto-Injector & Pralidoxime Chloride Injector)
Purpose:
To provide EMS agencies with guidelines on the appropriate use of “Mark I Kits”. The
“Mark I Kit” contains antidotes to be used in instances of exposure to a nerve or
organophosphate agent. The Mark I kit consists of two autoinjectors containing Atropine
Sulfate and Pralidoxime Chloride.
Key Provision:
Only those EMS services that are part of the Metropolitan Medical Response Systems
(MMRS) and/or a Municipal response Plans are authorized to purchase and utilize the
specialized equipment and medications needed in WMD incidents. This includes “Mark I
Kits”.
Guidelines:
The initial guidelines for the use of the “Mark I Kits” were developed by the BioTerrorism sub-committee of the State Emergency Medical Advisory Committee
(SEMAC). They were then adopted by the SEMAC as well as the State Emergency
Medical Services Council (SEMSCO), to provide guidance to EMS agencies who are a
part of the Metropolitan Medical Response System (MMRS) and/or a Municipal
Response Plan. This updated edition is to provide additional guidance on the use of the
Mark I kits.
There are five provisions in the guidelines:
1. An EMS agency must be participating in an MMRS or Municipal Response Plan for
WMD incidents.
2.
The decision to utilize the “Mark I” antidote must be done under the authority of
medical control.
3. At a minimum, an EMS provider must be trained to the WMD awareness level. The
Policy Statement 03-05
Page 1 of 10
awareness program should be a national training program or modeled after one of the
training programs developed by the Department of Defense (DOD), Department of
Justice (DOJ) or Federal Emergency Management Agency (FEMA).
An online WMD awareness course is offered through the Domestic Preparedness
Campus of Texas A&M University’s web site at:
http://www.teexwmdcampus.com
4. The “Mark I Kit” is not to be used for self-administration or prophylaxis.
5. Use of the “Mark I Kit” is to be based on signs and symptoms of the patient. The
Suspicion or identified presence of a nerve agent is not sufficient reason to administer
these medications.
Antidote Mechanism of Action:
1.
The nervous system controls body functions by secreting chemical
transmitters which act as “instructions” to nerves, muscles and glands at
the nerve endings.
2.
These neurological instructions come in two forms:
1) stimulate (move or work)
2) relax (stop or rest).
3.
When a nerve agent is present, it interferes with the normal instructions of
chemical transmitters that direct the muscle or gland to return to an unstimulated, relaxed state.
4.
By interfering with the normal chemical checks and balances, the action of
toxic nerve agents is to over-stimulate the nerve endings and central
nervous system.
5.
Over-stimulation of the nervous system causes muscles and certain glands
to over-react and cause the symptoms of: SLUDGEM + Respirations and
Agitation.
6.
The initial treatment for a nerve agent exposure consists of a two part
antidote:
1) Atropine, and
2) 2-PAM Chloride.
NOTE:
ATROPINE IS THE PRIMARY DRUG FOR TREATMENT OF
NERVE AGENT EXPOSURE!
Policy Statement 03-05
Page 2 of 10
7.
Atropine stops the effect of the nerve agent by blocking the effects of
over-stimulation. It effectively counters the actions of the nerve agent at
nerve receptors.
8.
Atropine relieves the smooth muscle constriction in the lungs (wheezing,
respiratory distress) and gastrointestinal (diarrhea, cramps) tract, and also
dries up respiratory tract secretions.
9.
The companion drug to Atropine is 2-PAM CL; this drug complements the
action of Atropine. 2-Pam Chloride acts to restore normal functions at the
nerve ending by removing the nerve agent and affecting toxin
irreversibility. This antidote is effective at re-establishing normal skeletal
muscle contraction (relieves twitching and paralysis of respiratory
muscles).
RECOMMENDED ANTIDOTE DOSING SCHEDULE FOR EXPOSURE TO
NERVE AGENT
1.
If severe signs and symptoms are present, three (3) Atropine auto-injectors and
three (3) 2-PAM CL injectors should be administered in rapid succession.
2.
If the patient exhibits SLUDGEM but no central nervous system (CNS) findings
are present, then two (2) Atropine auto-injectors and one (1) 2-PAM CL injector
should be given.
3.
In either case, remove secretions, maintain patient’s airway and, if necessary and
the situation permits, use artificial ventilation.
4.
Repeat dosages will be given as specified in the Extended Re-evaluation and
Treatment Schedule (Table 2).
5.
If symptoms resolve, then only monitoring is necessary.
6.
Pre-measured doses of auto-injectors should be safe in most adults. It should be
noted, however that auto-injectors were designed for a military profile:
approximate age 18-35, weight 70 kg. Or 154 lbs., healthy and with no
preexisting medical conditions.
7.
Pralidoxime (2-PAM CL) is most effective if administered immediately after
poisoning and following but not before Atropine, especially for severe exposures.
8.
When the nerve agent has been ingested exposure may continue for some time
due to slow absorption from the lower bowel. Fatal relapses have been reported
after initial improvement. Continued medical monitoring and transport is
mandatory.
Policy Statement 03-05
Page 3 of 10
9.
If dermal exposure has occurred, decontamination is critical and should be done
with standard decontamination procedures. Patient monitoring should be directed
to the same signs and symptoms as with all nerve agent exposures.
10.
Diazepam (Valium) may be given cautiously if convulsions are not controlled.
Antidote Dosing Schedules:
Signs & Symptoms
Severe Respiratory
Distress,
Agitation
SLUDGEM
Respiratory Distress,
SLUDGEM
Asymptomatic
None
Initial Treatment (Table 1)
Atropine Dose
Monitor Interval
2-Pam Dose
3 Auto-injectors (6 mg)
Monitor every 5 minutes
3 Auto-injectors
(1.8 gms)
2 Auto-injectors (4 mg)
Monitor every 10 minutes
Monitor for signs &
symptoms
every 15 minutes
1 Auto-injector
(600 mg)
None
In the initial phase, triage will be initiated in the Hot Zone, continued in the warm
zone, and performed only by trained personnel who are wearing appropriate Personal
Protective Equipment (as determined by the Incident Commander). Patient
decontamination will be simultaneous with and/or prior to treatment. Children should
be decontaminated and have expedited transport off scene especially if they are
demonstrating any signs and symptoms of exposure.
Extended Re-Evaluation & Treatment Phase:
This phase is reached once patients have been initially managed and patient
volume allows for more protracted patient assessments.
Extended Re-evaluation and Treatment Schedule (Table 2)
Atropine Dose
Monitor Interval
2 mg
Monitor every 5
minutes
Up to a maximum of
1.8 gms.
(3 auto-injectors)
Respiratory Distress
SLUDGEM
2 mg
Monitor every 5
to 15 minutes
Up to a maximum of
600 mg.
(1 auto-injector)
Atropine 5-10
minutes as needed
Asymptomatic
None
Monitor every 15
minutes
None
Atropine 5-15
minutes as needed
Signs & Symptoms
Severe Respiratory Distress,
Agitation,
SLUDGEM
Policy Statement 03-05
2 Pam Dose
Atropine Repeat
Dosing Frequency
Atropine 3-5
minutes as
needed
Page 4 of 10
Note: Personnel operating in this phase should be aware of the potential for “offgassing”. Off- gassing is the process by which vapors are given off by
chemically contaminated clothing.
Cautions For Use Of Auto-Injectors:
1.
Every potential exposure in the immediate vicinity of the incident must be
medically evaluated and monitored. Delayed symptoms may present anytime
post incident.
Any patient ill enough to receive even one dose of atropine must be evaluated
at an appropriate facility (e.g. casualty collection point, hospital, etc.).
2.
Signs or symptoms of nerve agent poisoning may reappear. Serial observations
are a critical part of the management process.
3.
Auto injectors have been developed for use in the adult population. Safety and
effectiveness of 2-PAM CL in children has not been established. The atropine
and 2-PAM CL antidote auto injectors should not be used in children 9 years
of age or younger.
For additional information on the treatment of pediatric patients contact medical
control or refer to local REMAC developed protocols.
Adverse Reactions:
Note: Adverse reactions may occur but there are no contraindications to treating
systematic patients.
1.
Atropine may cause chest pain. It may also exacerbate angina or induce a
myocardial infarction.
2.
Up to one hour after intramuscular injection of 2-PAM CL some pain may
be experienced at the site of injection.
3.
2-PAM CL may cause blurred vision, double vision (diplopia), dizziness,
headache, drowsiness, nausea, rapid heart rate (tachycardia), increased
blood pressure, and hyperventilation.
4.
Both (Atropine and 2-Pam CL) should be used with caution (but not
withheld) in patients with preexisting cardiac disease, high blood pressure,
or strokes, particularly in the Extended Re-evaluation and Treatment
Phase.
Auto-Injectors – General:
Note: Use of antidotes will not protect responders from anticipated exposures.
Policy Statement 03-05
Page 5 of 10
1.
Auto-injectors are self-contained, simple, compact injection systems that
come equipped with a pre-measured dose (normal adult dose) of antidote.
2.
An antidote relieves, counteracts, or reverses the effects of poisons or
drugs such as nerve agents.
3.
The Mark I kit must be kept at room temperature (about 25°C 77°F) and
must be protected from freezing.
4.
Mark 1 antidote kits are to be used only:
1)
when specific signs and symptoms of exposure are present
AND
2)
the scene has been declared the site of a nerve agent release
by a local competent authority
AND
3)
Following consultation with Medical Control and in
compliance with any local REMAC Nerve Agent Protocol.
a.
b.
The Mark 1 injectors are not to be used as a prophylaxis for
personal protection.
There is to be no self-administration of antidote.
5.
Auto-injectors permit rapid administration of antidote, prevent needle
cross-contamination between patients, and enable rapid and accurate
administration to a large number of patients (even if the emergency
provider and the patient are in chemical protective clothing).
6.
Auto-injectors facilitate treatment by providing simple, accurate, drug
administration of a pre-measured, controlled dose.
7.
Auto-injectors administer a predictable drug dose that is not operator
dependent.
8.
Auto-injectors contain pre-measured doses of the nerve agent antidotes:
1)
Atropine
2)
2-PAM Chloride (2-PAM CL; pralidoxime chloride)
9.
Each auto-injector contains pre-measured amounts of Atropine (2 mg total
dose per injection) and 2-PAM CL (600 mg total dose per injection).
10.
Mark 1 antidote kits are available and are only to be used under the
direction of medical control in accordance with a local REMAC approved
Policy Statement 03-05
Page 6 of 10
Nerve Agent Exposure protocol. EMS agencies must be identified as a
participant in a municipal response plan involving nerve agents.
Directions For Use Of Auto-Injector
1.
When auto-injector use is indicated, the recommended procedure is to
inject the contents of the auto-injector into the muscles of an anterolateral
(front and side) thigh (through the pocket).
2.
Procedure:
1)
Remove safety cap (yellow on Atropine; gray on 2-PAM CL). Do not touch the
colored end of the injector after removing the safety cap.
2)
Caution: The injector can and will inject into the fingers or hand if any
pressure is applied to either end of the injector.
3)
Hold injector as you would a pen. Place colored end (green on Atropine, Gray on
2-PAM CL) on thickest part of thigh and press hard until injector is activated.
4)
Pressure automatically activates the spring, which plunges the needle into the
muscle and simultaneously forces fluid (Atropine or 2-Pam CL) through it into
the muscle tissues.
5)
Hold firmly in place for ten seconds then remove. Massage the area of
injection.
6)
After each auto-injector has been activated, the empty container should be
disposed of properly. It cannot be refilled nor can the protruding needle be
retracted.
IMPORTANT:
Physicians and/or other medical personnel and emergency
responders assisting evacuated victims of nerve agent exposure
should avoid exposing themselves to cross-contamination by
ensuring that they do not come into direct contact with the
patient’s clothing.
Documentation:
•
When a patient has received treatment with the use of a Mark I kit(s) there must be a
method to record such information so persons providing subsequent care are aware of
that treatment and the amount of medication given.
•
If the resources are present it is recommended that a triage tag be placed on each
patient and that any treatment given be recorded on that tag.
Policy Statement 03-05
Page 7 of 10
•
If the patient is provided with care prior to decontamination than replace that triage
tag following decontamination with a new (dry) tag and copy over any information
regarding treatments already provided.
•
In the event triage tags are not available, documentation might be provided by
affixing a piece of medical tape on the patient indicating what care has been provided.
Be sure that if such a system is used that any tape applied prior to decontamination is
removed as part of decontamination and the information is exactly copied on any new
documents pertaining to the patient.
Sample Protocol:
Attached to this policy and guideline is a model “Mark I PROTOCOL” based upon
existing metropolitan response system protocols and various federal agency
recommendations for administration. This protocol is not mandated and was not
specifically approved by the SEMAC. This protocol is provided to assist a Regional
Medical Advisory Committee (REMAC) or municipal system Medical Director in
developing a local protocol. This model is not intended for independent use by an
EMS agency. It may be used only with medical authorization and participation of the
agency in a municipal or MMRS plan.
There are currently five metropolitan areas that are part of the MMRS program in New
York State:
New York City
Yonkers
Buffalo
Rochester
Syracuse
If your agency is included in an MMRS or municipal response plan you may have
received training and formal protocols for WMD response, including the use of the
“Mark I Kits”. This guideline, if different from the plan in which you participate, is not
meant to supercede your local protocol, medical control or policy.
This policy has been distributed to your REMAC, Regional EMS Councils and County
Emergency Management authorities.
Issued and Authorized by:
Edward G. Wronski, Director
Bureau of EMS
Policy Statement 03-05
Page 8 of 10
MODEL PROTOCOL FOR THE USE OF MARK I KITS
Purpose: These are antidotes to be used in instances of exposure to a nerve or
organophosphate agent.
Use: The Mark I is to be used only if you are part of the MMRS and or a Municipal
Response Plan.
Contents: (1) Atropine Auto-Injector ( 2 mg total dose per injection )
(2) 2-PAM (2-PAM CL; pralidoxime chloride) 600 mgs. total dose per
injection.
•
NOTE: These injectors are not to be used as a prophylactic modality. There is to
be no self-administration of the antidote.
I: Mark I Kit
(a) To be used only in a disaster situation and only if you are a part of the MMRS and or
a Municipal Response system.
(b) The Mark I Kit is only to be utilized under direct authority of Medical Control.
II: Auto Injector Use
(a) Pre measured doses in auto-injectors should be safe for most adults.
(b) Atropine auto-injector and Pralidoxime (2 PAM CL) may be administered by
qualified emergency personnel and designated emergency responders who have had
adequate training in on-site recognition and treatment of nerve and or
organophosphate agent intoxication in the event of a chemical release. This is specific
to the disaster setting.
(c) Medical treatment is directed to relieving respiratory distress and alleviating seizures.
III: Indications for use of the Auto Injectors
(a) It is a concern that the use of auto-injectors could lead to administration of
inappropriate and harmful doses during a non-chemical agent or minimal exposure
situations. The auto-injectors are to be used only if the patient presents with
SLUDGEM + RESPIRATIONS and AGITATION.
(b) The Atropine and 2-PAM CL auto injectors should be used by qualified emergency
medical personnel and designated emergency responders only after the following
events have occurred:
1) The recognition of the existence of a potential chemical or organophosphate agent
release in an area.
2) Some or all of the symptoms of the nerve agent poisoning cited below are present:
Policy Statement 03-05
Page 9 of 10
SLUDGEM + RESPIRATION and AGITATION
S – salivation (excessive drooling)
L – lacrimation (tearing)
U – urination
D – defecation / diarrhea
G – GI upset ( cramps )
E – emesis ( vomiting )
M – muscle ( twitching, spasm, “bag of worms” )
+
RESPIRATION – difficulty breathing / distress ( sob, wheezing )
+
AGITATION + CNS SIGNS – confusion, agitation, seizures, coma.
3) Atropine must be given first, do not give anything else until the effects of atropine
become apparent. Only when the effects of the atropine have been seen can you then
give 2 – PAM CL.
4) If symptoms resolve, then only monitoring is necessary.
5) If severe signs and symptoms are present; three (3) Atropine auto-injectors and
three (3) 2-PAM CL injectors should be administered in rapid succession
(stacked).
1.
2.
3.
4.
Remove secretions
Maintain an open airway
Use artificial ventilation in necessary and possible
Repeat Atropine immediately as directed
6) Pralidoxime ( 2-PAM CL ) is most effective if administered immediately after the
poisoning but not before Atropine, especially for severe exposures.
7) If available Diazepam ( Valium ) may be cautiously given, under direct medical
control, if convulsions are not controlled.
8) When the nerve agent has been ingested, exposure may continue for some time due to
slow absorption from the lower bowel, and fatal relapses have been reported after
initial improvement. Continued medical monitoring and transport is mandatory.
9) If dermal exposure has occurred, decontamination is critical and should be done with
standard decontamination procedures. Patient monitoring should be directed to the
same signs and symptoms as with all nerve or organophosphate exposures.
7/2/2002
Policy Statement 03-05
Page 10 of 10
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
03 - 04
Date: 02/10/03
Re: Chemical Terrorism
Preparedness and
Response Card
Supercedes/Updates: New
Pages: 10
Introduction:
The New York State Department of Health distributed the Chemical Terrorism
Preparedness and Response Card to all organizations involved in emergency response.
The card is designed to serve as a quick reference to providers when faced with a
potential act of chemical terrorism.
Emergency Medical Services agencies are encouraged to have all responders review this
document and understand what capabilities exist within their agency in complying with
the recommendations. All agencies are advised that the directions and recommendations
regarding antidote use should only be performed in accordance with established medical
protocols for your agency. The use of personal protective equipment including the use of
Self Contained Breathing Apparatus (SCBA), should only occur after providers have
received proper training on the use and fitting of such equipment.
The Bureau of EMS and the State Emergency Medical Advisory Committee (SEMAC)
believe that EMS personnel should not be providing patient care in an environment that
requires the use of SCBA. It is not the role of EMS personnel to enter a “hot zone” in an
identified WMD incident. EMS crews should operate in the “cold zone” and HazMat or
other specially equipped teams should bring patients out of the hot zone to be treated and
transported.
These guidelines are provided to assist you in providing care at the scene of a possible
Chemical Terrorism incident and not becoming a victim of one.
The attached pages of this policy statement contain the Chemical Terrorism Preparedness
and Response Card in its entirety. Should you desire additional copies, it is available in
several electronic formats on the Bureau of EMS’ WMD and Disaster Preparedness
Website, which can be located at:
http://www.health.state.ny.us/nysdoh/ems/main.htm
Policy Statement 03-04
Page 1 of 7
Prepared: August 2002
RECOGNIZING CHEMICAL TERRORISM-RELATED ILLNESSES
Adequate planning and regular training are the key to preparedness for terrorism-related
events. Healthcare providers should be alert to illness patterns and reports of chemical
exposure that might signal an act of terrorism. The following clinical, epidemiological and
circumstantial clues may suggest a possible chemical terrorist event:
•
•
•
•
•
An unusual increase in the number of people seeking care, especially with respiratory,
neurological or gastrointestinal symptoms
Any clustering of symptoms or unusual age distribution (e.g., chemical exposure in
children)
Location of release not consistent with a chemical’s use
Simultaneous impact to human, animal and plant populations
Any unusual clustering of patients in time or location (e.g., persons who attended the
same public event)
Any unusual symptoms, illnesses or clusters of these should be reported immediately.
EMS personnel should call their medical control facility and dispatching agency. The
county health department and local Poison Control Center should also be notified.
PHONE NUMBERS
New York State Department of Health (NYSDOH)
Bureau of Toxic Substance Assessment
518-402-7800
Wadsworth Center Laboratories
518-474-7161
After hours: NYSDOH Duty Officer
1-866-881-2809
After hours: SEMO State Warning Point
518-457-2200
(SEMO - State Emergency Management Office)
New York City Department of Health
Poison Control Center
212-764-7667
Your County Health Department
Consult phone book blue pages under “County Offices”
Poison Control Centers
1-800-222-1222
MEDICAL PREPAREDNESS REFERENCES AND RESOURCES
This response card is only a summary of important information. For more detail for
preparedness planning, review the following resources and those at the end of Table 2:
*Textbook of Military Medicine – Medical Aspects of Chemical and Biological
Warfare.
http://ccc.apgea.army.mil/products/textbook/HTML_Restricted/index.htm
http://chemdef.apgea.army.mil/textbook/contents.asp
*Centers for Disease Control and Prevention Public Health Emergency
Preparedness and Response
http://www.bt.cdc.gov/Agent/AgentlistChem.asp
TABLE 1
RECOGNIZING AND DIAGNOSING HEALTH EFFECTS OF CHEMICAL TERRORISM
Nerve
Agent Type
−
−
−
−
−
Agent Names
Cyclohexyl sarin (GF)
Sarin (GB)
Soman (GD)
Tabun (GA)
VX
Any Unique Characteristics
−
Miosis (pinpoint
pupils)
−
Copious secretions
−
Muscle twitching/
fasciculations
−
−
−
−
−
−
Asphyxiant/
Blood
−
−
−
Policy Statement 03-04
Arsine
Cyanogen chloride
Hydrogen cyanide
−
−
−
Possible cherry red
skin
Possible cyanosis
Possible frostbite*
−
−
−
−
−
Initial Effects
Miosis (pinpoint
pupils)
Blurred/dim vision
Headache
Nausea, vomiting,
diarrhea
Copious secretions/
sweating
Muscle twitching/
fasciculations
Breathing difficulty
Seizures
Confusion
Nausea
Patients may gasp for
air, similar to
Page 2 of 7
Choking/
Pulmonary-damaging
Blistering/
Vesicant
−
−
−
−
−
−
−
−
−
Incapacitating/
Behavior-altering
−
Chlorine
Hydrogen chloride
Nitrogen oxides
Phosgene
−
−
−
Mustard/Sulfur
mustard (HD, H)
Mustard gas (H)
Nitrogen mustard (HN1, HN-2, HN-3)
Lewisite (L)
Phosgene oxime (CX)
−
−
−
Agent 15/BZ
−
−
−
Chlorine is a greenishyellow gas with pungent
odor
Phosgene gas smells
like newly-mown hay or
grass
Possible frostbite*
Mustard (HD) has an
odor like burning garlic or
horseradish
Lewisite (L) has an
odor like penetrating
geranium
Phosgene oxime (CX)
has a pepperish or
pungent odor
May appear as mass
drug intoxication with
erratic behaviors, shared
realistic and distinct
hallucinations, disrobing
and confusion
Hyperthermia
Mydriasis (dilated
pupils)
−
−
−
−
−
−
−
−
−
−
−
−
−
−
−
−
−
−
*Frostbite may occur from skin contact with liquid arsine, cyanogen chloride or phosgene.
asphyxiation but more
abrupt onset
Seizures prior to death
Eye and skin irritation
Airway irritation
Dyspnea, cough
Sore throat
Chest tightness
Severe irritation
Redness and blisters
of the skin
Tearing, conjunctivitis,
corneal damage
Mild respiratory
distress to marked
airway damage
May cause death
Dry mouth and skin
Initial tachycardia
Altered consciousness,
delusions, denial of
illness, belligerence
Hyperthermia
Ataxia (lack of
coordination)
Hallucinations
Mydriasis (dilated
pupils)
`
TABLE 2
DECONTAMINATION AND TREATMENT
Agent Type
Nerve
Decontamination
−
−
−
−
Asphyxiant/
Blood
−
−
−
−
Choking/
Pulmonary-damaging
−
−
−
−
Blistering/
Vesicant
−
−
−
−
−
Incapacitating/
Behavior-altering
−
−
−
Remove clothing
immediately
Gently wash skin with
soap and water
Do not abrade skin
For eyes, flush with
plenty of water or normal
saline
Remove clothing
immediately if no frostbite*
Gently wash skin with
soap and water
Do not abrade skin
For eyes, flush with
plenty of water or normal
saline
Remove clothing
immediately if no frostbite*
Gently wash skin with
soap and water
Do not abrade skin
For eyes, flush with
plenty of water or normal
saline
−
Immediate
decontamination is
essential to minimize
damage
Remove clothing
immediately
Gently wash skin with
soap and water
Do not abrade skin
For eyes, flush with
plenty of water or normal
saline
−
Remove clothing
immediately
Gently wash skin with
water or soap and water
Do not abrade skin
−
−
−
−
−
−
−
−
−
−
−
−
−
−
First Aid
Assess ABCs
Atropine before other
measures
Pralidoxime (2-PAM)
chloride
Other Patient Considerations
−
−
Rapid treatment with
oxygen
For cyanide, use
antidotes (sodium nitrite and
then sodium thiosulfate)
−
Arsine and cyanogen
chloride may cause delayed
pulmonary edema
Fresh air, forced rest
Semi-upright position
If signs of respiratory
distress are present, oxygen
with or without positive
airway pressure may be
needed
Other supportive therapy,
as needed
Immediately
decontaminate skin
Flush eyes with water or
normal saline for 10-15
minutes
If breathing difficulty,
give oxygen
Supportive care
−
May cause delayed
pulmonary edema, even
following a symptom-free
period that varies in
duration with the amount
inhaled
−
Possible pulmonary
edema
Mustard has an
asymptomatic latent period
There is no antidote or
treatment for mustard
Lewisite has immediate
burning pain, blisters later
Specific antidote British
Anti-Lewisite (BAL) may
decrease systemic effects of
Lewisite
Phosgene oxime causes
immediate pain
Hyperthermia and selfinjury are largest risks
Hard to detect because it
is an odorless and nonirritating substance
Possible serious
arrhythmias
Specific antidote
(physostigmine) may be
available
−
−
−
−
−
−
Onset of symptoms from
dermal contact with liquid
forms may be delayed
Repeated antidote
administration may be
necessary
Remove heavy clothing
Evaluate mental status
Use restraints as needed
Monitor core temperature
carefully
Supportive care
−
−
−
−
*For frostbite areas, do NOT remove any adhering clothing. Wash area with plenty of warm water to release clothing.
References for Preparedness and Response Card:
Policy Statement 03-04
Page 3 of 7
1. Agency for Toxic Substances and Disease Registry (ATSDR). 2001. Managing
Hazardous Materials Incidents Vol. I, II, III. Division of Toxicology, U. S. Department of
Health and Human Services. Public Health Service: Atlanta, GA.
http://www.atsdr.cdc.gov/mhmi.html
2. Chemical Casualty Care Division USAMRICD. 2000. Medical Management of Chemical
Casualties Handbook, Third edition. U.S. Army Medical Research Institute of Chemical
Defense (USAMRICD). Aberdeen Proving Ground: Aberdeen, MD.
http://ccc.apgea.army.mil/products/handbooks/RedHandbook/001TitlePage.htm
3. U.S. Army Edgewood Research, Development and Engineering Center. 1999.
Technician EMS Course. Domestic Preparedness Training Program, Version 8.0. U.S.
Army SBCCOM. Aberdeen Proving Ground: Aberdeen, MD.
TABLE 3
ANTIDOTE RECOMMENDATIONS FOLLOWING EXPOSURE TO CYANIDE
Note – Victims whose clothing or skin is contaminated with hydrogen cyanide liquid or
solution can secondarily contaminate response personnel by direct contact or through offgassing vapors. Avoid dermal contact with cyanidecontaminated victims or with gastric
contents of victims who may have ingested cyanide-containing materials. Victims exposed
only to hydrogen cyanide gas do not pose contamination risks to rescuers. If the patient is
a victim of recent smoke inhalation (may have
high carboxyhemoglobin levels), administer only sodium thiosulfate.
Patient
Child
Adult
Mild
(conscious)
If patient is
conscious and has
no other signs
or symptoms,
antidotes may not
be necessary.
If patient is
conscious and has
no other signs
or symptoms,
antidotes may not
be necessary.
Severe
(unconscious)
Sodium nitrite1:
0.12 - 0.33 ml/kg,
not to exceed 10 ml
of 3% solution2 slow
IV over no less than
5
minutes, or slower if
hypotension
develops
and
Sodium thiosulfate:
1.65 ml/kg of
25% solution IV
over 10 - 20 minutes
Sodium nitrite1:
10 - 20 ml of 3%
solution2 slow IV
over no less than 5
minutes, or slower
if hypotension
develops
and
Sodium thiosulfate:
50 ml of 25%
solution IV over
10 - 20 minutes
Other Treatment
For sodium nitriteinduced orthostatic
hypotension, normal
saline infusion and
supine position are
recommended.
If still apneic
after antidote
administration,
consider sodium
bicarbonate for
severe acidosis.
1. If sodium nitrite is unavailable, administer amyl nitrite by inhalation from crushable
ampules.
2. Available in Pasadena Cyanide Antidote Kit, formerly Lilly Cyanide Kit.
Policy Statement 03-04
Page 4 of 7
TABLE 4
ANTIDOTE RECOMMENDATIONS FOLLOWING EXPOSURE TO NERVE AGENTS
Patient Age
Infants
(0-2 yrs)
Child
(2-10 yrs)
Adolescent
(>10 yrs)
Adult
Elderly,
frail
Antidotes
Mild/Moderate
Severe Effects2
Effects1
Atropine:
Atropine:
0.05 mg/kg IM, or
0.1 mg/kg IM, or
0.02 mg/kg IV;
0.02 mg/kg IV;
and
and
2-PAM Chloride:
2-PAM Chloride:
15 mg/kg IM or
25 mg/kg IM, or
IV slowly
15 mg/kg IV slowly
Atropine:
Atropine:
1 mg IM, or
2 mg IM, or
0.02 mg/kg IV;
0.02 mg/kg IV;
and
and
2-PAM Chloride3:
2-PAM Chloride3:
15 mg/kg IM or
25 mg/kg IM, or
IV slowly
15 mg/kg IV slowly
Atropine:
Atropine:
4 mg IM, or
2 mg IM, or
0.02 mg/kg IV;
0.02 mg/kg IV;
and
and
2-PAM Chloride3:
2-PAM Chloride3:
25 mg/kg IM, or
15 mg/kg IM or
15 mg/kg IV slowly
IV slowly
Atropine:
Atropine:
6 mg IM;
2 to 4 mg IM or IV;
and
and
2-PAM Chloride:
2-PAM Chloride:
1,800 mg IM, or
600 mg IM, or
15 mg/kg IV slowly
15 mg/kg IV slowly
Atropine:
Atropine:
2 to 4 mg IM;
1 mg IM;
and
and
2-PAM Chloride:
2-PAM Chloride:
25 mg/kg IM, or
10 mg/kg IM, or
5 to 10 mg/kg IV
5 to 10 mg/kg IV
slowly
slowly
Other
Treatment
Assisted ventilation
after antidotes for
severe exposure.
Repeat atropine
(2 mg IM, or 1 mg
IM for infants)
at 5 - 10 minute
intervals until
secretions have
diminished and
breathing is
comfortable or
airway resistance
has returned to
near normal.
Phentolamine
for 2-PAM-induced
hypertension:
(5 mg IV for adults;
1 mg IV for
children).
Diazepam for
convulsions:
(0.2 to 0.5 mg IV
for infants less
than 5 years;
1 mg IV for children
5 years and older;
5 mg IV for adults).
1. Mild/Moderate effects include localized sweating, muscle fasciculations, nausea,
vomiting, weakness, dyspnea.
2. Severe effects include unconsciousness, convulsions, apnea, flaccid paralysis.
3. If calculated dose exceeds the adult IM dose, adjust accordingly.
NOTE: 2-PAM Chloride is Pralidoxime Chloride or Protopam Chloride.
PERSONAL PROTECTIVE EQUIPMENT (PPE)
DO NOT BECOME A CASUALTY!
First responders face the greatest exposure potential, often to unidentified agents. To
protect yourself:
•
•
•
Be alert
Keep an appropriate distance
Stay upwind
Policy Statement 03-04
Page 5 of 7
•
Wait for assessment by a HAZMAT team before entering
Ideally, responders in an unknown situation should wear Level A PPE. Exposure can occur
from inhalation of vapors, dermal contact or eye contact. The following is a general
discussion to help responders/healthcare providers determine appropriate PPE.
PPE to Prevent Inhalation Exposure:
Protection from both vapors and particulates may be required when the chemical agent is
being released. After release, protection from vapors is most important. Surgical and N-95
masks will not protect against inhalation of vapors. Half-face and full-face respirators, with
the appropriate canister, will provide good protection from vapors. These operate by
negative pressure and must be fit tested for optimal protection. Powered, air-purifying
respirators (PAPR) and self-contained breathing apparatus (SCBA) provide even greater
protection and operate under positive pressure so that fit characteristics are
less important.
PPE to Prevent Dermal Exposure:
Latex examination gloves provide very little protection from most chemical agents and can
cause allergies. Gloves made of Viton, nitrile, butyl or neoprene provide more protection
and, in some styles, allow adequate dexterity. However, the resistance of these materials to
different chemicals varies and
it is best to have a variety of gloves available. Double gloving may provide additional
protection. Chemical-resistant aprons or suits can also prevent dermal exposure.
PPE to Prevent Eye Exposure:
Full-face respirators, PAPR and SCBA will provide protection from both splashes and
vapors. Protective eyewear, such as goggles or a face shield, will not provide protection
from chemical vapors. Protective eyewear is required during decontamination to prevent
splashing into eyes.
DECONTAMINATION GUIDELINES
Proper decontamination is often the most important first step in treating a patient exposed
to chemical agents. Immediate removal of patient clothing can remove up to 90 percent of
the contaminant. Removed clothing should be bagged, sealed and retained as possible
evidence.
After the clothing is removed, the patient’s skin and eyes may need to be decontaminated.
In most cases, decontamination of skin can be accomplished by gentle and thorough
washing with soap and water followed by a thorough water rinse. For eyes, flush with plenty
of water or normal saline. Decontamination water may need to be contained.
Bleach solutions, concentrated or dilute, should not be used on people. Diluted bleach (1
part household bleach to 9 parts water) can be used on equipment and other hard
surfaces. Because bleach solutions irritate the eyes, skin and respiratory tract, they must
be handled with caution and used with adequate ventilation.
It is important not to abrade the skin during washing or rinsing. This is especially true after
exposure to blistering/vesicant agents which bind to skin. These agents may leave the skin
compromised and susceptible to further damage. For choking/pulmonary-damaging agents
or capacitating/behavior-altering
agents, a rinse in water alone may be adequate.
Policy Statement 03-04
Page 6 of 7
ODORS
Some chemical agents are accompanied by a characteristic odor that may provide a
warning. However, after a while, people may become used to the chemical and no longer
detect the smell. The chemical may still be present even if there is no detectable odor.
DISCLAIMER
The information on this card is meant to be a quick guide and is not intended to be
comprehensive. This information or the web sites and references listed in this card are not
a substitute for professional medical advice, diagnosis, or treatment of the individual.
Please consult other references, Poison Control Center, and check antidote dosages,
particularly for children and pregnant women.
redness
and
Response Card
Policy Statement 03-04
Page 7 of 7
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: New
03 - 03
Date: 02/07/03
Re: Instructions for
completing a Version5, NYS PCR
Pages: 2 And
attachment
Introduction:
In 2003 the Bureau of Emergency Medical Services will introduce the fifth version
(Version-5) of the New York State Prehospital Care Report (PCR)(DOH 3283)
(sample attached). The primary purpose of the PCR remains a form used to
document all prehospital care and pertinent patient information. The secondary
purpose of the PCR is that of a data collection tool.
The Department of Health maintains a data system that tracks all inpatient care
in hospitals by linking some of the data, Version-5 of the PCR will allow for the
collection of additional data. That will allow linking prehospital patient care and
the care provided by the emergency department and if admitted the hospital
through to discharge. The linkage is obtained by certain identifying factors such
as digits of the social security number and several of the characters in the
patient’s last name. This will permit the EMS system to better determine the
effectiveness of the care given in a prehospital setting for quality assurance
purposes.
Version-5 also includes characteristics necessary to utilize this form as a
scannable instrument. Optical Character Recognition (OCR) will permit the form
to be scanned and have the data extracted from it into useable tables. The only
way this will be accomplished is if the person completing the form prints
legibly. This will allow agencies, counties or regions to consider scannable
systems locally.
Completing a Version-5 PCR:
While the form looks different, all of the previous items contained in a PCR are
continued on the Version-5. Several items have been added and the format that
information is entered has also been changed. Added to the Version-5 are:
•
•
Boxes for providing the patient’s social security number (SS#)
An indication if the patient was defibrillated by a Public Access Defibrillation
(PAD) Provider.
Policy Statement 03-03
Page 1 of 2
•
The patient’s Date of Birth is now an 8-character entry requiring the century to
be included. This field is located on the bottom line of the patient information
box between the box for the patient’s age and the circles for the patient’s
gender.
The other differences between Version-5 and the previous versions include:
•
Boxes are now provided for each character of agency and patient identifying
information.
¾ Please place one character in each box.
¾ Do not draw lines through boxes that are not relevant to the patient.
¾ Print carefully and legibly.
•
The Presenting Problem, Treatment Given and several other “Boxes” are
now circles.
¾ Please completely darken each circle that is applicable.
¾ The Presenting Problems and Treatment Given sections are now
printed with red ink. This red ink will not be recognized when the form
is scanned. This feature is essential when the scanning process is
implemented.
¾ Do not use X or √ to indicate a selection.
There are no special tools required to complete the PCR, however it must be
completed using black ink to be read by a scanner.
If you have any questions about completing a PCR please refer to DOH Policy
Statement 02-05 (or any subsequent replacement of that document).
Issued and Authorized by:
Edward G. Wronski, Director
Bureau of Emergency Medical Services
Policy Statement 03-03
Page 2 of 2
No.
03-01
Date: 01/22/03
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Ambulance &
Advanced Life Support
First Response Service
Certificates
Supercedes/Updates: 88-04
Page 1 of 2
SUBJECT: Ambulance and ALS FR Service Certificates
INTRODUCTION:
Operating certificates are documents issued by the Department to Ambulance
Services and Advanced Life Support First Response Services. The certificate
defines the services operating territory and contains the name under which the
agency is required to operate.
Certificates are valid for two years. The certificate’s expiration date is printed in
the upper right hand corner of the document. It is the certified service’s
responsibility to insure that their certification is maintained continuously.
RENEWAL PROCESS:
Renewal of operating authority applications are mailed to certified services sixty
to ninety days prior to expiration of their certificates. These mailings are sent to
the last official address filed with the Department by the agency. It is the
agency’s responsibility to provide the Bureau of Emergency Medical Services of
their current mailing address and to advise the Bureau of EMS of any address
changes.
Failure to receive this mailing is not justification for lapsed certification. Services
that do not receive renewal applications by mail or which need assistance may
find copies of the application and other needed forms in the DOH Bureau of
EMS Operations Resource Guide or on the Bureau’s site on the World Wide
Web: www.health.state.ny.us/nysdoh/ems/main.htm
It is the responsibility of operators of certified services to file complete
recertification applications with the Department at least thirty days prior to the
expiration date of their current certificate. Completed applications shall be
filed with the Department’s regional office as indicated in the application
packet or on the web site.
Policy Statement 03-01
Page 1 of 2
Completed recertification applications received by the Department prior to the
expiration of the current certificate, will result in a new certificate issued with an
expiration date two years from the current expiration date. This assures no lapse
in certification. However, at the Department’s option, window stickers for vehicles
may be withheld pending an inspection of the agency, its records and vehicles.
Applications filed after the expiration date or which are submitted incomplete will
be issued an expiration date two (2) years from the end of the month in which the
application is received and approved by the Department. Failure to file complete
recertification applications on time may result in periods of lapsed certification.
Additionally the Department may report lapses of certification to Medicaid,
Medicare, insurance carriers or other interested parties upon request. Services
may also be subject to disciplinary procedures if they operate without
certification.
The Regional Medical Advisory Committee (REMAC) will be advised of any lapse
of certification of an ALS agency as advanced life support may not be provided
by a service that is not currently certified by the Department. The authority to
posses and administer controlled substances held by any EMS service will be
considered suspended during any lapse in certification by the service.
All current operating certificates issued by the Department must be posted
conspicuously, as indicated on the certificate.
If there are any errors on the certificate that is issued to an agency it is the
agency’s responsibility to notify the Department to have a new certificate issued.
Certificates may not be transferred and remain the property of the NYS
Department of Health. Certificates must be surrendered to the Department upon
any termination of operation by a certified EMS agency.
Authorized and Issued by;
Edward G. Wronski, Director
Bureau of Emergency Medical Services
Policy Statement 03-01
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
02-11
Date: 09/25/02
Re: Preventive
Maintenance of EMS
Vehicles and Equipment
Supercedes/Updates: New
Page 1 of 3
PURPOSE:
This policy statement is intended to provide EMS agencies with guidance to assist them
in meeting their requirement to have policies regarding preventive maintenance for all
EMS vehicles and equipment pursuant to 10 NYCRR Part 800.21(p)(8).
EMS VEHICLES:
The most effective source of information regarding the preventive maintenance program
for an EMS vehicle comes from the manufacture’s “Operating Instructions” or “Owner’s
Manual” that was provided with the vehicle at the time of delivery. If your agency does
not have a copy of this type of information than it should be obtained from the
manufacturer.
An agency policy developed to comply with 800.21(p)(8) should include (but not be
limited to):
•
•
•
•
•
•
•
•
•
•
•
•
•
Annual DMV Inspection
Fluid and filter change intervals
Tire rotation intervals
Fluid level check schedule
Battery check intervals
Inspection of lights and the electrical system
Inspection of belts, hoses and clamps
Inspection of doors and gaskets
Brake service intervals
Evaluation of the heating and cooling system
Schedule of other maintenance procedures particular to vehicle
Procedures for daily/weekly inspections to be performed by members/employees
Procedures employees/members should follow in the event a malfunction occurs
As important as the performance of these procedures, of equal importance is their
documentation. Services are urged to maintain complete maintenance records on all their
vehicles. Such records should include inspection reports as well as records of services
Policy Statement 02-11
Page 1 of 3
performed by either the agency’s employees/members, outside vendors or representatives
of the vehicle manufacturer. This record might also contain any service bulletins or recall
notices issued by the manufacture and records of compliance with their
recommendations.
Personally owned vehicles operated as Emergency Ambulance Service Vehicles (EASV)
should also be covered by the agency’s policy to assure that the owner/operator of the
vehicle is maintaining the vehicle and it is capable of emergency response and safe
operation.
EMS EQUIPMENT:
Nearly all pieces of EMS equipment come with some form of an “Owner’s Manual” or
“Operator’s Guide”. These documents need to be retained and reviewed by appropriate
agency staff and the procedures for care and maintenance should be followed.
Each agency’s policy on preventive maintenance of equipment should include, but not be
limited to, provisions to:
•
•
•
•
•
•
•
Perform manufacture’s recommended calibrations/inspections
Perform manufacture’s recommended service (including lubrications) and the proper
materials to use in performing recommended service
Replace and service batteries (if applicable)
Proper inspection of all equipment available to provider
Proper cleaning and disinfecting procedures
Procedures for removing equipment from service
Procedures to be followed in the event of equipment failures
The following types of equipment should be covered by any preventive maintenance or
biometric service policy developed by an agency:
•
•
•
•
•
•
•
•
•
•
•
•
•
Radios and other communications equipment
Stretchers and stretcher mounting hardware
AEDs
ECG/Manual Defibrillator equipment
Pulse oxyimeters
Suction devices
Rechargeable battery powered lights
BP Cuffs; manual and automatic
Patient stabilization/transportation/immobilization devices
Oxygen regulators and delivery systems
Ventilators
Infusion devices
Specialized pieces of equipment owned or operated by the service
Policy Statement 02-11
Page 2 of 3
As with vehicles EMS agencies should have a record or log (paper or electronic) for each
piece of equipment that contains:
•
•
•
•
When and where the equipment was purchased/obtained
Documentation pertaining to repairs of the piece of equipment
Equipment maintenance schedule per the manufacturers instructions
Documentation pertaining to all maintenance performed on the equipment
All agencies are reminded that they must “maintain a record of all unexpected authorized
EMS response vehicle and patient care equipment failures that could have resulted in
harm to a patient and the corrective actions taken. A copy of this record shall be
submitted to the Department with the EMS service's biennial recertification application” 1
The development of clear and concise policies provide EMS service employees/members
with an understanding as to what each member of the organizations roles and
responsibilities are relating to maintaining, servicing and repairing agency equipment and
vehicles. These policies also serve to allow providers to have functioning vehicles and
equipment to provide the best possible patient care.
Issued and Authorized by:
Edward G. Wronski, Director
Bureau of EMS
1
10 NYCRR part 800.21(r)
Policy Statement 02-11
Page 3 of 3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: New
02 - 09
Date: 8/29/02
Re: Needlestick and
Sharps Injuries
Page 1 of 2
This policy provides advanced life support (ALS) EMS agencies with a brief explanation of the
recent revisions to the United States Department of Labor, Occupational Health and Safety
Administration (OSHA) regulations and the Needlestick Safety and Prevention Act. This policy
does not supercede or take precedence over any guidance that OSHA or New York State Public
Employee Safety and Health (PESH) may provide.
In 1992 the OSHA issued the Bloodborne Pathogen regulations (29 CFR 1910). In November
of 2000, the Needlestick Safety and Prevention Act was signed into law and took effect on April
18th, 2001. This new act required that OSHA revise the Bloodborne Pathogen standard to add
the following components:
♦
♦
♦
♦
Provide new examples in the definition of engineering controls.
Require that exposure control plans reflect how employers implement a needleless/safety and needle
stick prevention program.
Requires the employer to solicit input from direct patient care employees in the identification,
evaluation and selection of safer needle devices and work practices.
Require employers to establish and maintain a log of sharps related injuries.
This new section of the OSHA regulations requires that EMS services use sharps, such as
syringes and intravenous catheters that are engineered with built in safety features or
mechanisms that will reduce the risk of a blood or body fluid exposure by a needlestick injury.
In July of 2002 OSHA further clarified their position on the removal of needles from blood tube
holders in order to reuse the blood tube holder. OSHA stated that “Contaminated needles and
other contaminated sharps shall not be bent, recapped, or removed, unless the employer
can demonstrate that no alternative is feasible or that such action is required by a
specific medical or dental procedure.” More specifically, OSHA’s new compliance directive,
CPL 2-2.69 at XIII.D.5 states, “removing the needle from a used blood-drawing/phlebotomy
device is rarely, if ever, required by a medical procedure. Because such devices involve
the use of a double-ended needle, such removal clearly exposes employees to additional
risk, as does the increased manipulation of a contaminated device.” In order to prevent
potential worker exposure to the contaminated hollow bore needle at both the front and back
ends, blood tube holders, with needles attached, must be immediately discarded into an
accessible sharps container after the safety feature has been activated.
Policy Statement 02-09
Page 1 of 2
Engineering Controls
The revised definition of engineering controls means “controls (e.g. sharps, disposal containers,
self sheathing needles, safer medical devices such as sharps with engineered injury protections
and needleless systems) that isolate or remove the bloodborne pathogens hazard from the work
place”. Sharps with engineered injury protections are defined as non-needle or a needle with a
built in safety feature or mechanism that will effectively reduce the risk of a blood or body fluid
exposure.
Revision to the Exposure Control Plan (ECP)
EMS agencies must update their existing ECP to include changes in technology that will reduce
or eliminate exposure to blood or body fluids. The ECP must include the consideration and
implementation of safer medical devices and the solicitation of input from non-managerial
employees.
Sharps Injury Log
The revision of the OSHA regulations now requires that EMS services maintain a sharps injury
log. The log must include information regarding the type and brand of device involved,
the department or area the incident occurred and a description of the incident for each
needlestick injury.
Selection of Safer Medical Devices
In deciding what type of safety device to choose, the EMS agency should select an appropriate
device based on the agency’s exposure determination and one, which will not compromise
patient care. The service must identify any worker exposure to blood and body fluids, review all
processes and procedures that have a risk of exposure and re-evaluate any new processes or
procedures that are implemented. The OSHA regulation requires the agency to involve
employees in the testing and choosing of the devices that will be used in the field.
The process of choosing an appropriate safety device should be made in consultation with the
agency medical director. The Regional Emergency Medical Advisory Committee (REMAC) may
also be able to provide further guidance in determining an appropriate safe needle device.
Training and Education on the Use of Safer Devices
Recent studies have shown that health care providers that use safer needle devices, without the
proper in service training, may be at a greater risk of a needlestick injury than when using
unprotected needle devices. Additionally, poor or no training on new safer needle devices
may be attributed to a decrease in IV cannulation success rates. Therefore, it is imperative
that agencies provide a comprehensive training program with the safe needle devices, which
have been chosen, for use by the EMS agency. Each provider must have the opportunity to
practice using training manikins with the safe device. If possible, the provider should also be
able to use the safe devices under supervision in field practice.
Further Information
For further information please refer to the following web sites:
¾ NYS Department of Labor, Public Employees Health and Safety
www.labor.ny.us (Business in New York)
¾ US Department of Labor, Occupational Health and Safety
www.osha.gov (Bloodborne Pathogens)
Policy Statement 02-09
Page 2 of 2
No.
02 - 01
Date: 01/02/02
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
Re: Requirement to
report instances of
suspected child abuse or
maltreatment.
Page 1 of 7
On November 13th, 2001 § 413 of the Social Services Law was amended, in relation to persons and
officials who are required to report cases of suspected child abuse or maltreatment. Effective February
1st, 2002 the law will require Emergency Medical Technicians to report suspected child abuse they come
across while performing their jobs. The Bureau of EMS will not require EMTs to attend a specialized
course for child abuse. The current EMS course curricula include sections on child abuse. However, the
Bureau does reserve the right to amend the curricula in the future. Therefore, this Policy Statement and
attached fact sheet are intended to be used by New York State EMTs to help them better understand their
obligations as well as the signs and symptoms of possible child abuse or maltreatment.
Reporting Procedures:
§ 415 of the Social Services Law states that, “Reports of suspected child abuse or maltreatment made
pursuant to this title shall be made immediately by telephone or by telephone facsimile machine on a form
supplied by the commissioner. Oral reports shall be followed by a report in writing within forty-eight
hours after such oral report. Oral reports shall be made to the statewide central register of child abuse
and maltreatment unless the appropriate local plan for the provision of child protective services provides
that oral reports should be made to the local child protective service.” i
Oral Reports of suspected child abuse or maltreatment shall be made by calling the NYS Child Abuse
and Maltreatment Register at:
1-800-635-1522
NOTE: This phone number is for mandated reporters ONLY and should NOT be provided to the
general public.
•
All oral reports must be followed up with a written report within 48 hours using Form DSS-2221-A,
“Report of Suspected Child Abuse or Maltreatment” (Attached).
•
A copy of the completed and submitted Form DSS-2221-A should be attached to the agency copy of
the Prehospital Care Report retained by the agency.
Agency Policies
10 NYCRR Part 800.21(p)(11)(ii) requires all ambulance services to have and enforce a written policy
regarding the reporting of child abuse. Based on the addition to §413 of Social Services Law all services
should ensure that the policy developed regarding this requirement includes the mandatory reporting
requirement and the process required by Social Services Law § 415. The agency policy needs to address
areas such as Prehospital Care Report documentation, notifying the Emergency Room staff, calling the
above 800 telephone number, and the completion of form DSS-2221-A.
Immunity From Liability
Immunity from liability for reporting cases of suspected child abuse or maltreatment is provided to those
individuals required to report such cases under § 419 of the Social Services Law so long as the individual
was acting in, “good faith”.
Failure To Report
§ 420 Of the Social Services Law states:
1. Any person, official or institution required by this title to report a case of suspected child abuse or
maltreatment who willfully fails to do so shall be guilty of a class A misdemeanor.
2. Any person, official or institution required by this title to report a case of suspected child abuse or
maltreatment who knowingly and willfully fails to do so shall be civilly liable for the damages
proximately caused by such failure.
Attachments:
Child Abuse/Maltreatment Fact Sheet
Form DSS-2221-A
Issued and Authorized by:
Edward G. Wronski, Director
Bureau of Emergency Medical Services
i
Pertains to Onondoga and Monroe Counties Only
Child Abuse and Maltreatment
Fact Sheet
This fact sheet is intended to be used by New York State EMTs as a learning tool and guide to help them
better understand the signs and symptoms of possible child abuse or maltreatment. The signs and
indicators listed in this document are not conclusive proof of child abuse or maltreatment. There
can be other, reasonable explanations for what you observe.
Definition of Child Abuse:
An “abused child” is a child less than eighteen (18) years of age whose parent or other person
legally responsible for his/her care:
1. Inflicts or allows to be inflicted upon the child serious physical injury, or
2. Creates or allows to be created a substantial risk of physical injury, or
3. Commits or allows to be committed against the child a sexual offense as defined in
the penal law.
Definition of Child Maltreatment:
A “maltreated child” is a child under eighteen (18) years of age who has had serious physical
injury inflicted upon him/her by other than accidental means.
A “maltreated child” is also a child under eighteen (18) years of age whose physical, mental or
emotional condition has been impaired or is in danger of becoming impaired as a result of the
failure of his/her parent or other person legally responsible for his/her care to exercise a minimum
degree of care:
1. In supplying the child with adequate food, clothing, shelter, education, medical or
surgical care, though financially able to do so or offered financial or other reasonable
means to do so; or
2. In providing the child with proper supervision or guardianship; or
3. By unreasonable inflicting, or allowing to be inflicted, harm or substantial risk
thereof, including the infliction of excessive corporal punishment; or
4. By using a drug or drugs; or
5. By using alcoholic beverages to the extent that he/she loses self-control of his/her
actions; or
6. By any other acts of a similarly serious nature requiring the aid of the Family Court.
Some of the physical indicators of possible child abuse:
♦ Bruises in different stages of healing, welts, or bite marks on face, lips, mouth, neck, wrist,
thighs, ankles, or torso, or on several area of the body such as:
ü Injuries to both eyes or both cheeks (usually only one side of the face is injured in an
accident)
ü Marks that are clustered, that form regular patterns, that reflect the shape of such
articles as an electrical cord, belt buckle, fork tines, or human teeth.
ü Grab marks on the arms or shoulders; and/or
ü Bizarre marks, such as permanent tattoos
♦ Lacerations or abrasions to mouth, lips, gums, eyes, external genitalia, arms, legs, or torso.
♦ Burns:
ü From cigars or cigarettes, especially on soles, palms, back, or buttocks.
ü From immersion in scalding water (socklike or glovelike on feet or on hands,
doughnut-shaped on buttocks or genitalia)
ü That are patterned like an object, such as an iron or electric burner; burns from ropes
on arms, legs, neck, or torso.
♦ Any fractures:
ü Multiple or spiral, of the long bones, to skull, nose, or facial structure.
ü Other injuries, such as dislocation.
♦ Head Injuries:
ü Absence of hair or hemorrhage beneath the scalp from hairpulling.
ü Subdural hematomas
ü Retinal hemorrhage or detachment, from shaking
ü Eye injuries
ü Jaw and nasal fractures
ü Tooth or frenulum injury
♦ Symptoms that suggest fabricated or induced illness, sometimes known as Munchausen
Syndrome by Proxy (MSP); for example, a parent might be repeatedly feeding a child
quantities of laxatives sufficient to cause diarrhea, dehydration, or hospitalization, without
revealing the child has been medicated.
Some of the emotional and behavioral signs of possible child abuse:
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Apprehension when other children cry
Aggressiveness
Withdrawal
Fear of going home
Fear of parents and other adults
Extreme mood swings
Inappropriate mood
Habit disorder, such as nail-biting
Low self-esteem
Neuroses, such as hypochondria, obsessions
Refusal to remove outer garments
Attempted suicide
Some of the physical signs of possible child neglect:
ü
ü
ü
ü
ü
ü
ü
ü
Newborn with positive toxicology for drugs
Lags in physical development
Constant hunger
Speech disorder
Poor hygiene
Inappropriate dress for the season
Lack of medical care
Inadequate supervision
Some of the emotional and behavioral indicators of possible child neglect:
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Chronic fatigue
Habit disorder, such as thumb-sucking by a ten-year-old, rocking, biting
Reports no caregiver at home
Frequent absences from school or lateness
Hypochondria
Shifts from complaint to aggressive behavior
Age-inappropriate behavior
Begging for food
Lags in emotional or mental development
Use of alcohol or drugs
Some of the signs of possible child sexual abuse:
ü
ü
ü
ü
ü
ü
ü
ü
ü
Difficulty in walking and sitting
Pain or itching in the genital area
Torn, stained, or bloody underclothing
Bruises or bleeding of external genitalia or vaginal or anal areas
Bruises to the hard or soft palate
Sexually transmitted diseases, especially in preteens
Painful discharge of urine or repeated urinary infections
Foreign bodies in the vagina or the rectum
Pregnancy, especially in early adolescence
Some emotional and behavioral signs of possible child sexual abuse:
Many of the following indicators may also reflect problems unrelated to sexual abuse. Moreover,
no one child will show all of these signs.
Particularly in children who are less than eight years of age look for:
ü Eating disorders
ü Fear of sleeping alone
ü Enuresis (bed wetting at night or
daytime accidents)
ü Separation anxiety
ü Thumb or object sucking
ü Encopresis (soiling)
ü Language regression
ü Sexual talk
ü Excessive masturbation
ü Sexual acting out, posturing
ü Crying spells
ü Hyperactivity
ü Change in school behavior (fear of school,
drop in grades, trouble concentrating)
ü Regular tantrums
ü Excessive fear (including of men or women)
ü Nightmares or night terrors
ü Sadness or depression
ü Suicidal thoughts
ü Extreme nervousness
ü Hypochondria
In children over eight through adolescence:
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Fear of being alone
Peer problems
Frequent fights with family members
Poor self-esteem
Excessive nervousness
Emotional numbness (out-of body
experiences, or feelings of unreality)
Substance Abuse
Excessive guilt or shame
Mood swings
Sexual concerns or preoccupations
Withdrawn, isolated behavior
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Overly compliant behavior
Suicidal thoughts or gestures
Self-mutilation
Hyperalertness
Sexual acting out
Avoidant, phobic behavior, including sexual
topics
Unwillingness to change into gym clothes
Violent fantasies
Memory problems
Fear of future abuse
Intrusive, recurrent thoughts, or flashbacks
LDSS-2221A (Rev. 11/97)
Report Date
REPORT OF SUSPECTED
CHILD ABUSE OR MALTREATMENT
New York State
/
Case ID
Call ID
Local Case #
Local Dist/Agency
/
Time AM/PM
Office of Children and Family Services
SUBJECTS OF REPORT
Line #
List all children in household, adults responsible and alleged subjects.
Last Name
First Name
Aliases
Sex
Birthday or Age
(M, F, Unk)
Mo/ Day/ Yr
Ethnic
Code
Relation
Code
Role
Lang.
1.
2.
3.
4.
5.
6.
7.
MORE
List Addresses and Telephone Numbers (Using Line Numbers From Above)
Telephone No.
BASIS OF SUSPICIONS
Alleged suspicions of abuse or maltreatment. Give child(ren)'s line number(s). If all children, write "ALL".
______ DOA/Fatality
______ Child's Drug/Alcohol Use
______ Educational Neglect
______ Fractures
______ Emotional Neglect
______ Internal Injuries (i.e. Subdural Hematoma)
______ Poisoning/Noxious
Substances
______Choking/Twisting/Shaking
______ Lacerations/Bruises/Welts
______ Lack of Medical Care
______ Burns/Scalding
______ Malnutrition/Failure to Thrive ______ Abandonment
______ Excessive Corporal Punishment
______ Sexual Abuse
______ Parent's Drug/Alcohol Misuse
______ Inappropriate Isolation/Restraint(Institutional Abuse Only)
______ Inadequate Guardianship
______ Other specify)_____________
______ Inappropriate Custodial Conduct(Institutional Abuse Only)
______ Swelling/Dislocation/Sprains
State reasons for suspicion, including the nature and extent of each child's injuries, abuse or
maltreatment, past and present, and any evidence or suspicions of "Parental" behavior contributing
to the problem.
The Mandated Reporter Requests Finding of Investigation
CONFIDENTIAL
NAME
YES
______ Inadequate
Food/Clothing/Shelter
______ Lack of Supervision
(If known, give time/date of alleged incident)
____/____/____ Time________(AM/PM)
NO
CONFIDENTIAL
SOURCES OF REPORT
TELEPHONE
NAME
ADDRESS
ADDRESS
AGENCY/INSTITUTION
AGENCY/INSTITUTION
TELEPHONE
RELATIONSHIP ( ü = REPORTER, X = SOURCE)
Med. Exam/Coroner
Physician
Hosp. Staff
Law Enforcement
Neighbor
Social Services
Public Health
Mental Health
School Staff
Other Specify)_________________________
For Use By
Physicians
Only
Medical Diagnosis on Child
Relative
Signature of Physician who examined/treated child
Instit. Staff
Telephone No.
X
Hospitalization Required:
None
Under 1 week
1-2 weeks
Actions Taken Or
Medical Exam
X-Ray
Removal/Keeping
Not. Med Exam/Coroner
About To Be Taken
Photographs
Hospitalization
Returning Home
Title
Notified DA
Signature of Person Making This Report
Over 2 weeks
Date Submitted
Mo. Day Yr.
DSS-2221A (Rev. 11/97)(REVERSE)
NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES
ETHNICITY CODES
AA: African-American
AS: Asian
CW: Caucasian
HL: Hispanic
UK: Unknown
XX: Other
RELATION CODES
FAMILIAL REPORTS
AU: Aunt/Uncle
CH: Child
GP: Grandparent
FM: Other Fam. Member
FP: Foster Parent
IAB REPORTS ONLY
AR: Administrator
CW: Child Care Wkr
DC: DayCare Fac/Prov
DO: Director/Operator
XX: Other
PA: Parent
PS: Parent Substitute
UH: Unrelated Home Mem.
UK: Unknown
IN: Instit. Non-Prof
IP: Instit. Pers/Vol.
PI: Psychiatric Staff
ROLE CODES
LANGUAGE
AB: Abused Child
MA: Maltreated Child
AS: Alleged Subject
(Perpetrator)
NO: No Role
UK: Unknown
CH: Chinese
CR: Creole
EN: English
FR: French
GR:German
HI: Hindi
HW: Hebrew
IT: Italian
JP: Japanese
KR: Korean
MU: Multiple
PL: Polish
RS: Russian
SI: Sign
SP: Spanish
VT: Vietnamese
XX: Other
Abstract Sections from Article 6, Title 6, Social Services Law
Section 412. Definitions
1. Definition of Child Abuse (see N.Y.S. Family Court Act Section 1012(e)
An “abused child” is a child less than eighteen years of age whose parent or other person legally responsible for his care:
(1) Inflicts or allows to be inflicted upon the child serious physical injury, or
(2) Creates or allows to be created a substantial risk of physical injury, or
(3) Commits or allows to committed against the child a sexual offense as defined in the penal law.
2. Definition of Child Maltreatment (see N.Y.S. Family Court Act, Section 1012(f)
A “maltreated child” is a child under eighteen years of age whose physical, mental or emotional condition has been impaired
or is in danger of becoming impaired as a result of the failure of his parent or other person legally responsible for his care to
exercise a minimum degree of care:
1) in supplying the child with adequate food, clothing, shelter, education, medical or surgical care, though financially able to
do so or offered financial or other reasonable means to do so; or
2) in providing the child with proper supervision or guardianship; or
3) by unreasonable inflicting, or allowing to be inflicted, harm or a substantial risk thereof, including the infliction of
excessive corporal punishment; or
4) by using a drug or drugs; or
5) by using alcoholic beverages to the extent that he loses self-control of his actions; or
6) by any other acts of a similarly serious nature requiring the aid of the Family Court.
Section 415. Reporting Procedure. Reports of suspected child abuse or maltreatment shall be made immediately by telephone*
and in writing within 48 hours after such oral report…written reports shall be made to the appropriate local child protective services
on this form (Report of Suspected Child Abuse and Maltreatment, DSS-2221-A). Submit the written DSS-2221-A form for
Residential Institutional abuse reports directly to the State Central Register 40 N. Pearl St. Albany, N.Y. 12243.
Section 419. Immunity from Liability. Any person, official or institution participating in good faith in the making of a report, the
taking of photographs, or the removal or keeping of a child pursuant to this title shall have immunity from any liability, civil or of any
person required to report cases of child abuse or maltreatment shall be presumed.
Section 420. Penalties for Failure to Report.
1. Any person, official, or institution required by this title to report a case of suspected child abuse or maltreatment who willfully
fails to do so shall be guilty of a class A misdemeanor.
2. Any person, official, or institution required by this title to report a case of suspected child abuse or maltreatment who knowingly
and willfully fails to do so shall be civilly liable for the damages proximately caused by such failure.
*NYS CHILD ABUSE AND MALTREATMENT REGISTER: 1-800-635-1522 (FOR MANDATED REPORTERS ONLY)
1-800-342-3720 (FOR PUBLIC CALLERS)
STATE OF NEW YORK
DEPARTMENT OF HEALTH
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner
Albany, New York 12237
Dennis P. Whalen
Executive Deputy Commissioner
March 6, 2002
Dear EMS Agency:
In an earlier letter we shared that effective February 1, 2002, emergency medical technicians (EMTs) are
required to report suspected cases of child abuse or maltreatment to the New York State central child abuse
registry. We had also provided a copy of the Department of Health’s Policy Statement # 02-01, which describes
how EMTs and ambulance services are to comply with this new reporting requirement.
At this time we would like to clarify a few issues that have come to our attention concerning the reporting
of suspected child abuse cases by EMTs. Listed below is a summary of these issues:
1. EMTs are not required to take a course on how to comply with the reporting requirements. However, Regional
EMS Councils, EMS services, EMS Course Sponsors and other interested parties may offer an overview of the
legislation and guidelines on how best to achieve the desired results within their community or EMS agency.
Such a course may be designed to meet the continuing medical education requirements of the Pilot Project.
2. For the time being, EMTs are required to be the reporter of record for suspected cases even if the child is
transported and admitted to a hospital. EMTs can not and should not transfer the responsibility for reporting a
suspected case to hospital personnel or any other health provider.
3. If there are multiple EMTs responding to a call from the same EMS agency, it is only necessary for the EMT
of record (in-charge of patient care) from that agency to submit the required form. This may be confusing
when there are multiple agencies responding, treating, and transporting the same patient. The EMT of record
from each agency must file a separate report.
4. Reporting Procedures: An oral report must be made immediately to the NYS Child Abuse and Maltreatment
Register at 1-800-635-1522. This must be followed by a written report, using Form DSS-2221-A, within 48
hours to the local child protective services for where the child resides. The only time Form DSS-2221-A is to
be sent directly to the NYS Central Register is when the child resides in a Residential Institution.
5. EMS agencies are reminded that they must update their policies and procedures with regards to their personnel
reporting child abuse and/or neglect. These policies and procedures need to reflect the guidelines in BEMS
policy statement #02-01 as well as the required local reporting procedures for their area.
6. It is understood that EMTs will need to complete the DSS-2221-A form after an emergency situation. EMTs
are not expected to have the form filled out in its entirety. EMTs should fill out as much information as
possible, with the limited information they have and submit the form to their local child protective service who
will obtain the rest of the information on the form.
7. The Bureau of EMS encourages EMS agencies to continue to have open dialogue with their local Child
Protective Service to better understand issues at the local level
For assistance on how best EMTs and/or ambulance services can meet the new reporting
requirements, please contact the Bureau of EMS at 518-402-0996 Ext. 1, 4 (Education Unit). . EMTs should
refrain from contacting the NYS Central Register. The Requirement to Report Instances of Suspected Child
Abuse or Maltreatment Policy Statement is accessible at www.health.state.ny.us (click on providers for EMS
webpage). If you have questions about the mandatory reporter program, please visit the New York State Office of
Children and Family Services at http://www.ocfs.state.ny.us or contact them at 518-474-4670.
Thank you for your cooperation with this important reporting initiative.
Sincerely,
Edward G. Wronski, Director
Bureau of Emergency Medical Services
cc:
Regional EMS Councils
Regional Emergency Medical Advisory Committees
EMS Course Sponsors
No.
01 - 08
Date: October 18, 2001
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re:
Unknown Dry
Substance / Suspected
Anthrax Response
Advisory
Supercedes/Updates:
Page
1 of 3
ADVISORY FOR RESPONSE TO PATIENTS EXPOSED TO UNKNOWN SUBSTANCES
PLEASE DISTRIBUTE IMMEDIATELY
This advisory is being sent to you to assist when responding to an emergency
call involving a package, envelope or substance suspected of being Anthrax.
Also attached are Anthrax advisories/protocols developed by the Department of
Health to assist you in understanding what Anthrax is, mail handling protocols,
recommended patient/equipment, decontamination guidelines, specimen
handling and criteria for lab testing.
There are some primary things to understand about responding to an
emergency medical response which involves a call site alleged to contain
Anthrax or involving an unknown powder/substance:
1.
Confirm scene safety and type of incident. Responding EMS agencies are NOT
advised to enter an affected area until a competent authority has determined the
scene to be safe.
2.
If your arrive on the scene first, notify competent authority.
3.
If an unknown substance has been found in the air handling system, evacuate
the premises immediately and notify the competent authority.
4.
Anthrax is NOT contagious. Person to person transmission has never been
reported.
5.
There will be little or no need for prehospital medical care. Do not
transport the individual to a hospital, unless other medical conditions need
to be addressed (i.e., chest pain, severe anxiety). Patients should not be
transported to a hospital.
6.
If patient insists on being transported to the hospital, contact medical control for
physician consultation.
1
7.
If you transport to the hospital, notify the receiving hospital that you are bringing
a patient who has been exposed to a powder/unknown substance and request
the hospital to have staff meet you outside of the Emergency Department.
8.
Create a list of individuals who were in area of exposure to be given to the
incident commander or local police and shared with local public health officials.
All, or most individuals, should be released home with the self-monitoring
instructions attached.
9.
The need for testing of the substance will be determined by appropriate
authorities following risk assessment.
10.
Unless a lab test confirms the nature of the powder substance, there is no need
to immediately initiate prehospital medical treatment. These lab tests take at
least 24 hours to complete. There is no harm to an individual waiting for lab
results before beginning appropriate medical treatment
11.
The Centers for Disease Control (CDC) has advised that no treatment is
necessary for Anthrax in an otherwise healthy person exposed to an unknown
powder/substance.
12.
If you arrive at the scene and patient(s) have been decontaminated, you should
follow the above guidelines, but assist in addressing individual concerns about
infection and treatment.
13.
If you enter a scene and the patient has not been decontaminated and there is
an observable substance, contact a competent authority and perform the
following:
Χ
Χ
Χ
Χ
14.
If the patient has a powder or other substance on their skin or clothing,
ask the patient to remove their outer clothing. If the patient is not able to
undress themselves, put on PPE1 and remove the patients outer or
exposed clothing.
Provide the patient with a disposable garment or a sheet.
The patient’s clothing should be secured by the patient (if possible), in a
clear plastic bag and left with the competent authorities on the scene.
See attached Decontamination Advisory. This should be followed by the
appropriate local agency responsible for decontamination. EMS is not
generally responsible for decontamination.
Remember you are considered health care providers who the public expects will
be knowledgeable about Anthrax. Often, you will be the highest medical
authority at the scene. Please review the attached materials and be prepared to
work with local or state public health officials in calming public fears regarding
these incidents.
NOTE: This guideline is being provided to your local REMAC
for incorporation into local protocol.
1
Personal Protective Equipment (PPE) - Gloves, mask and eye protection. These may
not be necessary on every call. Use the appropriate PPE based on the patient assessment and
the presence of blood or body fluids and pertinent past medical history.
2
Attachments
Χ
Χ
Χ
Χ
Χ
Χ
DOH Anthrax Fact Sheet
Protocol for Mail Handling
Decontamination Advisory
Patient Self-monitoring Instructions
Criteria For Wadsworth Laboratory Testing
Protocol for Submitting Environmental Samples for Laboratory Testing
cc: Regional Emergency Medical Advisory Committees
County EMS Coordinators
Regional DOH Offices
State Emergency Management Office
County Emergency Managers
County Fire Coordinators
County Hazmat Teams
County/City Health Departments
New York State Police
Sheriffs Association
Hospital Emergency Departments
3
No. 01-07
Date: July 09, 2001
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Guidelines to Follow
in Case of an EMS
Vehicle Collision
Supercedes/Updates: 88-18
Page 1 of 2
SUBJECT: Sample Standard Operating Procedure to Follow in Case of an EMS
Vehicle Collision
In response to concerns of EMS service operators on how to handle an EMS vehicle
accident the following guidelines have been prepared for inclusion into each service’s
standard operating procedures.
If A Collision Occurs With An EMS Vehicle
1) Protect the scene with warning lights or flares. If the vehicles are in a hazardous
location or blocking traffic, they may be moved to the side of the street.
2) Notify the dispatcher immediately to request the following:
a) The supervisor
b) The appropriate police agency.
c) Any other necessary services such as Fire Department or towing service etc.
3) If the EMS vehicle was enroute to the scene of a call notify the dispatcher to
immediately dispatch another EMS unit to that assignment.
4) If a patient was being transported and the ambulance has been rendered inoperable,
have the dispatcher send an ambulance to transport the patient.
5) If the patient being transported is unstable and the ambulance is not rendered
inoperable, and there are no other unstable patients on the scene, then instruct the
other vehicle operator to remain at the scene until police arrive and provide them
with:
•
•
•
Service name;
Vehicle identifier; and
The ambulance operator’s name
NYS DOH Policy Statement 01-07
Page 1 of 2
•
•
Record the name, vehicle type, make, and license number of the other vehicle before
leaving the scene with your patient.
If the crew has an extra person, leave him/her at the scene to begin the paperwork.
6) If a stable patient is being transported assure that care is being provided to the
patient by an EMT while awaiting the arrival of the police, if waiting will not cause
excessive delay. While waiting for police to arrive exchange information then
continue transport to the original destination upon arrival of the police. Return to the
scene after delivering the patient to their destination.
7) Administer patient care to any injured persons.
8) If there is no patient exchange necessary, obtain information with other involved
person (license, registration and insurance card). Record the police officer’s name,
shield number, department; if any tickets are issued, and make a rough sketch of the
pertinent aspects of the scene.
9) Obtain name, address, telephone number and a brief statement from any witness.
10) Make sure even the minor injuries are well-documented and receive appropriate
emergency department follow-up as needed.
11) Per 10 NYCRR Part 800.21, report to the Department of Health EMS Bureau
Representative for your region, within 24 hours, any accident involving personal
injury and/or any accident that results in an ambulance being placed out of service.
12) New York State Vehicle and Traffic Law also requires the owner of any vehicle
involved in an accident resulting in any personal injury, death and/or damage
exceeding $1,000 (to any one vehicle) to file a report with the Department of Motor
Vehicles within 10 days. The required MV-104 form may be obtained at any police
station or DMV office.
13) Individual EMS agencies should contact their insurance carriers to determine if there
are any additional requirements they may have regarding this topic.
Issued and Authorized by
Edward G. Wronski, Director
Bureau of Emergency Medical Services
NYS DOH Policy Statement 01-07
Page 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
01 - 05
Date: 06/1/01
Re: Abandoned Infant
Protection Act
POLICY STATEMENT
Supercedes/Updates: New
Page 1 of 2
Background Information
The Abandoned Infant Protection Act was created in Chapter 156 of the Laws
of 2000. Under this provision a parent, guardian or other legally responsible
person may leave their infant (who must be five days old or less) at a safe place.
The law requires that an adult must intend that the child be safe from physical
injury, cared for in an appropriate manner, with an appropriate person, in a
suitable location and promptly notify an appropriate person of the child’s location.
People leaving an infant in compliance with this law are not required to provide
their names. Such individuals will not be prosecuted as a class E felony of
Abandonment of a Child and class A misdemeanor of Endangering the Welfare
of a Child.
The governing legislation did not specify or define what is an acceptable safe
location. Instead, local district attorneys are to determine whether the parent left
the child in an appropriate location. Individuals who give up their infants do not
automatically surrender their parental rights; and may later seek to reclaim the
child. It is important to note that this legislation does not amend provisions of the
Social Services law which make abandonment of an infant reportable to the New
York State Central Register for Child Abuse and Maltreatment.
The New York State Office of Children and Family Services has released several
Public Service Announcements and brochures about this program. In these
materials; the public is provided with the intent of the new law; including a listing
of suggested safe places where infants may be brought. The sites include
hospitals, police stations, fire stations and other safe places. Some county
district attorneys have already defined what constitutes a safe place within their
county. Other counties have not yet done so.
1
Role of Emergency Medical Services Agencies
In the event a parent or legal guardian chooses to relinquish care of their
newborn infant to an emergency medical service agency; the following guidelines
should be considered:
1. In keeping with the intent of the governing legislation; parents are not required to provide their
names to the safe location or staff. In a non-judgmental manner, EMS staff may ask the
presenting adult if there is any medical information that is important to know in the care of the
infant.
2. EMS services and systems may want to contact their county Office of the District Attorney to
determine what if any locations have been identified as “safe places” by the District Attorney
for the purposes of this legislation.
3. Infants received by an EMS service agency should be transported to the nearest hospital for
medical assessment/care. EMS agencies should not be expected to interact with local child
protection service agencies unless directed to do so.
4. If a parent seeks follow up information about the child they relinquished to the care of the
EMS service agency; a referral should be made to the hospital where the infant was
transported or the local office of social services.
Further Information
Information about this program may be obtained by contacting:
New York State Office of Children and Family Services
Capital View Office Park
52 Washington Street
Rensselaer, New York 12144
1-800-345-SAFE
http://www.dfa.state.ny.us
Issued by
Edward Wronski, Director
Bureau of Emergency Medical Services
2
No.
01 - 04
Date: 05/16/01
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: EMT Staffing
Standard for Voluntary
Ambulance Services
Supercedes/Updates: New
Page 1 of 2
There have been issues raised about the EMT staffing standard that became
effective January 1, 2001 for voluntary ambulance services. Article 30 of the
Public Health Law states that “the minimum staffing standard for a voluntary
ambulance service shall be an Emergency Medical Technician with the patient.”
The following is intended to help clarify the meaning of the law. This policy is
written for ambulance service operation. It does not address first response
service operation.
1. A voluntary ambulance service must have an Emergency Medical Technician (EMT)
or higher, attending to the patient at the scene and in the ambulance while
transporting the patient to the hospital.
2. If a voluntary ambulance service has a written response policy in place in which an
EMT is allowed to respond directly to the scene from home or work, the ambulance
may respond to the scene of the emergency even if an EMT is not on board.
3. If the EMT responding directly to the scene is delayed and the only other ambulance
crew available are Certified First Responders (CFR), the CFR may begin care. It is
acceptable to have a CFR as a part of an ambulance crew. The EMT assumes
responsibility for care upon arriving at the scene.
4. If the EMT does not arrive at the scene and another service is immediately available
with appropriate staffing, the patient should be transported by that service. If no other
service is immediately available the patient should be transported. While this is a
violation of Public Health Law, it is in the best interest of the patient to transport to a
hospital where appropriate care is available, only as a last resort option.
Continual and repeated failure of a service to assure an EMT arrives at the scene to
provide care may result in the Department taking disciplinary action against the
service and/or the individual. It is recommended that any service unable to routinely
provide an EMT to an emergency, whether on the ambulance or arriving
independently, file for an exemption to the staffing standard with the local Regional
EMS Council.
5. An ambulance should NOT respond to the scene of an emergency if it is known that
an EMT is not available. It is recommended that all ambulance services preplan for
the lack of staffing by written mutual aid agreements with neighboring ambulance
services and by alerting the local Public Safety Answering Point (PSAP) or dispatch
authority as early as possible. An ambulance service that responds to the scene of
an emergency when called without an EMT should consult with an attorney regarding
civil liability for not providing the statutory standard of care to a patient.
6. A service may send an ambulance and equipment to the scene of an emergency if
they know another service will provide the EMT staff necessary to perform patient
care. The service sending the ambulance would share responsibility for the care
being provided. These types of mutual agreements to share the staff and equipment
must be done in writing in advance.
7. The staffing standard requires one (1) EMT with a patient. Therefore, an ambulance
must be staffed with at least one EMT. While it is preferable to have more than one
EMT if there are multiple patients, the law does not require it. In the event of a
multiple patient situation, the EMT would assume supervision of the care being
provided to the patients being treated and transported.
NOTE: In a multiple casualty incident (MCI), local or regional protocols should be
followed.
Please remember that there has always been a public expectation to be
treated by a trained Emergency Medical Technician when they call 9-1-1 in
a medical emergency. The law now requires this. Please work with us to
assure that this standard of care is provided to all of our patients. Thank
you.
Issued by:
Edward Wronski, Director
Bureau of Emergency Medical Services
No.
01 - 02
Date: 06/29/01
New York State
Department of Health
Bureau of Emergency Medical Services
Re: EMS use of the
Incident Command
System.
Page 1 of 5
POLICY STATEMENT
Supercedes/Updates: 98-05
Introduction:
Governor’s Executive Order Number 26, issued on March 5, 1996, established the
Incident Command System (ICS). It states that ICS shall be used in New York State,
“as the standard command and control system during emergency operations.”
ICS is the model tool for command, control, and coordination of a response. It provides a
means to coordinate the efforts of individual agencies as they work toward the common
goal of stabilizing the incident and protecting life, property, and the environment. ICS
uses principles that have been proven to improve efficiency and effectiveness in a
business setting and applies the principles to emergency response.
ICS Overview:
ICS was developed in the 1970s in response to a series of major wild-land fires in
southern California. At that time, municipal, county, State, and Federal fire authorities
collaborated to form the Firefighting Resources of California Organized for Potential
Emergencies (FIRESCOPE). Although originally developed in response to wildfires, ICS
has evolved into an all-risk system that is appropriate for all types of fire and non-fire
emergencies.
Many incidents, whether major accidents (such as Haz Mat spills), minor incidents (such
as house fires and utility outages), or disasters (such as tornadoes, hurricanes, and
earthquakes), require a response from a number of different agencies. Regardless of the
size of the incident or the number of agencies involved in the response, all incidents
require a coordinated effort to ensure an effective response and the efficient, safe use of
resources. In Hazardous Materials incidents the use of the ICS is required by Federal
Labor Law.
NYS DOH Policy Statement 01-02
Page 1 of 5
The ICS organization is built around five major components:
♦ Command
♦ Planning
♦ Operations
♦ Logistics
♦ Finance/Administration
These five major components are the foundation of the ICS. In small-scale incidents, all
of the components may be managed by one person, the Incident Commander. Large-scale
incidents usually require that each component, or section, be set up separately. Each of
the primary ICS sections may be divided into smaller functions as needed.
INCIDENT COMMAND:
The ICS organization has the capability to expand or contract to meet the needs of the
incident, but all incidents, regardless of size or complexity, will have an Incident
Commander. A basic ICS operating guideline is that the Incident Commander is
responsible for on-scene management. The person who initially assumes the command of
an incident retains it until command authority is transferred to another person, who then
becomes the Incident Commander.
As New York is a “Home Rule State” there are numerous New York State, County and
Local Statutes that define the roles and responsibilities of Law Enforcement, Fire Service
Personnel, County Emergency Management Personnel, as well as State, County and
Local Government Officials. It is to the service’s advantage to find out who is
responsible for what in your service’s location prior to an event occurring.
Based on the ICS system and the scope of the incident, EMS providers may be assigned
or responsible for any number of roles. These roles may range from incident commander
on a strictly medical situation to that of an operational or support unit member in a large
multiple agency response to a major incident.
OPERATIONS:
Patient care is the primary operational function of EMS personnel. It is the responsibility
of those certified EMS providers who are employees/members of Basic Life Support First
Response (BLS FR) agencies, certified ALS First Response (ALS FR) and Ambulance
Services to provide care in accordance with all established standards and protocols.
Individuals who are not functioning as part of an EMS systems have no patient care
responsibility. Such a duty to act only arises from participation with an agency having
jurisdiction.
REMAC Responsibility:
The Regional Medical Emergency Medical Advisory Committee (REMAC) has the
statutory authority for the development of prehospital polices, procedures, triage,
treatment and transportation protocols. These protocols should address concerns when
multiple EMS providers, of various levels of certification, from one or more agencies are
operating at the same scene. The protocols developed by the REMAC should also include
NYS DOH Policy Statement 01-02
Page 2 of 5
a provision regarding the transfer of patient care from one prehospital care provider or
agency to another when needed. In addition the protocols should include a method for
requesting additional and/or specialized resources and the coordination of these
resources.
Access To Patients:
There are situations where circumstances may delay contact by EMS providers to the
patient. This may occur when a patient must be dis-entangled from an automobile crash,
extricated from a confined space or when the patient’s placement in an environment that
causes an immediate danger to life and health (IDLH) requires Self Contained Breathing
Apparatus for access such as a hazardous materials incident.
These situations require the use of specialized tools, equipment and personnel to bring the
patient to the EMS providers. In these situations the EMS personnel should serve as
advisers to the incident commander or operational staff who have the expertise and
equipment to approach the patient safely. This should occur while EMS providers remain
at a safe location, waiting for the patient to be brought to them.
EMS providers must be cognizant of the fact that they can provide no benefit to patients
if they become victims themselves.
Other Roles of EMS providers:
EMS providers may also be requested to participate in emergency operations that do not
directly involve an injury or illness. These involve providing EMS support to responder
monitoring or rehabilitation efforts at incidents such as a release of a hazardous material.
In these situations the command structure calls for EMS to support the operational
mission of the responders. In such incidents EMS command becomes subordinate to the
operations officer of the Incident Command System.
PRE-INCIDENT PLANNING:
Prior to the need to implement the Incident Command System all EMS agencies should
prepare a written plan outlining their agency’s operating guidelines including (but not
limited to):
•
•
•
•
•
•
•
•
•
When the ICS plan should be implemented.
Who in the agency may implement the ICS plan.
Transition of command.
Medical control notification.
Personnel accountability system.
Roles and responsibilities for all responders.
Notification that the plan has been implemented.
Releasing information to the media.
Communications procedures.
NYS DOH Policy Statement 01-02
Page 3 of 5
•
Written agreements with other agencies that will function as part of the agency’s ICS
plan. These should include;
• Other EMS agencies;
• Fire service agencies;
• Law enforcement agencies;
• Disaster response agencies;
• Transportation providers;
• Any government agencies affected i.e. dispatch centers, public health depts.; and
• Receiving hospitals.
Any plan developed should include a provision for incidents the agency has been brought
into as a support agency or as part of another agency’s ICS Plan.
FINANCE AND ADMINISTRATION:
As part of the planning process the aspect of financing and administration can be
reviewed. This includes the issue of the costs associated with an incident and how these
costs will be covered.
An agency that is called to stand by or provide rehabilitative services at an incident may
incur expenses that it wishes to have reimbursed. Having an arrangement about such
issues prior to an event may eliminate problems at or after an incident.
There is also the possibility that funds may be available for agency reimbursement from
various government entities depending on the scope and magnitude of the incident and if
a disaster declaration is made. Services should investigate funding sources when they are
involved in a large scale response; including documentation required to support such
reimbursement.
LOGISTICS:
As part of the logistics of a large incident EMS agencies should give consideration to
several areas. These include, but are not limited to:
•
•
•
•
•
•
Communications capabilities with other responding agencies;
Access to the stockpiles of supplies and equipment needed in an emergency;
Availability to contact members/employees and advise them additional human
resources are needed;
Personnel accountability;
Equipment tracking; and
Availability of Personnel Protective Equipment (PPE) for responding
employees/members.
Statutory Requirements:
NYS DOH Policy Statement 01-02
Page 4 of 5
In addition to the requirement set forth by Executive Order #26 requiring use of the
Incident Command System, 10 NYCRR Part 800.21 requires ambulance services to have
and enforce polices on:
•
•
•
Mutual aid;
A response plan for Hazardous Materials Incidents; and
A response plan for Multiple Casualty Incidents
Each of these policies should address the agency’s use of the Incident Command System.
Training:
Upon implementation of a plan, an agency should conduct exercises using the plan to
both educate members/employees and determine its effectiveness. These exercises may
include participation in incident drills conducted by local hospitals, participation with
other local emergency service agencies conducting exercises or an independent exercise
within the agency. It is recommended that the agency conduct these exercises utilizing
the plan as needed to assure all personnel are familiar with the plan and to assure those
who may have a specific duty within the plan are aware of their roles and responsibilities.
Training in the Incident Command System can be obtained by contacting:
The Federal Emergency Management Agency
National Emergency Training Center
16825 South Seton Avenue
Emmitsburg, MD 21727
www.fema.gov
A CD-ROM based ICS Self study course is available free from FEMA at:
http://www.usfa.fema.gov/nfa/tr_ertss4.htm
New York State Department of State
Office of Fire Prevention and Control
41 State Street
Albany, NY 12231-0001
(518) 474-6746
Local County Fire Coordinator
Issued and Authorized by:
Edward G. Wronski, Director
Bureau of Emergency Medical Services
NYS DOH Policy Statement 01-02
Page 5 of 5
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 98-01
01 - 01
Date: 04/11/01
Re: Authorizing Private
Vehicles as EASVs (Use of
Red Lights and Sirens)
Page 1 of 4
Introduction:
This policy is intended to clarify the requirements and procedures for utilizing personally
owned vehicles (POV) as Emergency Ambulance Service Vehicles (EASV).
Authorization as an EASV involves more than just the use of red lights and a siren on a
vehicle. It is expected that every EASV is in compliance with all of the provisions of 10
NYCRR Part 800.21 & .26. This includes proper agency identification, vehicle marking
and patient care equipment. All vehicles authorized by the service as EASVs may be
subject to inspection. In the event violations to the code are found, the violations will be
charged against the service authorizing the vehicle.
Legal Basis for Use of Red Lights and Sirens in Private Vehicles
The New York State Vehicle and Traffic Law, § 115-c states:
“An emergency ambulance service vehicle shall be defined as an appropriately equipped
motor vehicle owned or operated by an ambulance service as defined in section three
thousand one of the public health law and used for purposes of transporting emergency
medical personnel and equipment to sick and injured persons.”
The Attorney General has issued an opinion (dated May 4, 1995) interpreting this section
of the law as follows:
“…‘owned or operated by’ includes an appropriately equipped privately-owned vehicle
operated by an agent of an ambulance service and used in transporting emergency
medical personnel and equipment to sick and injured persons.”
The Counsel to the Commissioner of Motor Vehicles previously rendered an opinion that
states;
“An emergency medical technician, whether a paid employee or a volunteer, performing
duties for an ambulance service may equip his private vehicle with red lights and sirens
and may use these red lights and sirens, in accordance with the above quoted section
115-c, to arrive at the scene of an emergency faster.”
NYS-EMS Policy Statement 01-01
Page 1 of 4
Authorization
An ambulance service shall issue written authorization using the Emergency Vehicle
Authorization Card (DOH-4136). The authorization card shall be signed by both the
Chief Executive Officer of the service and the EMT to whom it is issued. A copy of the
authorization card and a record of it being issued shall be maintained by the service.
Authorization expires on the expiration date of the individual’s EMT certification. The
ambulance service may impose a shorter authorization period (e.g. annual) and has the
authority, without department approval, to remove the authorization at anytime for cause.
The EASV authorization shall be considered invalid for the following reasons:
•
The individual is no longer an active member or employee of the authorizing
ambulance service.
•
The individual is not currently certified by the New York State Department of Health
as an Emergency Medical Technician or Advanced Emergency Medical Technician.
•
The service is no longer certified by the New York State Department of Health as an
ambulance service.
An ambulance service is not required to issue any EASV authorization to a member or
employee if the service feels it is not necessary for the operation of the service. The
Commissioner of the New York State Department of Motor Vehicles has stated in an
opinion:
“Because the law allows an emergency medical technician to use red flashing lights does
not mean that an ambulance service has to allow it. Due to the fear of liability, or for
other reasons, an ambulance service may prohibit some or all of its members from using
red flashing lights.”
Agency Policies and Procedures:
Any service wishing to authorize its employees/members to use their personal vehicles as
EASVs must develop and implement an agency policy and procedures for the issuance of
EASV authorization. It is recommended these include, but may not be limited to, the
following:
a)
b)
c)
d)
e)
The issuance of such authorization.
Training requirements prior to the issuance of the authorization.
Maintaining authorization.
Equipment, maintenance, and inventory requirements.
Documentation requirements for the routine inventory of equipment and supplies.
NYS-EMS Policy Statement 01-01
Page 2 of 4
f) Insurance coverage.
g) Maintaining a copy of the members EMT certification, Driver’s License, Vehicle
Registration and verification of DMV Inspection.
h) Vehicle operations, response etc.
i) Procedures for revoking the authorization.
Training:
Prior to the issuance of authorization for an EASV the organization should assure the
member/employee is appropriately trained in the operation of an emergency vehicle. It is
recommended that the member/employee have completed at least one of the following
courses:
ƒ
ƒ
ƒ
ƒ
Emergency Vehicle Operators Course (NYS Office of Fire Prevention and Control)
Coaching the Emergency Vehicle Operator – Ambulance (National Safety Council)
Ambulance Accident Prevention Seminar (NYS DOH)
Emergency Vehicle Operators Course – Ambulance (US DOT NHTSA)
Accountability:
A personal vehicle authorized as an EASV must meet all the requirements of the NYS
Vehicle and Traffic Law, Article 30 of the Public Health Law, 10 NYCRR Part 800 and
all applicable EMS Policy Statements.
The inappropriate use of red lights and sirens and/or the unsafe operation of any EASV
may subject the EMT to violations of the Vehicle and Traffic Law.
Procedure for obtaining EASV authorization cards:
Only agencies certified as ambulance services by the Department of Health may apply for
authorization of personally owned EASVs.
1) Prior to issuance of authorization as an EASV the Chief Executive, or their designee,
shall complete a copy of the Affirmation of Compliance (DOH - 1881) that indicates
each vehicle is in compliance with 10 NYCRR part 800 and have it notarized.
2) Any time a vehicle is added to the list of authorized vehicles an Affirmation of
Compliance must be completed and notarized for the added vehicle. In the event a
vehicle is removed, the department must be notified in writing.
3) The completed Affirmation of Compliance shall be sent to the DOH regional office
for the service’s operating area. The regional office will issue the appropriate window
decal(s) and NYS Certification “logo” stickers for the vehicle(s).
NYS-EMS Policy Statement 01-01
Page 3 of 4
4) A copy of the completed and executed Affirmation of Compliance shall be sent, along
with a cover memo on agency letterhead, to the Bureau of EMS’s Central Office. The
Central Office will issue the numbered Emergency Vehicle Authorization Cards
(DOH - 4136) to the service.
Authorized & Issued By
Edward G. Wronski, Director
Bureau of Emergency Medical Services
NYS-EMS Policy Statement 01-01
Page 4 of 4
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 88-20, 98-12, 99-02
00 – 13
Date: 11/01/00
Re: The Operation Of
Emergency Medical
Services Vehicles
Page 1 of 7
The Operation of Ambulances and Other EMS Response Vehicles
Including a Model Standard Operating Procedure for EMS Agencies
PURPOSES
1.
To describe the legal requirements in New York State for driving
ambulances and other EMS response vehicles.
2.
To establish a standard in New York State for EMS response vehicle
emergency operations.
3.
To create a climate to help reduce the number of crashes and accidents
and thereby reduce the injuries and property damage associated with
EMS response vehicle emergency operations.
4.
To provide information to develop educational programs for EMS
emergency vehicle operators.
BACKGROUND
The epidemic of ambulance vehicle crashes and accidents that had been identified has
continued and has involved the loss of civilian life and injury to civilians and EMS
personnel. The magnitude of the problem requires that every NYS EMS agency be
made aware of the problem and take immediate steps to reduce the potential for these
accidents.
New York State Department of Motor Vehicle statistics illustrate a consistent yearly
frequency of over 400 ambulance accidents or crashes, injuring almost 2 persons per
day. These statistics also show that most of these accidents are avoidable. Based on
these statistics, if each EMS response vehicle were able to stop at every controlled
intersection, 75% of all of these accidents could be prevented.
EMS emergency response vehicles must be operated in a manner that provides for due
regard and the safety of all persons and property. Safe arrival and patient welfare shall
always have priority over unnecessary speed or hazardous driving practices while
enroute to an incident or to the hospital. The NYS Vehicle and Traffic Law (V&T)
authorizes privileges that ambulance and other emergency vehicle drivers may use
NYS-EMS Policy
Pg. 1 of 7
during an emergency operation. Modern EMS practices,1 2 3 including the use of
Emergency Medical Dispatch (EMD), EMT and Advanced EMS training and the patient
treatment modalities available today, dramatically reduce the need for emergency
operations
LEGAL BACKGROUND
The NYS Vehicle and Traffic (V&T) Law states the following 4:
∋ 114-b. Emergency Operations – the operation, or parking, of an authorized emergency
vehicle, when such vehicle is engaged in transporting a sick or injured person… Emergency
operation shall not include returning from such service.
∋ 101. Authorized emergency vehicles – every ambulance, … emergency ambulance service
vehicle.
∋ 1104 Authorized Emergency Vehicles –
(a) The driver of an authorized emergency vehicle, when involved in an
emergency operation, may exercise the privileges set forth in this section, but subject to
the conditions herein stated.
(b) The driver of an authorized emergency vehicle may:
1. Stop, stand or park irrespective of the provisions of this title;
2. Proceed past a steady red signal, a flashing red signal or a stop sign,
but only after slowing down as may be necessary for safe operations;
3. Exceed the maximum speed limits so long as he does not endanger life or
property;
4. Disregard the regulations governing directions of movement or turning in
specified directions.
c) Except for an authorized emergency vehicle operated as a police vehicle, the
exemptions herein granted to an authorized emergency vehicle shall apply only when audible
signals are sounded from any said vehicle while in motion by bell, horn, siren, electronic device
or exhaust whistle as may be reasonably necessary, and when the vehicle is equipped with at
least one lighted lamp so that from any direction, under normal atmospheric conditions from a
distance of five hundred feet from such vehicle, at least one red light will be displayed and
visible.
(e) THE FOREGOING PROVISIONS SHALL NOT RELIEVE THE DRIVER OF AN
AUTHORIZED EMERGENCY VEHICLE FROM THE DUTY TO DRIVE WITH DUE REGARD 5
FOR THE SAFETY OF ALL PERSONS, NOR SHALL SUCH PROVISIONS PROTECT THE
DRIVER FROM THE CONSEQUENCES OF HIS RECKLESS DISREGARD FOR THE SAFETY
1. Use of Warning Lights and Siren in Emergency Medical Vehicle Response and Patient Transport,
NAEMSP & NASEMSD, Prehospital and Disaster Medicine, April-June 1994.
2. Scope of Performance of EMS Ambulance Operations F1517-94, American Society for Testing and Materials .
3. National Fire Protection Association (NFPA) Part 1500, section 4-2
4. NYS MV&T Law, italics provided to indicate direct quotation
5. A principle of legal accountability in which a review of the specific circumstances of a crash or accident will
determine if a reasonably careful person, performing similar duties and under similar circumstances would act in the
same manner. This legal concept is analogus to the prudent man in ordinary liability cases.
NYS-EMS Policy
Pg. 2 of 7
OF OTHERS.
DISCUSSION
It is important to note that the V&T law does not define specific operations permitted by
the various types of emergency vehicles, such as police, fire or EMS. Generally
personal opinion and tradition, not statute or regulation have defined the perception of
requirements for ambulance emergency operations. An example is the mistaken belief
that an ambulance’s red lights must be on if a patient is on board. This historical
precedent must change. There is no requirement that emergency operations be used
for any EMS response.
Emergency operations in EMS are always an affirmative decision that is made at the
time of each response. Today, EMD, industry data, EMS educational materials, legal
case precedents, and other industry practices set a standard of care for emergency
vehicle operation which is binding on all EMS providers. Drivers of emergency vehicles
are reminded that they solely bear the responsibility for driving safely and with due
regard. There is no immunity from liability provided in NYS law for driving.
Operating a vehicle in emergency mode is one of the most dangerous activities that an
EMS provider is routinely involved in. Careful consideration must always be given for
the lives and safety of the driver, the crew, the patient and for the safety of every other
person that the vehicle will encounter during the call.
NYS – EMS POLICY
•
Every EMS response vehicle must be driven safely at all times, operating at a speed
commensurate with the needs of the patient and the safety of all involved. Drivers
exercising any of the V&T Law privileges must do so cautiously and with due regard
for the safety of all others.
•
Types of Responses ¾ Non-emergency Operations - anytime an EMS response vehicle is out of the
station on an assignment other than an emergency run, shall be considered to be
a non-emergency operation. All non-emergency operations shall be made
using headlights only - no light bars, beacons, corner or grill flashers or
sirens shall be used. During a non-emergency operation, the EMS response
vehicle shall be driven in a safe manner and is not authorized to use any
emergency vehicle privileges as provided for in the V&T Law.
¾ Emergency Operations - shall be limited to any response to the scene where
the driver of the emergency vehicle actually perceives, based on instructions
received or information available to him or her, the call to be a true emergency.
EMD dispatch classifications 6, indicating a true or potentially true emergency
6. i.e. Emergency Medical Dispatch, U.S. Dept. of Transportation, Feb. 1996
NYS-EMS Policy
Pg. 3 of 7
should be used to determine the initial response type. Patient assessments
made by a certified care provider, should determine the response type to
the hospital. In order for a response to be a true or potentially true emergency,
the operator or EMT/AEMT must have an articulable7 reason to believe that
emergency operations may make a difference in patient outcome. During an
emergency operation headlights and all emergency lights shall be
illuminated and the siren used as required in the vehicle and traffic law.
•
Each EMS response vehicle operator must recognize that the emergency vehicle
has no absolute right of way, it is qualified and cannot be taken forcefully 8.
•
During emergency operations every EMS response vehicle must be operated in
such a manner and at such a speed upon approaching an intersection, controlled by
a traffic control device so as to permit safe passage through the intersection. Before
entering the intersection the operator must reduce the speed of the vehicle to be
able to stop the vehicle if necessary to permit such safe passage. They should
come to a complete stop if they have a red signal or stop sign.9
•
Every EMS response vehicle must stop upon encountering a stopped school
bus with red lights flashing; any non controlled railroad crossing or railroad
crossing at which safety gates and/or warning lights are activated or if
requested by a police officer.
•
EMS response vehicles are discouraged from using escorts or traveling in convoys
due to the extreme dangers associated with multiple emergency vehicles operating
in close proximity to each other. For the purpose of this policy statement and any
developed from it emergency vehicles should maintain a spacing of at least 300 –
400 feet between them in ideal driving conditions and more when visibility is limited
or road conditions are less than ideal. 10
•
At emergency scenes the use of emergency warning lights must be governed by the
need to protect the safety of all personnel, patients and the public. In some cases
the use of emergency lights should be minimized.
•
Per Part 800.21 of NYCRR, every NYS ambulance or ALSFR service must have
and enforce a written policy which describes the authorized practices for
driving EMS response vehicles by their members or employees. The service
policy must be consistent with this policy and must include the following:
-
A definition of emergency and non-emergency call types, including dispatch criteria
for determining the type of call,
-
A description of the authorization required to use emergency operations on dispatch
and enroute to the hospital, including call types, dispatcher and crew chief authority
and other criteria,
7. Capable of being expressed in coherent verbal form, American Heritage Dictionary.
8. EMT Legal Bulletin, Vol. 15, No. 4, Med/Law publishers, Inc.
9 NFPA 1500 4-2.7(b)(c)
10 U.S. DOT, NHTSA Emergency Vehicle Operator Course, Ambulance
NYS-EMS Policy
Pg. 4 of 7
-
A statement regarding exceeding the posted speed limit,
-
A statement regarding the speed permitted and stopping requirements through
intersections which are uncontrolled or controlled,
-
Frequency and content of driver screening and training requirements for individuals
authorized by the service to drive an EMS response vehicle. and
-
Insurance company driver screening including age, driving record, training, and other
requirements.
•
Every NYS-EMS agency shall have a training program11 for all individuals authorized
by the service to drive an EMS emergency response vehicle. The program shall
include a curriculum, approved instructors, and frequency of training and
documentation.
•
Every NYS EMS agency shall have a notification policy in the event of an accident or
crash. This shall be consistent with Part 800.21(p).
•
A prompt, safe response can be attained by:
¾ Knowing where you are going.
¾ Having all personnel on board, seated with seat belts secured unless actively performing
necessary emergency medical care.12
¾ Leaving the station in a safe and standard manner:
- quickly boarding the vehicle
- opening station doors fully
¾ Using warning devices to move with and around traffic and to request the right-of-way.
¾ Driving defensively, at reasonable speeds, slowing or stopping at all intersections and
giving approaching traffic adequate time to recognize the vehicle and yield the right of
way.
¾ Using pre-planned response routes which take into account hazards, construction, traffic
density, etc.
11. NYS-EMS Ambulance Accident Prevention Seminar, DOT EVOC, National Safety Council, programs provided by
Insurance Carrier, etc.
12 NFPA 1500 4-3.1.1
NYS-EMS Policy
Pg. 5 of 7
MODEL SERVICE SPECIFIC POLICY
The following model policy may be easily adopted by any EMS service to be
included as a part of the service’s policies and standard operating procedures.
<Service Name>
Policy and Standard Operating Procedure for Emergency Vehicle Operations
Purpose - There shall be established a system for the safe operation of all EMS
emergency response vehicles.
Scope - These policies are binding on every driver and certified care provider in charge
of patient care.
Types of Responses Non – emergency Operations - anytime an EMS response vehicle is out of the
station on an assignment other than an emergency run shall be considered to be
a non-emergency operation.
Emergency Operations - shall be limited to any response to a scene, which is
perceived to be a true emergency situation. True emergencies are defined by
EMD and dispatch policy for a response to any situation in which there is a high
probability of death or life threatening illness or injury. The risk of emergency
operations must be demonstrably able to make a difference in patient outcome.
Emergency Vehicle Operations
First and Foremost – DO NO Harm !
1.
Emergency operations are authorized only to responses deemed by dispatch
protocol to be emergency in nature where the risks associated with emergency
operations demonstrably make a difference in patient outcome.
2.
Upon dispatch, emergency operations are only authorized when the dispatch call
type justifies an emergency response.
3.
All operations considered non-emergency shall be made using headlights only no light bars, beacons, corner or grill flashers or sirens shall be used. During a
non-emergency operation, the EMS response vehicle should be driven in a safe
manner and is not authorized to use any emergency vehicle privileges as
NYS-EMS Policy
Pg. 6 of 7
provided for in the V&T Law.
4.
Emergency operations are authorized at a scene when it is necessary to protect
the safety of EMS personnel, patients or the public.
5.
EMS response vehicles do not have an absolute right of way, it is qualified and
cannot be taken forcefully
6.
During an emergency operation the vehicle’s headlights and all emergency lights
shall be illuminated and the siren used as required in the vehicle and traffic law.
7.
Once on the scene, the decision for determining the type of response for
additional EMS vehicles responding to the scene shall be made by a NYS
certified provider following assessment of the scene and all patients. It will be the
responsibility of that certified responder to notify the dispatcher or other
responding units of the type of response that is warranted, emergency or nonemergency.
8.
The EMT/AEMT in charge of patient care, following assessment of the patient,
shall be responsible for determining the response type enroute to the hospital
9.
EMS response vehicles shall not exceed posted speed limits by more than ten
(10) miles per hour.
10.
EMS response vehicles shall not exceed posted speed limits when proceeding
through intersections with a green signal or no control device.
11.
When an EMS response vehicle approaches an intersection, with or without a
control device, the vehicle must be operated in such a manner as to permit the
driver to make a safe controlled stop if necessary.
12.
When an EMS response vehicle approaches a red light, stop sign, stopped
school bus or a non controlled railroad crossing, the vehicle must come to a
complete stop.
13.
The driver of an EMS response vehicle must account for all lanes of traffic prior
to proceeding through an intersection and should treat each lane of traffic as a
separate intersection.
14.
When an EMS response vehicle uses the median (turning lane) or an oncoming
traffic lane to approach intersections, they must come to a complete stop before
proceeding through the intersection with caution.
15.
When traffic conditions require an EMS response vehicle to travel in the
oncoming traffic lanes, the maximum speed is twenty (20) miles per hour.
16.
The use of escorts and convoys is discouraged. Emergency vehicles should
maintain a minimum distance of 300 – 400 feet when traveling in emergency
mode in ideal conditions. This distance should be increased when conditions are
limited.
NYS-EMS Policy
Pg. 7 of 7
No.
New York State
Department of Health
Bureau of Emergency Medical Services
00 - 11
Date: 10/03/00
Re: Sexual Harassment
POLICY STATEMENT
Supercedes/Updates: New
Page 1 of 2
Purpose:
The intent of this policy is to advise individuals participating in Department of Health (DOH)
approved courses and those working in the Emergency Medical Services field that they are
entitled to an environment that is free from sexual harassment.
Policy:
DOH requires all course sponsors to develop and implement a policy on sexual harassment.
DOH also encourages all EMS provider agencies to develop their own agency policy on sexual
harassment.
Sexual harassment is not merely offensive but it is a form of discrimination in violation of Federal
and State Law.1
Definitions:
Employer:
Includes any Emergency Medical Services provider agency, including but not
limited to municipal entities, volunteer fire departments, volunteer ambulance
corps, commercial, industrial and hospital provider agencies.
Employee:
Any person, compensated or not, that is employed by or a volunteer for any EMS
provider agency or course sponsor.
Workplace:
Any location or vehicle that an employee is at in the course of their duties for the
employer.
Student:
Any person enrolled in a DOH approved EMS training course.
Educational
Setting:
Sexual
Harassment:
1
Includes any location being used for EMS education. This definition extends to
locations used for clinical and field training of EMS providers.
Any unwanted verbal or physical advances, sexually explicit derogatory
statements, or sexually discriminatory remarks made by someone in a workplace
or educational setting which are offensive or objectionable to the recipient, cause
the recipient discomfort or humiliation, or interfere with the recipient’s job
performance or educational progress.
Title VII of the Civil Rights Act of 1964
Executive Order No. 19 Issued 5/31/83
It may include: Visual harassment; posters, magazines, calendars etc
Verbal harassment or abuse: repeated requests for dates, lewd comments
sexually explicit jokes, whistling etc.
Written Harassment: Love poems, letters, graffiti
Offensive gestures
Subtle pressure for sexual activities
Unnecessary touching, patting, pinching or kissing.
Leering or ogling
Brushing up against another’s body.
Promise of promotions, favorable performance evaluations or grades, etc in
return for sexual favors
Demanding sexual favors accompanied by implied or overt threats to a person’s
job, promotion, performance evaluation, grade, etc.
Physical assault, rape.
Implementation:
All course sponsors shall, and all EMS provider agencies are encouraged to, develop a policy to
address sexual harassment in their location.
These policies should include a notification to all employees and students that sexual harassment
is a violation of law and is intolerable in either the educational or employment setting.
The policy statement should state that sexual harassment is considered a form of employee
and/or student misconduct and that sanctions will be enforced against individuals engaging in
sexual harassment and against supervisory, administrative or managerial personnel who
knowingly allow such behavior to continue.
Policies should also include a procedure for the following:
‰ making a complaint of sexual harassment ;
‰ to whom complaints are to be made;
‰ in what form the complaint should be filed, and
‰ the procedure the sponsor/employer will follow in investigating the complaint.
The policy should provide for a subsequent review to determine if sexual harassment has been
effectively stopped.
In addition to filing a complaint within the procedure of the workplace or course sponsor’s policy
or for agencies that do not have policies, individuals are also entitled to seek relief by filing a
complaint with:
‰
‰
‰
‰
New York State Division of Human Rights
Federal Equal Employment Opportunity Commission
U.S. Labor Department – Office of Civil Rights
A court having appropriate jurisdiction
Once developed, the policy should be widely distributed by providing a copy of it to all
employees, it should be included in all new employee and student orientations and publicized
within the workplace or educational setting.
All employers developing polices should conduct appropriate training to instruct and sensitize all
employees to the policy.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
00-10
Date: 09/25/00
Re: EMT-B / AEMT
POLICY STATEMENT
Supercedes/Updates: Policy Statement 92-04
Page 1 of 3
Functional Position Description
Emergency Medical Technician – Basic (EMT-B)
Advanced Emergency Medical Technician (AEMT)
Purpose:
Provide a guide for those who are interested in understanding what qualifications,
competencies and tasks are expected of the EMT-B and/or the AEMT.
Qualifications:
• Complete the Application for Emergency Medical Services Certification (DOH-65),
including affirmation regarding criminal convictions
• Successfully complete an approved New York State EMT-B or AEMT course
• Achieve a passing score on the practical and written certification examinations
• Must be at least 18 years of age prior to the last day of the month in which they are
scheduled to take the written certification examination
• Knowledge and Skills required show need for high school or equivalent education
• Ability to communicate effectively via telephone and radio equipment
• Ability to lift, carry and balance up to 125 pounds (250 pounds with assistance)
• Ability to interpret oral, written and diagnostic form instructions
• Ability to use good judgement and remain calm in high stress situations
• Ability to be unaffected by loud noises and flashing lights
• Ability to function efficiently without interruption throughout an entire work shift
• Ability to calculate weight and volume ratios
• Ability to read English language, manuals and road maps
• Ability to accurately discern street signs and addresses
• Ability to interview patients, patient family members and bystanders
• Ability to document, in writing, all relevant information in prescribed format in light
of legal ramifications of such
• Ability to converse, in English, with coworkers and hospital staff with regard to the
status of the patient
• Possesses good manual dexterity with ability to perform all tasks related to the
highest quality patient care
• Ability to bend, stoop and crawl on uneven terrain
• Ability to withstand varied environmental conditions such as extreme heat, cold and
moisture
• Ability to work in low light situations and confined spaces
• Ability to work with other providers to make appropriate patient care decisions
1
Competency Areas:
The EMT-B
Must demonstrate competency is assessment of a patient, handling emergencies
using Basic Life Support equipment and techniques. Must be able to perform CPR,
control bleeding, provide non-invasive treatment of hypoperfusion, stabilize / immobilize
injured bones and the spine, manage environmental emergencies and emergency
childbirth. Must be able to use a semi-automatic defibrillator. Must be able to assist
patients with self-administration or administer emergency medications as described in
state and local protocol.
The AEMT-Intermediate
Must demonstrate competency in all EMT-B skills and equipment usage. Must be
able to provide Advanced Life Support using intravenous therapy, defibrillator and
advanced airway adjuncts to control the airway in cases of respiratory and cardiac arrest.
The AEMT-Critical Care
Must demonstrate competency in all EMT-B skills and equipment usage. Must be
able to provide Advanced Life Support using the AEMT-Intermediate skills and
equipment. Must be able to administer appropriate medications.
The EMT-Paramedic
Must be capable of utilizing all EMT-B and AEMT-intermediate skills and
equipment. Must be able to perform under Advanced cardiac Life Support (ACLS) and
Basic Trauma Life Support (BTLS) standards. Must be knowledgeable and competent in
the use of a cardiac monitor/defibrillator and intravenous drugs and fluids. The EMTParamedic has reached the highest level of pre-hospital care certification.
Description of Tasks:
Responds to calls when dispatched. Reads maps, may drive ambulance to
emergency site using most expeditious route permitted by weather and road conditions.
Observes all traffic ordinances and regulations.
Uses appropriate body substance isolation procedures. Assesses the safety of the
scene, gains access to the patient, assesses extent of injury or illness. Extricates patient
from entrapment. Communicates with dispatcher requesting additional assistance or
services as necessary. Determines nature of illness or injury. Visually inspects for
medical identification emblems to aid in care (medical bracelet, charm, etc.) Uses
prescribed techniques and equipment to provide patient care. Provides additional
emergency care following established protocols. Assesses and monitors vital signs and
general appearance of patient for change. Makes determination regarding patient status
and priority for emergency care using established criteria. Reassures patient, family
members and bystanders.
Assists with lifting, carrying and properly loading patient into the ambulance.
Avoids mishandling patient and undue haste. Determines appropriate medical facility to
which patient will be transported. Transports patient to medical facility providing
ongoing medical care as necessary enroute. Reports nature of injury or illness to
receiving facility. Asks for medical direction from medical control physician and carries
2
out medical control orders as appropriate. Assists in moving patient from ambulance into
medical facility. Reports verbally and in writing observations of the patient’s emergency
and care provided (including written report(s) and care provided by Certified First
Responders prior to EMT-B/AEMT arrival on scene) to emergency department staff and
assists staff as required.
Complies with regulations in handling deceased, notifies authorities and arranges
for protection of property and evidence at scene.
Replaces supplies, properly disposes of medical waste. Properly cleans
contaminated equipment according to established guidelines. Checks all equipment for
future readiness. Maintains ambulance in operable condition. Ensures cleanliness and
organization of ambulance, its equipment and supplies. Determines vehicle readiness by
checking operator maintainable fluid, fuel and air pressure levels. Maintains familiarity
with all specialized equipment.
3
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: Policy Statement 93-01
00-09
Date: 09/25/00
Re: Certified First
Responder
Page 1 of 2
Functional Position Description
Certified First responder (CFR)
Purpose:
Provide a guide for anyone who is interested in understanding what qualifications,
competencies and tasks are expected of the CFR.
Qualifications:
• Complete the Application for Emergency Medical Services Certification (DOH-65),
including affirmation regarding criminal convictions
• Successfully complete an approved New York State CFR course
• Achieve a passing score on the practical and written certification examinations
• Must be at least 16 years of age prior to the last day of the month in which they are
scheduled to take the written certification examination
• Knowledge and Skills required show a need for high school or equivalent education
• Ability to communicate effectively via telephone and radio equipment
• Ability to lift, carry and balance up to 125 pounds (250 pounds with assistance)
• Ability to interpret oral, written and diagnostic form instructions
• Ability to use good judgement and remain calm in high stress situations
• Ability to be unaffected by loud noises and flashing lights
• Ability to function efficiently without interruption throughout an entire work shift
• Ability to read English language, manuals and road maps
• Ability to accurately discern street signs and addresses
• Ability to interview patients, patient family members and bystanders
• Ability to document, in writing, all relevant information in prescribed format in light
of legal ramifications of such
• Ability to converse in English with coworkers and hospital staff with regard to the
status of the patient
• Possesses good manual dexterity with ability to perform all tasks related to the
highest quality patient care
• Ability to bend, stoop and crawl on uneven terrain
• Ability to withstand varied environmental conditions such as extreme heat, cold and
moisture
• Ability to work in low light situations and confined spaces
• Ability to work with other providers to make appropriate patient care decisions
Competency Areas:
• Patient Assessment
• Use of Basic Life Support Equipment within the scope of practice for the CFR
• Ability to perform Cardio-Pulmonary Resuscitation (CPR)
• Control Bleeding
• Provide non-invasive treatment for hypoperfusion
• Manage environmental emergencies
• Provide initial care in medical and trauma emergencies, and emergency childbirth
Description of Tasks:
Responds to calls when dispatched. Reads maps, may drive emergency response
vehicle to emergency site using most expeditious route permitted by weather and road
conditions. Observes all traffic ordinances and regulations.
Uses appropriate body substance isolation procedures. Assesses the safety of the
scene, gains access to the patient, assesses extent of injury or illness. Communicates with
dispatcher requesting additional assistance or services as necessary. Determines nature of
illness or injury. Visually inspects for medical identification emblems to aid in care
(medical bracelet, charm, etc.) Uses prescribed techniques and equipment to provide
patient care. Provides additional emergency care following established protocols. Assess
and monitor vital signs and general appearance of patient for change. Makes
determination regarding patient status and priority for emergency care using established
criteria. Reassures patient, family members and bystanders. Avoids mishandling patient
and undue haste. Reports verbally and in writing, information gathered about patient’s
emergency and care rendered to EMT or AEMT in charge of ambulance crew on scene.
Assists with lifting, carrying and properly loading patient into the ambulance.
Complies with regulations in handling deceased, notifies authorities and arranges
for protection of property and evidence at scene.
Replaces supplies, properly disposes of medical waste. Properly cleans
contaminated equipment according to established guidelines. Checks all equipment for
future readiness. Maintains emergency vehicle in operable condition. Ensures cleanliness
and organization of emergency response vehicle, its equipment and supplies. Determines
vehicle readiness by checking operator maintainable fluids, fuel and air pressure levels.
Maintains familiarity with all specialized equipment.
No.
00 - 08
Date: 08/21/00
New York State
Department of Health
Bureau of Emergency Medical Services
Re: Use of Bicycles as
EASVs
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 3
Introduction:
Bicycles provide rapid access to areas not always accessible by motorized vehicles. Many EMS
agencies use mountain bikes as Emergency Ambulance Service Vehicles (EASVs) in order to
provide rapid first response capabilities at mass gatherings, sporting events, special events and in
remote areas.
In addition to transporting an EMS provider, bicycles can carry a moderate amount of equipment
allowing a provider to initiate care until the arrival of a more traditional first response vehicle or
ambulance. Bicycles provide a way to transport a provider amongst large crowds with minimal
disturbance and with lessened risk of injury to event participants and spectators.
Some agencies may choose to utilize bicycles for responses to areas where motor vehicle access
is difficult or limited on a regular basis while others may only utilize them on selected occasions.
In addition to the obvious response advantages there is also a public relations advantage seeing
EMS providers in the community in a manner other than inside an ambulance.
Policy Development:
Every agency that intends to utilize bicycles as EASVs to provide first response EMS should
develop policies and procedures to include:
• Staffing patterns
• When bicycles will be used
• Equipment to be utilized, requirements and location
• Inventory control
• Communications equipment requirements and procedures
• Procedures for obtaining/simultaneous dispatch of an ambulance or other patient transport
vehicle when required
• Medical Direction
Equipment Selection:
In selecting a bicycle for use in EMS, the agency should choose a medium to heavy duty
mountain bike equipped in compliance with NYS V&TL §1236. (This section includes the
minimum requirement for lights, reflectors and audible warning devices on bicycles.)
Bicycles should be fit to the person riding them. Each bike or rider should be equipped with a
water bottle to provide the rider with adequate hydration. Bikes should also be equipped with a
kickstand that will support the bike and all equipment attached to it.
Bike pedals should have cages and straps. Handle bars with bar ends will offer riders additional
hand placements and help reduce rider fatigue.
It is strongly urged that all EMS agencies using bicycle units develop a policy that requires all
persons wear an ANSI or SNELL Foundation approved bicycle helmet.
All riders should also wear eye protection and well padded cycling gloves.
Equipment racks and packs should be securely mounted to prevent equipment from shifting
while riding and additional padding may be required to prevent damage to equipment and
supplies. Depending on the amount of equipment and supplies being carried by the bike, panniers
may or may not be used.
Additional equipment may include emergency warning lights, horns and sirens as the service
chooses.
In addition to EMS supplies it is imperative that the bicycle carry minimal maintenance and
repair equipment, ie. patch kit, portable pump and a tool kit/multi tool.
The agency should develop and implement a check sheet to be completed on a regular basis to
require routine checks on tires (inflation/tread), brakes, shifters, chain lubrication, lights,
communications equipment and any emergency warning equipment used.
Ideally, EMS providers should utilize teams of two providers working together as one first
response unit. This will allow for a distribution of the equipment and the weight associated with
it.
For a BLS first response using a bicycle, the equipment required by Part 800.26 shall be
carried. Services may request waivers through the normal process.
EMS bike units may also carry a defibrillator, either manual or automatic, depending on the level
of care to be provided by the bicycle rider and per medical director approval.
ALS services may also carry ALS equipment with the approval of their medical director and
REMAC
Bags of IV solutions, drip sets and related materials may be carried on the bicycles. However,
syringes, needles, IV catheters and any medications should be carried on the person of the
certified AEMT. These items should be carried in a fanny or back pack to protect them from
theft. It should also be considered, depending on the type of event, whether to carry these items
at all if doing so might put the provider in harms way from someone who might be attempting to
forcibly take these items.
Communications:
As per DOH Bureau of EMS policy statement 98-02, Radio Communications Systems for EMS
Services, bike units should be equipped with communications equipment that allows for
communication with dispatch, other responding EMS units and medical control for the event or
activity.
It is not advisable to depend solely on portable cellular telephones for any phase of the bike unit
communications needs. This is particularly true in remote areas or at mass gatherings where local
cell site capabilities might be overwhelmed by an influx of cellular users.
Rider Selection:
In choosing employees/members to staff a bike unit consideration should be given to the fact that
it takes a considerable amount of stamina to operate a bike that is weighted down with EMS
equipment for the duration of a special event or a tour of duty.
Also to be considered is the physical exertion of pedaling to a scene and then finding a situation
that requires additional strenuous physical activity, i.e. doing CPR.
Prior to assigning employees/members to a bike unit consideration should be given to providing
a comprehensive medical assessment of the employee/member by a physician. It is advisable to
consider the creation of an agency policy requiring such an examination prior to assignment to a
bike unit.
Training:
Since there are no specific training programs to prepare a person to provide EMS while on a
bike, it is advisable to open up communications with local bike clubs or police bike units who
might provide technical support on bike selection and riding technique.
Any training should include proper bike fitting, rider safety, an understanding of NYS Vehicle
and Traffic laws relating to operating a bicycle, understanding cadence and gearing, proper
nutrition for a rider and basic bicycle maintenance.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
2000-07
Date: August 16, 2000
Re:
No Smoking Policy
POLICY STATEMENT
Supercedes/Updates: 89-10
Page 1
of 1
POLICY STATEMENT ON SMOKING
Background:
This policy replaces Policy Number 89-10 (No Smoking in Ambulances), the Department of
Health policy statement that encouraged all EMS agencies to adopt a strict policy banning
cigarette smoking in ambulance vehicles at any time.
Since that time the Occupational Safety and Health Administration has issued guidelines
concerning this topic as it relates to the Blood Borne Pathogen Standard (OSHA 1910). The
Environmental Protection Agency has also issued a statement concerning the exposure to
Environmental Tobacco Smoke.
As a reminder, smoking has been proven to be a health hazard and known to cause cancer and
cardio-pulmonary disease. It should be noted that smoking and exposing others to second hand
smoke are both recognized as health hazards. The presence of cigarette smoke in an enclosed
compartment, such as an ambulance, causes damage to disposable supplies and is prohibited.
OSHA regulations state that there shall be no smoking within 20 feet of any compressed cylinder
including oxygen (29 CFR 1910.101b). This rules out smoking in any ambulance or EMS
response vehicle as well as within most garages or apparatus bays where EMS vehicles are
housed. This sentiment is echoed by the National Fire Protection Association (NFPA) in their
standards. In accordance with the New York State Clean Indoor Air Act, smoking is not permitted
in most public and government owned buildings.
In addition to all of the known health and safety related aspects of smoking, the public relations
perspective must also be examined. The health care community has repeatedly indicated the
hazards of smoking. As a professional representative of the healthcare community, EMS
providers must support the public health warnings and not permit smoking in the health care
environment. Disregarding this may lessen the public confidence and understanding of EMS
professionals as health care providers.
Policy:
It is the policy of the Bureau of EMS that there should be no smoking in or around any ambulance
or EMS response vehicle at any time. This includes vehicle garages and apparatus bays, as well
as during an EMS response in which patients are being treated. Smoking should be restricted to
defined areas. It is recommended that smoking and/or loitering be prohibited in stairwells,
vestibules, entrances and exits.
All provider agencies need to develop and institute policies consistent with this Policy Statement.
No.
00-06
Date: 08/24/00
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Security of Drug Boxes
and Drug Paraphernalia on
EMS Response Vehicles
Supercedes/Updates: 86-19
Page 1 of 2
This policy is designed to clarify the minimum requirements of the NYS Codes,
Rules and Regulations specific to the security of medications and authorized
controlled substances as well as needles and syringes utilized in the (EMS)
environment. Local REMACs may have additional requirements in place. It is
each agency and individuals responsibility to become familiar with all appropriate
requirements within the state and their region.
Part 800.23 (f) of the New York State Emergency Medical Services Code states
that for each ambulance carrying controlled substances, drugs or needles, there
shall be a securely locked cabinet in which these items are stored when not in
use. Additionally, 80.136 (4) (i )(ii) requires that controlled substances be locked
in a box within a locked stationary cabinet under a two-lock system using
different keys.
These laws, rules and regulations will be interpreted as follows for ambulance,
EASV or ALS first response vehicles carrying these materials:
1.
Drug boxes or bags holding syringes or needles (used or unused), IV
starter sets containing syringes and/or needles, non-controlled drugs, (items not
found in Article 33 PHL) shall be kept in a key-locked compartment within the
ambulance vehicle at all times when not being used for patient care purposes.
The drug box or bag need not be locked inside the compartment.
Agencies using sharps disposal bins will be considered to be in compliance with
the security requirements so long as the disposal container is secured in the
vehicle and the manufacturer’s original security/safety barrier is intact. Agencies
which carry smaller disposal bins such as the ones carried in “first-in bags”, are
reminded that these types of disposal bins still need to be stored within the
locked cabinet.
Non-medicated IV solutions and oxygen do not need to be locked, but do need to
be secured within the vehicle.
2.
Drug boxes or bags holding authorized controlled substances (items found
in Article 33 PHL, ie: morphine and/or diazapam) must be double locked at all
times using a two different key lock system, when not being used for patient care
purposes. This means that the container holding the controlled substances must
be locked and stored inside a key locked compartment within the ambulance,
EASV or ALS first response vehicle in accordance with the approved agency
controlled substance plan.
If a soft style first in bag is to be used in conjunction with controlled substances,
the container holding the controlled substances must be constructed of a hard
rigid plastic or metal and must be able to be locked with a key.
The requirement for securing of controlled substances may also be accomplished
by having the approved certified and authorized personnel maintain direct
possession of controlled substances while on duty. Individuals are not allowed to
carry controlled substances on their person while “on call”.
3.
For the purpose of this policy, a locked ambulance, EASV or ALS first
response vehicle will be considered a locked cabinet so long as all compartments
and doors are able to be secured and are fully operational.
An ALS ambulance, EASV or ALS first response vehicle not carrying controlled
substances may keep an unlocked drug box outside a compartment so long as
the vehicle is locked at all times. In this instance the vehicle is the cabinet.
If controlled substances are a part of the medication formulary, a two key locking
system is required. One of these systems may be the locked ambulance, EASV
or ALS first response vehicle.
4.
Access to drugs, controlled substances and needles must be carefully
monitored. In most cases, only properly certified and authorized personnel
should have access to or posses keys which allow access to these items. Each
agency needs to develop policies addressing these issues in accordance with
regional and state guidelines. Agency administrators are advised to contact their
local Department of Health office for further assistance.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
00-03
Date: 05/19/00
Re:
Transition of Care
POLICY STATEMENT
Supercedes/Updates: New Policy
Page 1 of 2
Transition of Care
With the passage of Chapter 552 of the Laws of 1998 (Public Access Defibrillation) and more
recently, Chapter 578 of the Laws of 1999 (Epinephrine Auto-Injector), EMS Providers will
increasingly encounter situations where a patient has been defibrillated or administered epinephrine,
prior to the arrival of EMS, by a non-license/non-certified "first responder." It is important that
there be a smooth and orderly "transition of care" between civilians and EMS providers as well as
between EMS providers of different levels. This includes the transfer of information and
continuation of appropriate care.
Public Access Defibrillation
When arriving at a call where a patient is being treated by a "first responder" with an AED, the EMS
Provider should immediately confirm the patient's status (responsive, unresponsive, apneic, pulseless,
etc..), and determine if a "shock" is indicated. Treat the patient appropriately, request ALS if
available and prepare for immediate transport. The "first responder's" AED should remain on the
patient until a full cycle of the AED has been completed. The AED and/or pads are usually changed
when the patient is ready for transport or upon treatment by an ALS provider.
For patients where "no shock" is indicated, the EMS Provider should continue CPR (verify that CPR
is being performed correctly) and prepare for immediate transport.
For patients where a "shock" is indicated, the EMS Provider should administer a complete set of 3
"shocks" and prepare for immediate transport.
If the EMS unit does not have a defibrillator/AED, the "first responder" should accompany the
patient to the hospital, follow regional protocols and provide CPR as indicated (the ambulance should
pull over and stop when analyzing and shocking the patient).
The EMS Provider should attempt to gather the following information:
1.
2.
3.
4.
5.
how long the patient has been down,
when was CPR initiated,
when was the patient first "shocked,"
how many "shocks" the patient has received, and
any pertinent patient history that is available.
Transition of Care
Policy 00-03
05/19/00
Epinephrine Auto-Injector for Anaphylactic Reactions with Respiratory Distress or Shock
When arriving on the scene of a patient experiencing an anaphylactic reaction, if the patient is being
treated by a "first responder" who has administered epinephrine by an auto-injector, the EMS
Provider should immediately confirm the patient's status. The EMS Provider should pay close
attention to the patient's airway, respiratory distress and any signs or symptoms of hypoperfusion
(shock). Treat the patient appropriately, request ALS if available and prepare for immediate
transport.
The EMS Provider should attempt to gather the following information:
1.
2.
3.
4.
5.
6.
determine the substance the patient was exposed to,
how long ago the exposure occurred,
the initial symptoms the patient reported,
the time and dosage of the epinephrine administered,
the name of the individual who administered it, and
the patient's response to the treatment.
Medical Control must be contacted prior to administering a second epinephrine injection.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
99 - 11
Date: 12/30/99
Re: EMS Response to
school Incidents
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 3
EMS Response to School Incidents and Bus Accidents
The purpose of this policy statement is to furnish information to EMS providers and
agencies concerning responses to schools and the management of school bus accidents.
Background
The potential number of patients, the frequent presence of uninjured children who do not
require hospitalization, the jurisdiction of the school district and the responsibilities of
EMS providers often raise conflicting issues of jurisdiction, consent, treatment, and
transportation. The roles and responsibilities of the school district and the EMS agency
must be identified in advance of any incident, by jointly developing operations plans so
that a common understanding of their respective expectations and responsibilities
are well defined.
Legal Responsibilities
Several citations in Education Law place responsibility for student health and safety on
the local school board/districti:
State Education Law §912 places responsibility on the school board for the health and
welfare of all children including the administration of emergency care programs for all ill
or injured pupils.
Formal Opinion of Counsel No. 213(1967) the State Education Department cites
several authorities for schools to provide health and safety and pupil transportation for
children in their jurisdiction.
In Decision 10,587(1981) the State Education Commissioner found that the
responsibility for pupil safety shifts from the parent at the point of pick up by the school
bus.
These citations clearly identify the roles and jurisdiction for a school’s health services
and administrative employees and it’s agent provider of transportation. These
responsibilities include student health and safety and pupil guardianship. The exact nature
of the responsibility is left to local district policy, procedure and practice.
No specific statute clearly defines responsibility in the case of a school bus crash. As in
most other prehospital situations more than one agency has a role and jurisdiction. In the
case of a school bus accident the school district, law enforcement and EMS each have
specific and unique roles. As in many field situations the use of well established plans
and a unified incident command structure provides the means to define whom is in charge
of the incident.
Emergency Planing with Schools
Utilizing long established practice of pre planning for responses to known situations,
EMS agencies need to establish the necessary dialog with school administrators and
health services personnel to develop, implement, periodically drill, and review response
plans to school incidents including bus accidents.
The State Education Department in guidelines2 provided to local school districts
identifies a requirement3 to develop comprehensive emergency plans for all
contingencies. It specifies that all community resources be identified and policies and
action plans be
developed and coordinated with local emergency services. Additionally, the emergency
procedure guidelines require training in the response to catastrophic emergencies and
conducting periodic instruction in disaster, fire and bus drills.
Recommendations
EMS agencies need to communicate with the administrators of all school districts in
their response areas and develop, implement and/or review specific emergency response
plans to school emergencies, including bus crashes. It is helpful if this planning is done in
a coordinated environment, which would include law enforcement, fire, and the local
office of emergency service/management.
The authority, jurisdiction and responsibilities of the school and each response agency
must be included in the plan.
Assessment and triage protocols need to take into account the behavior of children in
such incidents. The protocols also must recognize that passengers may be injured, act as
if they are injured or may not be injured at all. The objective for EMS providers is to
render appropriate care and/or transportation for passengers who require emergency
medical care and/or transportation.
Any student presenting injury or a sign or symptom suggesting injury should be
properly assessed, triaged and transported in accordance with state and local treatment
protocols.
Any student presenting with no complaint or injury can be released to school health
services personnel or administrator on the scene for further evaluation and transportation.
Once the student has been released to the school district, its personnel assume
responsibility for the student and any further assessment, treatment or transportation to a
hospital as needed.
All persons on the bus need to be identified and recorded as being involved in the
crash. Treatments provided and passenger disposition may be documented via log, triage
tag or PCR if treated and/or transported. A copy of all documentation should be made
available to the school upon request. Schools and EMS agencies should develop a
tracking system for use in such situations.
School bus crashes are difficult and emotional incidents for all involved. Each one is
different and a well-developed and rehearsed plan conducted using a unified incident
command management system will facilitate the most effective outcome for the patients,
schools, EMS services and other responsible local authorities.
Endnotes:
i
will be referred to as schools
2
Emergency procedures in the School Setting, State Education Department, 1993.
3
State Education Commissioner's Regulations § 155.13
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
99-10
Date: 12/30/99
Re: Frequently Asked
Questions re: DNR’s
Page 1 of 4
PURPOSE
The purpose of this statement and the frequently asked questions (FAQ) is to provide prehospital providers with clarification and information on accepting non-hospital and
hospital Do Not Resuscitate Orders (DNR). Readers are referred to PHL § 29-B and
DOH Memo 92-32, DNR Orders that are the governing documents for detailed
discussions on the subject. This policy does not supercede any other DOH document.
These guidelines are intended to assist local emergency medical services (EMS) agencies
in developing DNR policies. EMS agencies should develop policies that instruct crews
how to properly respond to patients who have a DNR. DNR policies allowing
patients to refuse resuscitation ensure that patient’s legal rights are honored and are a
critical part of the healthcare and EMS systems. Patients must be provided their legal and
ethical rights to consent to or refuse medical care in the prehospital setting.
DNR patients are generally, although not always, victims of terminal illnesses, and are
encountered in skilled nursing facilities, private residences and other settings. They may
or may not be clients of hospices. In some cases, patients use the EMS system solely to
obtain medical transportation. In other cases accident victims may present a DNR order.
Despite instructions not to perform resuscitation or call an ambulance, family members
and employees of nursing facilities frequently activate 9-1-1 when death is imminent.
In addition to providing palliative care for patients, prehospital care providers may
benefit families by assisting in determining when death has occurred. This may be an
appropriate role for the EMS system although it should be restricted to private residences
and not to licensed facilities which are expected to have policies for determining death by
house medical staff.
EMS agencies are encouraged to meet with all components (hospitals, nursing facilities,
hospices, etc.) of the health care system in their community in order to develop common
understandings and policies to mutually manage patients with DNRs in emergency
situations.
What is an "Out of Hospital" DNR?
The New York State Department of Health has an approved standard Out of Hospital
DNR form that is legally recognized statewide for DNR requests occurring outside of
Article 28 licensed facilities. This form is intended for patients not originating from a
hospital or nursing home. The form (DOH-3474) is available on the Department’s web
site (www.health.state.ny.us) or from your local DOH EMS Office or health department.
There are NO other approved Out of Hospital DNR forms. Copies can be kept on
ambulances and made available to patients, facilities or physicians as a part of their
community education program.
What is a recognized DNR Bracelet?
A standard DOH approved metal bracelet, worn by the patient, which includes a
caduceus and the words "Do Not Resuscitate". EMT’s should assume that a DNR order is
in place authorizing the bracelet. It is not necessary to locate the written DNR order.
Where/When is an Out of Hospital DNR Order Valid?
For any patient NOT originating from a hospital or nursing facility including but not
limited to:
•
•
•
The patient’s home
A hospice
A clinic
What determines the validity of the Out of Hospital DNR?
•
Merely the presentation of a signed Out of Hospital DNR form (or a copy) or a DNR
bracelet to the EMT.
•
A good faith attempt to identify the patient. A witness who can reliably identify the
patient is useful.
•
Out of hospital DNRs do not expire.
•
The Out of Hospital DNR form and/or bracelet should be taken with the patient.
Hospital & Nursing Home DNR orders
All Article 28 licensed facilities are required to issue, review and maintain DNR orders.
EMS providers will honor hospital DNR orders for patient transports originating from the
facility. The DNR can not be expired. The facility staff must provide a copy of the order
and/or patient's chart with the recorded DNR order to the ambulance crew. Facilities,
other than hospitals or nursing homes, are encouraged to use the NYS-DOH approved
non-hospital DNR Form as supplemental documentation to avoid confusion and
potentially unwanted resuscitation.
May EMS providers accept living wills or health care proxies?
A living will or health care proxy is NOT valid in the prehospital setting.
Under what circumstances may an EMS provider disregard an Out of Hospital
DNR order?
Any case where there is reasonable evidence to suggest that the DNR order has been
revoked or cancelled.
If the patient is conscious and states that they wish resuscitative measures, the DNR
Form should be ignored.
If the patient is unable to state his or her desire and a family member is present and
requests resuscitative measures for the patient and a confrontational situation is likely to
result, if the request is denied.
A physician directs that the order be disregarded.
What procedures are and are not preformed if the patient presents a DNR?
Do not resuscitate (DNR) means, for the patient in cardiac or respiratory arrest, NO
chest compressions, ventilation, defibrillation, endotracheal intubation, or medications.
If the patient is NOT in cardiac or respiratory arrest, full treatment for all injuries,
pain, difficult or insufficient breathing, hemorrhage and/or other medical conditions must
be provided.
Relief of choking caused by a foreign body is usually appropriate, although if
breathing has stopped, ventilation should not be assisted.
CPR must be initiated if no Out of Hospital or facility DNR is presented. If a DNR
order is presented after CPR has been started, stop CPR.
For unusual situations or questions on individual patient circumstances, contact
medical control.
What documentation is required for a patient with a DNR order?
Emergency medical technicians/paramedics should attach a copy of the Out of
Hospital DNR form, hospital DNR order and/or copy of the patient’s chart to the patient
care report, along with all other usual documentation. It should be noted on the patient
care report that a written DNR order was present including the name of the physician,
date signed and other appropriate information.
If the cardiac/respiratory arrest occurred during transport, the DNR Form should
accompany the patient so that it may be incorporated into the medical record at the
receiving facility.
Patients who are identified as dead at the scene need not be transported by ambulance,
however, local EMS agencies should consider transportation for DNR patients who
collapse in public locations. In these cases it may be necessary to transport the individual
to a hospital without resuscitative measures in order to move the body to a location that
provides privacy. Local policies need to be coordinated with the Medical
Examiner/Coroner and law enforcement.
Liability Protections
PHL§2977.12 "No person shall be subjected to criminal prosecution or civil liability, or
be deemed to have engaged in unprofessional conduct, for honoring reasonably and in
good faith pursuant to this section a non hospital order not to resuscitate, for disregarding
a non hospital order pursuant to section ten of this section, or for other actions taken
reasonably and in good faith pursuant to this section".
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
No.
99 – 09
Date:
11/24/99
Re:
Patient Care
and Consent
for Minors
Page 1 of 4
It is the purpose of this policy to clarify the legal issues surrounding consent to medical
care and/or the refusal of care by minors in the pre-hospital EMS setting.
Emergency Medical Services (EMS)providers are often presented with patients who are
considered by law to be minors. The issue of providing care and/or the patient’s right to
refuse care becomes a complex circumstance EMS providers must address. In the
prehospital situation the issue at hand is not usually providing care but rather the failure
to treat.
Legal Background
A minor, in New York State, is defined as a person who is under eighteen (18) years of
age.
This is defined by the General Obligations Law '1-202, Domestic Relations Law '2 and
Public Health Law '2504. Under this section of Public Health Law, a person who is
eighteen or older may give effective consent for health care.
Public Health Law ' 2504
Enabling certain persons to consent for certain medical, dental, health and
hospital services.
1. Any person who is eighteen years of age or older, or is the parent of a
child or has married, may give effective consent for medical, dental, health
and hospital services for himself or herself, and the consent of no other
person shall be necessary.
NYS-EMS Policy 99-09 (11/24/99)
Pg. 1 of 4
2. Any person who has been married or who has borne a child may give
effective consent for medical, dental, health and hospital services for his
or her child.
3. Any person who is pregnant may give effective consent for medical,
dental, health and hospital services relating to prenatal care.
4. Medical, dental, health and hospital services may be rendered to
persons of any age without the consent of a parent or legal guardian
when, in the physician’s judgment an emergency exists and the person is
in immediate need of medical attention and an attempt to secure consent
would result in delay of treatment which would increase the risk to the
person’s life or health.
5. Anyone who acts in good faith based on the representation by a person
that he is eligible to consent pursuant to the terms of this section shall be
deemed to have received effective consent.
In addition to these provisions for health care consent by ‘emancipated’ individuals,
there are other statutory provisions for minors who are in military service or are seeking
treatment for AIDS (PHL '2781) and other sexually transmitted diseases (PHL '2305).
So long as the individual is a minor, the presumption is that he or she is not
emancipated and the burden of proof rests on the individual asserting it.
The Mental Hygiene Law also addresses consent but for situations not usually within
the scope of EMS. Additionally in '9.41 it permits peace and police officers to ‘direct the
removal of any person to a hospital who is conducting himself in such a manner which
is likely to result in serious harm to himself or others’.
Other governmental agencies, such as law enforcement, mental health or corrections,
may have legal definitions for individuals under eighteen that describe specific rights or
responsibilities. Unfortunately, these do not impact health care decisions including the
ability to consent or refuse care in the prehospital setting.
Refusal of Medical Assistance (RMA)
An individual who is legally a minor cannot give effective legal/informed consent to
treatment and therefore, conversely, cannot legally refuse treatment.
NYS-EMS Policy 99-09 (11/24/99)
Pg. 2 of 4
Documentation
Complete an assessment of the patient. Fully document all circumstances including
subjective and objective findings, attempts to contact parents, note any objections or
refusals by the patient and all other pertinent situational facts. Include witness
statements. Always consider contacting medical control for assistance.
Collaboration with other Agencies
EMS agencies are advised to work with hospital administrators, local law enforcement
agencies, school administrators and community youth group leaders to develop policies
and procedures to best serve the medical needs of minors in time of an emergency.
There are alternatives to EMS and hospitals for custody and supervision of minors. An
uninjured child may be supervised by law enforcement personnel or a school or activity
(soccer, etc.) supervisor until a parent is contacted. In some situations, a responsible
adult (grandparent, aunt, brother, etc.) with the child can assist in the decisions making.
EMS agencies should work with local youth activities to ensure they have made plans to
contact parents, have provided consent to treatment forms or have other permissions in
place for the children in their supervision.
EMS agencies also need to work and plan with all police agencies for those situations
involving minors, particularly those who are not injured and do not require
hospitalization. Local and state police have broad powers which can be used to protect
minors and facilitate custody.
However, all else failing, the EMS provider may remain responsible for providing care
and/or transportation of a minor to a hospital.
EMS Agency Protocols
Agency policies and regional BLS and ALS protocol sets can contain guidance for
treating minors in the prehospital setting. Contacting medical control is always an
acceptable option for EMS providers faced with uncertain situations. Medical control
may be able to influence the situation, even if it can’t change the consent options.
Recommendations
EMS providers may find themselves responsible for minors, in situations they have
been called to when there is no parent or guardian present or reachable.
Although it is easy to determine a legal definition of a minor, the responsibility to treat or
NYS-EMS Policy 99-09 (11/24/99)
Pg. 3 of 4
release is a much more complex legal, ethical, social and public relations problem. The
nature of children and their special needs coupled with their inability to legally give
informed consent, present special and unique matters for EMS personnel to consider
and evaluate. Careful assessment, decision making and documentation are key as is
discussion and planning with other agencies.
Act in the best interest of the patient – EMS providers must strike a balance between
abandoning the patient and forcing care. There may be instances in which a minor
appears mature enough to make an independent judgment, however legally, the minor
is unable to make a decision. Always contact medical control for assistance if there is
any question !
Common sense, prior agreements, sufficient documentation, and acting in the best
interest of the patient must prevail.
Issued:
John J. Clair
Associate Director – Operations
NYS-EMS Policy 99-09 (11/24/99)
Authorized:
Edward G. Wronski
Director
Pg. 4 of 4
No.
99 – 08
Date: 10/10/99
New York State
Department of Health
Bureau of Emergency Medical Services
Re:
Medical
Transportation
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 2
The purpose of this policy is to clarify the appropriate use of the various types of
medical transportation available for non-emergency patient transports to, from, or
between medical facilities. This policy refers to the patient care and operational aspects
of ambulance and other forms of medical transportation, it does not address medical
necessity for reimbursement by third party payers.
Many factors are involved when deciding on which type of medically related
transportation is to be used for a specific patient. Included are patient condition at the
time of transport, the specific level and type of care (ALS, BLS) or medical monitoring
needed, personal preference, contracts and economics.
Ambulance service and patient care during transport are governed by Article 30 of the
New York State Public Health Law. Patient care and or medical monitoring may only be
provided by certified or licensed healthcare providers in an ambulance.
In the medical transportation industry there are ambulance, “ambulette”1 and livery
forms of transportation. Each has an appropriate use. In each situation the patient’s
medical condition and the type and level of care required to treat the patient’s condition
must be the first consideration when deciding on which type of transportation to use for
the transfer.
1
A.k.a.: Para-transit, wheelchair, invalid coach
NYS – EMS Policy 99-08 (10/10/99)
Pg. 1 of 2
POLICY
Transportation by ambulance is required if the patient requires medical
care or medical monitoring as directed by a physician during the
transport. Examples include, but are not limited to, administering oxygen
to a patient who does not normally use it, assessment, maintaining IV’s,
cardiac (EKG) monitoring, or the periodic monitoring of pulse, respiration,
blood pressure or other vital signs and documenting changes in a patient’s
condition. Medical care and/or patient monitoring can only be provided by
a certified or licensed health care provider and can only be provided in an
ambulance.
Ambulette or livery transportation is appropriate for patients who DO NOT need medical
care or medical monitoring during the trip. Ambulette’s may carry a patient’s individually
prescribed and provided oxygen (as if the patient is in a private vehicle). An ambulette
service MAY NOT provide oxygen or oxygen delivery equipment and ambulette
personnel MAY NOT monitor or deliver oxygen or adjust flow rates.
A service not licensed as an ambulance may not advertise the ability to provide medical
care during transport. Services should exercise caution using medically trained staff on
any vehicle that is not an ambulance. Such advertising and staffing only serves to
confuse the public or health care institution regarding the actual levels of medical care
and capabilities available.
Issued:
Authorized:
John J. Clair
Edward G. Wronski
Associate Director – Operations
Director
NYS – EMS Policy 99-08 (10/10/99)
Pg. 2 of 2
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 98 - 19
99 – 06
Date: 9/1/99
Re:
Exposure to
Blood and/or
Body Fluids
Page 1 of 5
GUIDELINES FOR EXPOSURE TO BLOOD AND/OR BODY SECRETIONS
BACKGROUND
The New York State Department of Health receives many requests for guidance in the
area of infection control from emergency medical service (EMS) personnel who may be
exposed to contaminated or potentially contaminated blood or body secretions.
For many years the medical community has been aware of problems caused by human
immunodeficiency virus (HIV) and has more recently identified the hepatitis C (HVC)
virus as a potential problem.
This policy statement, developed with the assistance of the Department’s Wadsworth
Center for Laboratories and Research, updates the information published in previous
versions of this policy.
UNIVERSAL PRECAUTIONS
These guidelines are intended to prevent or minimize exposure to the transmission of
bloodborne infectious diseases, particularly HIV and viral hepatitis, to employees
whose duties put them at risk. All emergency medical services organizations should
ensure full implementation of universal precautions and body substance isolation1 (BSI)
techniques, and require immunization of all employees2 who are identified as being at
risk.
According to the U.S. Department of Labor, Occupational Safety and Health
Administration, “universal precautions” refers to the method of infection control in which
all human blood and certain human blood fluids are treated as if known to be infectious
for bloodborne pathogens. Universal precautions are to be observed in all situations
where there is a potential for contact with blood or other potentially infectious material.
In emergency situations, differentiating between body fluid types is difficult or
1
Body substance isolation – an infection control concept and practice that assumes that all body fluids are
potentially infectious. Emergency Care and Transportation of the Sick and Injured, AAOS 7th Edition 1998
2
For these purposes, employee means volunteer and paid individuals who act on behalf of the EMS service.
impossible, and all body fluids are to be considered potentially infectious. Universal
precautions and BSI techniques must be applied correctly and consistently, to provide
a very low incidence of worker exposure to HIV and various hepatitis viruses.
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
EMS services are encouraged to review, with their medical director, the service
exposure control plan and the federal Bloodborne Pathogen Regulations, 29CFR Part
1910.1030, to ensure that all appropriate and required actions are taken with regard to
EMS personnel education and training, personal protective equipment, the use of new
safer equipment, particularly for sharps, pre-exposure vaccination and post-exposure
follow-up.
Issued:
John J. Clair
Assoc. Director – Operations
Authorized:
Edward G. Wronski
Director
SAMPLE OPERATING PROCEDURE
The Department recommends these sample operating procedures be included in EMS
service exposure control plans.
What to Report
EMS personnel should immediately report to their supervisor all percutaneous,
nonintact skin or mucous membrane contact with blood or body secretions; and
supervisors should refer exposed employees for immediate medical attention.
Initial Response
•
Thoroughly cleanse area of exposure. (See below for cleansing instructions.)
•
Seek immediate attention and exposure evaluation.
•
Review the exposed employee’s immunization history.
•
Refer the exposed employee for appropriate medical evaluation, care and any
necessary post exposure follow up treatment.
•
Have the exposed employee’s supervisor complete necessary documentation and
required reports. (See below for administrative responsibilities).
Testing
•
Have service designated officer (DO) seek any existing information on the source..
•
Inform the patient of applicable laws and regulations concerning disclosing the
identity and infectious status of the source individual.
•
Have the source individual’s blood tested for HIV and the various forms of hepatitis
as soon as consent has been obtained.
•
Test the exposed employee for HIV and the various forms of hepatitis.
Notification and Counseling
Share test results with the exposed employee, who should also be counseled about his
or her health status and, if necessary, treatment options.
Wound Cleansing
•
For a puncture cleanse with betadine immediately and follow up by soaking the site
for five minutes in a solution of betadine and sterile water.
•
For skin contact, first wash the area with soap and water. Then, clean it with
betadine.
•
For mucous membranes: if in mouth, rinse out mouth with large quantity of tap
water; if eyes, flush with water from eyewash. If eyewash is not available, use tap
water.
Administrative Responsibilities
Once the area of contact has been cleansed, and the exposed employee referred for
further medical treatment, the supervisor should do all paperwork needed to document
the incident. He or she should:
•
Direct the member/employee to the appropriate location for evaluation and
immediate medical treatment.
•
Prepare an incident report and note the incident on the prehospital care report for
the call in which the exposure took place.
•
Advise the employee to initiate a Workers’ Compensation claim.
•
Verify that appropriate employee health records have been updated.
•
Follow-up on the employee’s medical care, and confirm that appropriate medical
care has been given.
Testing Guidelines
Supervisors should arrange to have the source individual’s blood tested for HIV and
various forms of hepatitis as soon as possible after consent has been obtained. If the
source individual is unable or unwilling to give consent, the EMS organization should
consider seeking the legal authority to act without his or her consent. If it is impossible
to draw blood from the source individual, but some other sample of his or her blood is
available, this should be used. (If the source individual is already known to be infected
with one or more bloodborne pathogens, the test for that pathogen may be omitted.)
Supervisors should ask the exposed employee for his or her permission to begin
baseline blood tests for HIV and various forms of hepatitis. This should be done as
soon as possible after exposure. Follow-up testing for HIV should take place at six
weeks, 12 weeks, 26 weeks and 52 weeks after exposure.
Treatment Possibilities
HIV prophylaxis may include the administration of antiretroviral treatment. Highly active
retroviral therapy (HAART) should be initiated as soon as possible, preferably within
one hour following exposure, particularly if the EMS provider is HIV negative and the
source is HIV positive or at risk.
The risk of transmission of hepatitis B (HBV) or hepatitis C (HCV) is significantly greater
than the risk of transmission of HIV. Chronic HBV infection can be prevented in the
nonimmune employee by administration of prophylactic hepatitis B immune globulin
(HBIG) and the hepatitis B vaccine series. There is no known effective prophylaxis for
HCV. The exposed employee should be referred for medical management to a
specialist knowledgeable in this area. Obtained baseline HCV serology should be
repeated in four to six months.
In cases of possible HBV infection, use the attached treatment protocol, developed and
recommended by the Wadsworth Center.
Because the treatment of pregnant woman can present special medical problems,
medical personnel treating women who may be pregnant should implement appropriate
additional safeguards.
No.
98 - 16
Date 10/15/98
New York State
Department of Health
Bureau of Emergency Medical Services
Re:
Equipment
Update
POLICY STATEMENT
Supersedes /Updates:
Page 1 of 2
Recent ambulance inspections and reports from manufacturer’s representatives have identified several areas
of concern regarding equipment on ambulances and emergency ambulance service vehicles (EASV) that are
in need of clarification and in some cases service attention. Service managers need to review the following
areas to identify any items relevant to their individual service.
Equipment Storage
Section 800.23 (d) intends that all equipment within the vehicle must be secured whenever the vehicle is in
motion or an item is not directly being used for patient care. One of the purposes of this requirement is to
prevent loose items from injuring members of the crew. This would include any equipment on open side
shelves or storage racks where cardiac monitors, portable suction units and the like are usually kept. A
manufacturer’s supplied restraining device or light duty strap holding these items in place is acceptable.
Each piece of equipment placed in service on an ambulance or EASV must have an identified storage
location. The vehicle’s floor is not acceptable. Equipment bags may be kept on the vehicle’s stretcher so long
as they are strapped to the stretcher with the head of the stretcher in the raised position.
Pediatric Equipment
Part 800.24 (h) lists the pediatric equipment that must be maintained on each ambulance vehicle. Due to the
relatively low use of this equipment, it is recommended that services devise specific storage methods to
locate all pediatric equipment in one common area or kit separate from adult items. Common storage
facilitates locating specific pediatric items when they are needed and lessens loss.
It is acceptable to have a sealed pediatric kit so long as there is a visible list of the contents outside of the kit.
The kit’s contents need to be inventoried at regular intervals and at any time the seal is broken.
Bag Valve (BVM) and Masks
Agencies are reminded that 800.24 (b) (1) requires each vehicle to have an adult-sized bag valve mask
ventilation device with at least two (2) clear adult masks in different sizes. Additionally, 800. 24 (h) (2)
requires a total of three (3) pediatric masks in newborn, infant, and child sizes. Because of infection control
policies and procedures, many services now use a disposable BVM and mask system with BVMs and masks
commonly replaced by the receiving hospital as a single unit. However, we are finding that the exchange
BVMs, as well as other prepackaged BVMs, do not contain the required number of differently sized masks.
Services who have exchange programs must insure that proper sizes and quantities, as called for by Part
800, are available and accessible at all times.
Equipment Items with Batteries
Part 800.23 (a) requires that all equipment be clean and operable. In the case of portable equipment,
operable means functioning at full capacity while away from the vehicle. Several reports have been received
where patient care equipment, powered by a battery, has failed while in use. Agencies usually leave
equipment such as portable battery operated suction units and defibrillators permanently attached to a shore
line or direct AC source inside the vehicle to maintain a full charge. To insure proper performance and
operating condition, all equipment which has a battery power source should be removed from its charger or
charging power source, (e.g., shore line ) and be fully tested as it would be if it were being used for patient
care.
Providers need to be familiar with manufacturer’s instructions and recommendations pertaining to battery
charging indicators, as well as other lights or signals pertaining to each items maintenance, testing and
operation.
Linen
Section 800.24 (f) (1,2) requires one (1) set of linen on the cot and one (1) spare set. Often we find anywhere
from several to dozens of extra pieces of linen stored under the cot mattresses, under the bench seat and
other odd locations within the ambulance. These storage methods allow linen to become entangled in the cot
or it’s securing mechanisms and frequently is not clean enough to be used.
It is recommended that only the required spare linen, or if needed, enough linen for the duty shift, be stored in
one cabinet.
Padded Splints
800.24 ( c ) (4) requires six (6) padded board splints. Due to infection control concerns, every effort should
be made to insure that these splints are covered with a non permeable covering to prevent contamination
from body fluids. Routine maintenance and cleaning in accordance with individual manufacturer’s and agency
policy will prolong the usefulness of these items. It is further recommended that any padded splint with a rip
or tear in its protective covering be repaired or replaced immediately.
Long Spine Boards (Wooden)
Many agencies continue to use wooden spine boards for spinal immobilization. Services need to maintain
wooden spine boards in such a way as to insure that the board has a non permeable waterproof finish on its
entire surface that is able to be cleaned (scrubbed) and insure that the board is not splintered. Wooden
boards with a damaged or worn finish are easily contaminated and are not able to be cleaned properly.
Wooden spine boards which are splintered or where the surface is no longer able to be cleaned must be
repaired or replaced immediately.
Storage of Drugs and Needles
800.23 (f) requires all drugs and needles to be stored in a locked compartment. Services should refer to NYS
EMS Policy Statement 86-19 for specific guidelines. Service managers need to insure that ALS crews
routinely comply with the locking requirement to maintain security and accountability.
Issued:
John J. Clair
Associate Director-Operations
Thomas M. Fortune
Sr. EMS Representative
Authorized:
Edward G. Wronski
Director NYS EMS
No.
98-11
Date 9/01/98
New York State
Department of Health
Bureau of Emergency Medical Services
Re:
EMS Service
Incident
Reporting
Requirements
POLICY STATEMENT
Supercedes /Updates:
Page 1 of 2
Purpose
The purpose of this policy statement is to provide clarification to the requirements of Section
21.q of Part 800 which specifies incident reporting responsibilities and requirements for EMS
services. Reports must be made for incidents in which a patient under the charge and care of
the service was injured or harmed by actions or omissions of a service employee as well as for
on duty death or injury of a service member/employee.
Notification Requirements
The chief executive officer of an EMS service is required to notify the DOH Area Office of the
occurance of any incident or circumstance in which a patient, or member/employee is harmed,
injured or killed in any of the circumstances listed below. Questionable situations should be
referred to the area office for resolution.
Notification must be made to the Department’s Area office by telephone by the close of business
the day following the incident and in writing within five days.
Types of Reportable Events1
The following types of situations must be reported to the DOH:
!
a patient dies, is injured, killed or otherwise harmed due to actions of commission or
omission by a member of the ambulance service;
!
an EMS response vehicle operated by the service is involved in a motor vehicle crash in
which a patient, member of the crew or other person is killed or injured to the extent
requiring hospitalization or care by a physician;
!
any member of the ambulance service, while on duty, is killed or injured to the extent
requiring hospitalization or care by a physician;
!
patient care equipment fails while in use, causing patient harm;
1
State EMS Code, Part 800, Section 21(q) 1 -5 and Section 21(r)
!
it is alleged that any member of the ambulance service has responded to an incident or
treated a patient while under the influence of alcohol or drugs;
The definitions of the type of events listed above are very general in nature as EMS services
and crews have broad and varying operating conditions and situations. The Department’s
interest is in those events in which a patient, under the charge and care of the service, is injured
or harmed by acts of commission or omission by a service member/employee. Examples might
include failure to maintain an airway, failure to resuscitate, not honoring a properly executed
DNR order, dropping a patient, etc. The situations described here are not to be considered an
all inclusive list.
Additionally, to meet the requirements of Part 800.21(q)2 & 3 the DOH does require the
reporting of any line of duty death or serious injury of a member or employee. This means that if
a member of the service is killed or seriously injured in a sudden or unexpected circumstance
(not a chronic situation) a report to the Area Office needs to be made.
The written report to the Area Office needs to describe the circumstances, outcomes and
injuries or deaths of all involved. A copy of any motor vehicle accident report should be included.
The Department will in each instance review the report and information submitted and determine
what follow up action(s) or aditional documentation will be required by the service.
Having the incident identified and/or reviewed by the service or regional Quality Improvement
process does not relieve the service from these reporting requirements.
Equipment Failures
Services are to notify the Bureau of EMS in writing, of all unexpected authorized EMS response
vehicle and/or patient care equipment failures that could have resulted in harm to a patient. One
example is a defibrillator failing to discharge. Any corrective actions taken by the service should
be included. The intent of this section is to track trends in vehicle or equipment failures so that
reports may be made to manufacturers and other appropriate agencies.
The reporting of equipment failure to the Department does not relieve the agency from any
requirements of the US Food and Drug Administration’s(FDA) mandatory medical device
reporting. A copy of any FDA report filed will meet the intent of this requirement.
Issued by:
John J. Clair
Associate Director - Operations
Authorized by:
Edward G. Wronski
Director
No.
98-09
Date 9/01/98
New York State
Department of Health
Re:
ALS Intercepts
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes /Updates:
Page 1 of 3
INTRODUCTION
Advanced Life Support (ALS) is an essential level of out-of-hospital medical care.
Various predictors indicate that under ordinary situations 5 to 25 percent of all calls in
a system will be for patients in need of ALS care. It is important that every prehospital
patient needing ALS care receive it without delay and that all are transported to
definitive care at a hospital in a timely fashion.
The policy serves to:
!
Define ALS intercepts.
!
Define parameters for the utilization of ALS as well as to provide objectives
every intercept should meet
* Minimize delay in transporting patients to definitive care at a hospital.
* Enhance the provision of patient care by maximizing the availability of
ALS for those patients identified as being in need of ALS care.
* Provide guidelines to assist in identifying and accessing the most
appropriate ALS service at the time of request.
!
Encourage REMACs to develop regional specific guidelines and protocols that
enhance the availability of ALS and the appropriate use of ALS intercepts in the
region.
New York State Statewide BLS Protocol
In 1996, the NYS BLS protocols were changed to introduce the concept of ALS
intercepts and their use as the principal method of providing ALS care to patients
needing this level of care when the initial EMS system contact is a BLS ambulance.
The provision of ALS by intercept permits the appropriate utilization of ALS resources
by identifying a hospital or ALS service as the nearest ALS provider at the time of
need. Call location, staffed ALS unit availability and/or direction of travel will effect the
decision.
Excerpt from NYS BLS Protocol:
The goal of prehospital emergency medical care is DEFINITIVE CARE for the
patient as rapidly and safely as the situation indicates with no deterioration of
his/her condition and, when possible, in an improved condition. BLS units shall
deliver their patients who will benefit from ALS care to this higher level of
care as soon as possible. This may be accomplished either by intercepting with
an ALS unit or by transport to an appropriate hospital, which ever can be
effected more quickly.
A system of ALS intercept (when available within a given area) shall be prearranged. Formal written agreements for the request of ALS shall be
developed in advance by those agencies not able to provide ALS.
A request for ALS intercept shall occur as noted in specific treatment protocols.
Initiation of patient transport shall not be delayed to await the arrival of an
ALS unit, unless an on-line medical control physician otherwise directs.
Immediate Transport Decision:
Determine patient status (CUPS):
Critical or Unstable --- Immediate transport
Potentially Unstable -- Secondary survey and transport
If the patient’s condition dictates immediate transport, the vital signs,
secondary assessment, and treatment should be completed en route to the
nearest appropriate hospital (as defined below in Section VII, Transport).
Intercept with an ALS unit (if available) en route to the nearest appropriate
hospital as noted in specific treatment protocols.
Note: Do Not delay patient transport to await the arrival of an ALS unit.
ALS Intercepts
C
An intercept is an authorized and staffed ALS unit, dispatched by request or
protocol, meeting a BLS unit while it is en route to the nearest appropriate
hospital.
C
A BLS unit assesses the patient, determines the need for and requests ALS,
NYS-EMS Policy 98-09 (9/1/98)
Page 2 of 3
packages and begins patient transport. The BLS unit shall not wait on the scene
for the ALS unit’s arrival. The request for ALS should be made as soon as the
the patient’s condition is recognized as needing ALS.
C
A hospital emergency department (ED) is the highest level of ALS medical care.
Patients should be transported without delay to the nearest appropriate ED by
the BLS unit. Definitive medical care can only be provided at a hospital ED.
C
ALS mutual aid is a misnomer and does not exist. The statutory definition of
mutual aid1 as well as the need for priority transport makes the use of the term
“mutual aid” inappropriate in these circumstances.
C
BLS services should identify ALS services in advance which are staffed and
readily available to provide ALS intercept. More than one service may need to
be identified if the BLS service regularly transports to more than one hospital.
All formal response agreement needs to be established in advance. Dispatch
entities should monitor actual staffing and operational status of ALS resources
to insure their availability at the time of the call and minimize any potential
delay. The use of the “closest unit” concept is appropriate to dispatch ALS
units.
C
All ALS patients should be transported to the hospital without delay by a BLS
ambulance, particularly when the arrival of the ALS unit to the scene is
estimated to be longer than the transport time to the hospital.
C
In developing ALS intercept relationships, REMACs must consider the patient’s
and ALS unit’s proximity to the hospital. Patient transport to an emergency
department should not be delayed. BLS/ALS care should ideally be
administered en route.
C
Simultaneous dispatch of BLS and ALS resources should only be provided
under the direction of dispatchers trained in the principals of emergency medical
dispatch for those calls identified by a recognized dispatch algorithm.
C
REMACs should develop protocols that permit a certified provider who arrives
on the scene after the time of dispatch, to cancel initially dispatched ALS
resources when, after assessment, it is determined that ALS care is not needed.
Issued:
Authorized:
John J. Clair
Associtate Director - Operations
1
Edward G. Wronski
Director
Reference NYS-EMS Policy 95-04, “EMS Mutual Aid”
NYS-EMS Policy 98-09 (9/1/98)
Page 3 of 3
No.
98 - 06
Date 5/10/98
New York State
Department of Health
Bureau of Emergency Medical Services
Re:
Ambulance Oxygen
Systems &
Equipment
POLICY STATEMENT
Page 1 of 4
Supersedes /Updates:
All Previous
This policy updates a number of previously issued policy statements and
memorandums sent to services over the last several years detailing use and safety
concerns for oxygen delivery equipment. This policy supersedes all previously issued
statements.
AMBULANCE OXYGEN SYSTEMS
Oxygen delivery systems in ambulances are a potential source of hazard if the
distribution system and cylinders are not properly installed and maintained. Oxygen
systems in ambulance vehicles need to be maintained in accorance with the original
equipment manufacturer’s (OEM) specifications and inspected periodically for leaks,
cleanliness and system integrity. Any unexplained noise or loss of oxygen gas should
be investigated thoroughly. Caution should be exercised when replacing any
component in the system to avoid installing an incompatible or incorrect piece of
equipment (eg. liter flow regulator to replace a pressure reduction valve). At no time
should adhesive tape or similar materials, or petroleum products be used to seal
connections or repair leaks.
OXYGEN CYLINDERS
Poorly maintained or the incorrect handling of oxygen cylinders can be hazardous to
staff and/or patients. The Department recommends that all providers become familiar
with the applicable Federal US DOT regulations (CFR-49-100/199) pertaining to the
maintenance of oxygen cylinders.
Services should take all necessary measures to ensure cylinder integrity. Specific
attention should be given to the following areas concerning oxygen cylinders.
a. Cylinder leaks, abnormal bulging, defective or inoperative valves or
safety devices.
b. Physical presence of rust or corrosion on a cylinder or cylinder neck.
c. Any foreign substances or residues, such as from adhesive tape
around the cylinder neck, oxygen valve or regulator assembly. The
presence of these materials may hamper the ability of the oxygen delivery
equipment to work properly and in some cases may have the potential to
cause fire or explosion.
d. All oxygen cylinders must have proper hydrostatic testing and be
marked appropriately. Services need to be aware of the specific
requirements for the testing requirements of steel and aluminum tanks
(eg. ten (10) years initial testing for steel cylinders and five (5) years for
aluminum cylinders). Figure A identifies the proper definitions and
markings for pressurized gas cylinders.
[
Plus sign indicates cylinder may be overcharged 10%
5 - 66
q
Latest date indicates last cylinder retest
Five pointed star symbol indicates a
ten year retest interval
Fig. A
Any cylinder placed in service by an EMS service, whether or not it is currently on a
vehicle, must be within test requirements as evidenced by a valid hydrostatic test date
imprinted on the cylinder.
Paper labels on a cylinder usually indicate a gas expiration date and are not a valid
cylinder test date.
NYS - EMS Policy 98 - 06 (5/10/98)
Pg. 2 of 4
MINIMUM SUPPLY/CYLINDER PRESSURE
An adequate supply of oxygen must be available at the beginning and at all times
during a shift or ambulance call. To meet the requirements of 800.24.b, the
Department will accept a minimum of 2,000 psi in any combination of portable
cylinders (eg. 1 @ 1700 and 1 @ 700) on a vehicle at the beginning of the shift.
Oxygen used during a shift must be documented on a PCR. One portable cylinder
must contain at least 500 psi at any time. A vehicle with less than 500 psi in one
portable cylinder must be considered out of service until restocked.
An ‘installed’ cylinder (H, K, Q, etc.) must contain at least 500 psi.
Services must develop policies and procedures to address cylinder replacement when
there is a low volume (eg. 500, 700 psi) and such replacement needs to be based on
the number of cylinders carried, resupply cabability, shift length, etc.
INSTALLED OXYGEN SYSTEMS WITH HUMIDIFIERS
The Department recommends that disposable type oxygen humidifiers be the unit of
choice. Services that continue to use non-disposable humidifiers must take steps to
ensure the sanitary condition of the system at all times including a separate supply of
sterile water, as required by 800.23(a). At no time is water to be stored in a ‘refillable’
humidifier. Any refillable system must be dry unless it is currently in patient use, as
open sterile water can quickly become contaminated with microorganisms.
OXYGEN CYLINDER SECURING DEVICES
Part 800.23 (e) requires that each pressurized gas cylinder in any ambulance be
mechanically secured. For installed oxygen systems, this must be accomplished by
using the OEM supplied securing system or a similar replacement system that is
maintained in proper condition. Portable and spare cylinders, must be mechanically
fixed in place using a cup & yoke or equivalent device.
Portable cylinders may be packaged in a rigid or padded protective case and then
stored in a cabinet or strapped to the ambulance cot with the head of the cot in the
elevated position. In all situations the cylinder head and regulator are to be protected.
At no time are oxygen cylinders to be stored in a cabinet or under the squad bench
held in place by other items of equipment.
NYS - EMS Policy 98 - 06 (5/10/98)
Pg. 3 of 4
LIQUID OXYGEN SYSTEMS
Liquid oxygen systems are beginning to be used in ambulance vehicles as a “bulk”
source. Each service is advised to fully research the feasibility of using a liquid
oxygen system prior to making a decision to use this type of system. Issues
concerning the use of liquid oxygen systems include but are not limited to:
a. Liquid oxygen systems bleed off almost constantly, and may waste a lot
of oxygen making these systems unsuitable for low volume ambulance
vehicles where more oxygen will be exhausted than used.
b. Liquid oxygen systems may be classified as a hazardous material in
certain quantities, and in some jurisdictions are prohibited on
thoroughfares, bridges and/or tunnels.
c. Source and ability to refill the unit.
Issued By:
John J. Clair
Associate Director - Operations
Authorized By:
Edward G. Wronski
Director
Thomas M. Fortune
Sr. EMS Representative - Operations
NYS - EMS Policy 98 - 06 (5/10/98)
Pg. 4 of 4
No.
New York State
Department of Health
Bureau of Emergency Medical Services
98-04
Date: 03/30/98
Re: Equipment Update
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 3
This policy is another in a continuing series published in an effort to help keep EMS
services informed of changes in equipment and answer common questions pertaining to
equipment requirements of the State EMS Code, Part 800.
Item 1- Battery Lantern (800.24.g.2 & 800.26.d.2)
A battery lantern is considered to be a device capable of providing a sufficient amount of
light to provide limited patient care when lighting or electrical failures occur in a vehicle
and also capable of providing light remotely at a scene. One two “D” cell or larger hand
held or free standing light with a halogen or krypton light source is acceptable and will
meet the requirements of the code.
Item 2 - Penlight/Flashlight (800.24.f.15 & 800.26.b.6)
A flashlight may be a reusable or disposable pen size or mini flashlight generally used
while performing patient assessment duties such as pupillary response. A battery lantern
meeting the requirements of item one (1) of this policy does not meet the requirement for
this item.
Item 3 - Adult Extrication Collars (800.24.c.5 & 800.26.a.14)
Each certified ambulance or ALS-FR service must have adult rigid extrication collars
available in three (3) different sizes which provide access to the patients anterior neck.
The Department has determined that, when used according to manufactures
specifications, one adjustable style collar is equivalent to the three (3) individual adult
sizes required. Therefore, one (1) adjustable rigid collar may replace the three (3) adult
sized collars. One adjustable collar does not however, replace the need for a pediatric
collar. Services are advised to discuss the choice of adjustable cervical collars with their
service medical director and insure that all personnel are fully trained in the application,
sizing and use of any cervical collar.
It is recommended, that enough collars, of the same style and manufacture be available
to provide for the possibility of two (2) or more patients. It is also recommended that
collars not be carried or stored on a vehicle handrail as they may become easily soiled or
contaminated.
NYS-EMS Policy 98-04 (3/30/98)
Page 2 of 3
Item 4 - Blood Pressure Cuffs (800.24.f.5 & 800.26.a.13)
Many vehicles have fixed blood pressure cuffs in the patient compartment. Thus, a
provider cannot perform an adequate assessment for a patient away from the vehicle.
Therefore, at least one blood pressure cuff needs to be available to permit adequate
patient assessment away from the vehicle. Any blood pressure cuff which is currently on
a certified vehicle must be in good working order, including proper calibration of the
gauge to zero.
Item 5 - Adult Bag Valve Mask (B.V.M.) (800.24.b.1 & 800.26.b.2)
Each certified vehicle is required to have a manually operated self-refilling adult size
B.V.M. with two (2) different sized adult masks. Masks must be clear and have an
inflatable air cushion. One (1) clear adult Blob type mask may replace the two (2)
different sized adult masks. Merely having two (2) similar sized adult masks does not
meet the requirements of 800.24.b.1.
It is recommended that the two (2) different sized adult masks be stored in the same
container as the adult B.V.M.
Item 6 - Pediatric Bag Valve Mask (B.V.M.) (800.24.h.1&.2 & 800.26.b.2)
Each certified vehicle is required to have a pediatric size B.V.M. with three (3) different
sized clear pediatric masks with an inflatable rim. These sizes will include child, infant,
and neonate. One (1) pediatric Blob mask does not replace the need for three (3)
pediatric masks.
It is recommended that the three (3) pediatric masks be stored in the same container as
the pediatric B.V.M.
Item 7 - Adult and Pediatric Oral Airways (800.24.b.2&h.4 & 800.26.b.3)
A total of ten (10) oral airways are required and need to include four (4) adult airways in
various sizes and 2 sets of three (3) pediatric airways in child, infant, and neonate sizes.
Oral airways must be kept clean and sanitary, and are not required to be sterile or
individually wrapped. Do not wrap individual oral airways in foil or plastic wrap.
Pediatric airways may be stored separately if there is a separate pediatric kit or cabinet
routinely maintained on the vehicle.
It is recommended that one complete set of seven (7) airways be stored in a box or plastic
bag that is easily accessible to the care giver. Do not store bulk quantities of multiple
sized airways in one container.
Item 8 - Secured Equipment (800.23.d)
It is the intent of this requirement to minimize possible injury to crew members or
patients, and damage to the vehicle or the equipment itself, that may result from
equipment not being properly secured. All equipment in each vehicle will be secured,
as far as is practical, except when the equipment is being used to provide patient care.
All items of equipment, such as defibrillator units, jump kits, and portable oxygen units
need to have a secure storage area. These items may be stored strapped to the ambulance
NYS-EMS Policy 98-04 (3/30/98)
Page 3 of 3
stretcher so long as the head of the stretcher is in the raised position. Cabinet doors and
other coverings must be functional and unbroken. It is recommended that ,whenever
possible, every effort be made to secure all equipment during patient transport.
Item 9 - Sealed \ Pre- inventoried Equipment Bags and Cabinets
Services may use pre-inventoried kits or cabinets for equipment or supplies, and may seal
or secure them to guarantee the contents. Any such seal must be easily broken to ensure
availability and access for use. Furthermore, the attendant must be able to readily
locate, identify and access any equipment that is contained in a sealed kit or cabinet.
Services must have policies in effect which call for the routine opening, cleaning, and re
inventory of these sealed areas. Each kit or cabinet must have an inventory list visible
or available in the vehicle. Items considered to be “lifesaving” in nature, such as suction
catheters or tubing and oxygen delivery devices, must have at least one item located
outside of any sealed cabinet.
Item 10- Sharps Containers
Part 800 does not directly address the issue of sharps containers. Each service will have a
policy addressing the storage and disposal of used/contaminated sharps. It is not
required that a sharps container to be locked in a cabinet, but it is required that the
container be properly secured. Caution should be taken when using these containers to
prevent over filling and accidental exposure. Never break, bend, cut, or recap any
needles prior to disposing of them. Never forcefully push a needle into a container.
Smaller volume agencies should make provisions to empty small containers at the end of
each day. Similar practices of maintenance and cleaning should pertain to all other trash
containers.
It is recommended that a service use the smallest size collection bin reasonable for the
daily needs of the service.
No.
98-03
Date: 03/30/98
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Personal
Equipment on
Ambulance Vehicles
Supercedes/Updates:
Page: 1 of 1
Objective
The objective of this policy is to identify the responsibilities of EMS services and
individuals in regards to equipment required by Part 800 that may be considered by a
service to be personal issue.
Background
Part 800 of the New York State EMS Code defines what equipment must be available
and operational on each certified emergency response vehicle ( Ambulance, EASV or
ALSFR vehicle). Services may issue their members/employees certain items of EMS
equipment such as penlights, stethoscopes, and blood pressure cuffs, or may permit
members/employees to carry their own similar equipment.
Policy
Any service which issues or permits the use of personal equipment by its
members/employees must have written policies in effect which clearly define which
items of equipment are personal issue, and the responsibility of each member/employee
for the availability, cleanliness and operational condition of each item when on duty. The
service may limit what equipment members/employees may carry. Individual
members/employees should receive a copy of the policy and acknowledge its receipt.
The service’s daily vehicle inspection report should identify any items of equipment
considered to be personnel issue.
As with any item of equipment required by Part 800, the EMS service is held responsible
for the availability, cleanliness and operating condition of any personal issue equipment.
Issued by:
John J. Clair
Associate Director-Operations
Thomas Fortune
Sr. EMS Representative-Operations
Authorized by:
Edward G. Wronski
Director
No.
98-02
Date: 03/30/98
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Re: Radio
Communications
Systems for EMS
Services
Supercedes/Updates:
Page 1 of 3
Statement of Purpose:
Radio communications resources for EMS services need to be capable of providing:
> Initial dispatch of the service including, equipment and/or personnel.
> The ability for the vehicle dispatched, while en route to a location within a designated
response area, to be reached by the dispatching point and conduct 2-way
communications.
> Within a reasonable distance and at least 10 minutes prior to arrival, contact a
destination Hospital ED to provide patient status and time of arrival information.
> The ability for a destination hospital or Medical Control Physician to reach and
converse with EMS personnel, prior to arrival, if needed.
> Medical Control activities, as required by the region’s Medical Advisory Committee
(REMAC), at all points within the service area.
> Participation in local/regional interagency routine EMS activities (mutual aid,
intercepts, etc)
> Participation in local/regional interagency MCI/Disaster activities in accordance with
local or regional preplans.
> Other agency or local communications needs as identified by individual services or
systems.
Policy:
Each EMS agency shall have available 2-way radio communications capability and a
back up or redundant capability for each Emergency Response vehicle and /or it’s
personnel to meet the needs as stated above.
Examples of the types of EMS services that shall have this capability include:
> ALS First Response
> BLS Ambulance
> ALS Ambulance
Any certified ambulance must have operational communications equipment in
accordance with part 800.22(e) which states, “ALL AMBULANCES SHALL: have twoway voice communication equipment to provide communication with hospital emergency
departments directly or through a dispatcher, throughout the duration of an ambulance
call within their primary operating area. It shall be licensed by the Federal
Communications Commission in other than the Citizens Band. Alternative
Communication systems are subject to the approval of the department as being
equivalent in capability.1”
Any vehicle identified as an Emergency Ambulance Service Vehicle (EASV) must
have operational communications equipment in accordance with part 800.26(c) which
states, “Any emergency ambulance service vehicle (other than an ambulance) shall be
equipped and supplied with: A two-way voice communications enabling direct
communication with the agency dispatcher and the responding ambulance vehicle on
frequencies other than citizens band.”
800.22(e) means, any service (Ambulance or ALS First Response) which is
authorized by a REMAC to provide Advanced Life Support (ALS) care shall have
communications capability to access and use a REMAC approved communications
system for the purpose of establishing On Line Medical Control and conversing directly
with an approved Medical Control point at any location where a patient is to be received
within the service’s authorized territory.2
800.26(c) means, any EASV or ALS First Response Vehicle shall have
communications capability to; communicate directly with Medical Control to insure
appropriate patient care, maintain communications with the incident dispatch point, and
communicate with any ambulance or personnel to which it is responding to provide
additional EMS assistance including ALS intercept. These communications capabilities
need to be operable throughout the service’s authorized territory.
1
A cellular phone type communications capability may not be used to provide redundancy to another cellular phone type system. A
cellular phone may be used however to provide communications redundancy to a standard two-way radio system and vice versa. A
Separate two-way radio system may be used to provide redundancy to any primary two-way radio system.
2
This applies to territory within the constraints of each REMAC region or system within which the service has authority
and actually provides ALS patient care. Some services may operate under multiple communications systems depending
on the ALS systems within which they have REMAC approval.
Any service which is a participant in a local or regional preplan or contract for
mutual aid, ALS Intercept, MCI or Disaster Response, shall have communications
capability to; contact or be contacted by the dispatch control point, incident site, field
command, county or regional control center and/or other services in accordance with the
provisions of said plan.
Each agency or service shall hold a valid FCC issued license for the operation of
communications equipment on frequencies used by the service OR hold a valid “Letter
of Authority” from an appropriately licensed entity to operate communications equipment
on frequencies used by the authorizing service.
For the purposes of this policy, communication systems include land mobile twoway, trunked, commercial and public safety systems under Part 90 of the FCC Rules
and Regulations and cellular phone systems authorized by the Federal Communications
Commission. Specifically excluded from use are CB, GMRS, Marine, all FCC
designated “unlicensed” radio services and other non Part 90 Radio Services.
Additional Notes:
In areas where communications are not reliable due to geographic and
topographic considerations, it is the responsibility of the REMAC of each system to
evaluate communications systems proposed to be used for Medical Control and endorse
specific communications methods to be used. Alternative communications systems
(e.g.: Cellular Telephone) may be recommended by a REMAC for either redundancy or
replacement of conventional systems where deemed appropriate. This may be the case
for example where REMAC protocols reflect actual communications capabilities,
conventional systems have been demonstrated to provide inadequate coverage, or to
provide for medical control in the event of communications failure. (NOTE:
Communications failure is the sudden and unexpected loss of communications
capability. It is NOT characterized by an inability to communicate reliably under normal
conditions.)
In instances where hand carried devices are used to provide communications for
an EMS service, the device should be capable of being connected to an antenna system
affixed to the exterior of the vehicle and the device should also be capable of being
operated using the vehicles fixed electrical power system. Such devices may serve as
back up communications to an alternate communications service.
In all cases, hand held communications devices should be kept at least three (3)
feet from patients with pacemaker implants, or any electronic medical device, while the
communications device is in use.
Issued By:
John J. Clair
Associate Director-Operations
Dana L. Jonas
Sr. EMS Representative-Operations
Authorized by:
Edward G. Wronski
Director, Bureau of Emergency Medical Services
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
95-06
Date: 09/15/95
Re: Interim Policy of
AED Training
Page 1 of 2
The following interim policy statement on AED training is effective immediately.
As a new AED course curriculum is adopted and our data processing system
upgraded, we will update this policy.
Introduction
Since January 1991, a number of first responder agencies have participated in a
demonstration study to consider moving Automated External Defibrillation (AED)
to the basic life support (CFR & EMT) level. Based on the data from this study,
several other national studies and the recommendations of the 1992 National
Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care,
the State EMS Council has recommended and the Commissioner of Health
adopted regulatory changes to the State EMS Code (10NYCRR-800) which
defines AED as a basic life support skill. Non-transporting first response EMS
agencies are no longer required to obtain Certificate of Need (CON) approval in
order to provide AED level care. However, all services are required to have
Regional Medical Advisory Committee (REMAC) approval, be part of an
Emergency Medical Services System, and have medical control.
Specific questions from agencies wishing to provide AED level care should be
directed to their Regional Emergency Medical Advisory Committee (REMAC).
AED Training
To use the Automated External Defibrillator the CFR/EMT/AEMT must
successfully complete training which meets or exceeds the State approved AED
Standard Curriculum [800.15(d)(4)]. The curriculum which should be used until
the revised AED curriculum is published should be the currently published EMTDefibrillation curriculum.
A. Who can conduct AED Courses?
Any BLS or ALS Course Sponsor, currently approved by the Department
of Health, may conduct AED original training, in accordance with the State
approved AED Standard Curriculum. The Course Sponsor must file a
Course Application (DOH-782) and course schedule at least 30 days prior
to the start of the AED course. Attached to the application should be a
copy of the course schedule covering the objectives of the curriculum.
Please check the box Basic EMT-D Original to indicate this is a standalone AED course.
B. Who can teach AED Courses?
The AED instructor must be a currently Certified Instructor Coordinator
(CIC) and hold current certification at or above the EMT-Defibrillation
level, as outlined in Policy Statement 93-8. It is the responsibility of the
Medical Director to assure that quality of medical instruction.
C. End of Course Documentation
Within 10 days of course completion the sponsor must submit a Course
Memorandum (DOH-263), a Final Practical Skills Examination Summary
Sheet (DOH-2733), and an Application for EMT-Defibrillation Certification
(DOH-3306) for each candidate (CFR or EMT) which have successfully
completed the course.
D. Retraining and Reauthorization
Periodic "retraining" is the responsibility of the Service Medical Director. In
low call volume areas the Medical Director may wish to conduct AED drills
or in-service training as frequently as every 90 days.
E. Who maintains course completion records?
1. Course Sponsor
The State EMS Code (10NYCRR-800) Section 800.20(9) requires that
Course Sponsors maintain individual course and student records for a
period of 5 years. These records should include attendance, learning
contract, practical skills and written examinations.
2. EMS Agency
Section 800.21(k) of the State EMS Code requires that all EMS agencies
maintain current and accurate personnel files on all CFR/EMT/AEMT
personnel. Training records must include:
a. copies of state issued certification;
b. record of additional or specialized training; and
c. in-service training and continuing education programs.
Verification of original AED training must be maintained as a record of
specialized training. AED "retraining" approved by the Service Medical
Director must be maintained as a record of in-service training.
Certified First Responder
A Certified First Responder is eligible for AED training. However, it needs to
be clearly understood that the current regulations do not include a level of
certification called "CFR-Defibrillation". Within the limitations of the 51 hour
CFR course, AED training is not included. The department will not be issuing
a certification for this level.
There are future plans to issue a certificate of course completion for AED
Training.
Funding
The current budget allows for reimbursement of $50 per eligible student who
completes the "stand alone" EMT-D original or "stand alone" AED course.
See Course Funding policy statement for details.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
95-04
Date: 09/01/95
Re: EMS Mutual Aid
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 3
The purpose of this policy is to provide EMS services with guidance as mutual aid
plans and policies are developed. This policy statement discusses the concept,
history and legal basis for EMS mutual aid in New York State.
EMS services have the responsibility to routinely provide the type and level of
service authorized and/or expected by the community, in a timely and reliable
manner.
From time to time, to meet peak demand or extraordinary resource utilization, it
may be necessary to request assistance to answer a call or provide additional
resources. This is the concept of and intent of EMS mutual aid.
EMS mutual aid requests must be made with the intent of having the closest1 available
EMS unit respond to a patient's medical need, at a time when the resources of the
requesting agency are temporarily unavailable or have been expended.
The response to multiple casualty incidents (MCI's) and other large scale events are
usually conducted in accordance with a county or other pre-determined resource
allocation and management plan. These may require mutual aid responses but are
developed independently due to the special planning needs required.
EMS services are required by the State EMS Code (800.21.p) to have a written
mutual aid plan. Regional EMS Councils are encouraged to coordinate the
development of agency and/or county mutual aid plans and the Councils have the
authority to approve an EMS service operating beyond its primary operating
territory for purposes of fulfilling the provisions of a mutual aid agreement
(PHL3010.1.b).
Issued by: John J. Clair
Associate Director - Operations
Authorized by: Edward G. Wronski
Deputy Director
Background:
The provision of mutual aid by fire departments is provided for in several sections
of the General Municipal Law (GML) however, without definition, terms or
conditions. The GML does specify that the requesting fire department is responsible
for responding equipment and the responding fire service retains responsibility for
personnel. The GML does not address mutual aid with non fire agencies - eg.
volunteer or commercial.
For EMS mutual aid, the provisions of Article 30 with regard to primary operating
territory must prevail, all other circumstances being the same - eg. response time,
location, staffing, etc.
There is no statutory or regulatory definition requiring, presuming or defining who
may, or must or who can not request mutual aid. In other words, there is no
definition or prohibition regarding what type of agency a requesting agency must
call. Therefore any service type may request the assistance of any other EMS
service:
•FD < = = > VAC
•VAC < = = > Commercial
•FD < = = > Commercial
Insurance policies are available to cover the assets and liabilities of any agency
requesting or responding to a request for EMS assistance. There is no restriction
with regard to who may obtain or provide such coverage.
Conclusion:
It may be concluded that mutual aid in New York State may be easily achieved
within the current regulatory and statutory definitions if:
•Services providing an EMS response to a request for EMS assistance maintain
responsibility for their own liability -specifically; vehicles, equipment and personnel.
•EMS mutual aid is requested from the closest, available, appropriate agency
capable of responding at the time of the request.
Mutual Aid Plans:
EMS agencies need to develop and maintain written mutual aid plans (800.21.p).
These plans, while agency specific, should be developed in conjunction and
cooperation with counties and Regional EMS Councils.
For assistance in developing mutual aid plans, refer to NYS-EMS policy 89.2
Mutual Aid Planning Guidelines.
Mutual aid plans must insure that any request is made with the intent of having the
closest [ usually means the unit with the shortest response time to the patient]
available EMS unit respond to a patient's medical need, at the time the resources of
the requesting service are temporarily unavailable or have been expended.
Mutual aid plans and agreements for normal day to day requests are the
responsibility of the individual EMS service. Typically such agreements identify the
closest EMS unit that is to be requested. Frequently, an EMS service's area of
operation is divided, within a plan, to facilitate a timely response based on the
location of the neighboring service. Service type (eg. volunteer, fire, hospital,
commercial) must not be a consideration in any plan or to any request. Staffing, unit
availability, response time and primary operating territory are the primary
concerns to be addressed. The specific agency to be requested for a mutual aid
response may vary with day or time based on availability.
Mutual aid plans for multiple patients are usually developed and coordinated at a
county level to insure an adequate response as well as to provide coverage of all
affected areas.
The statutory definition of mutual aid excludes inter-facility transfers and ALS
intercepts.
Counties providing coordinated dispatch, ( 911, fire control, etc.) will need to
monitor crew status and service availability, to assist in implementing agency
mutual aid plans - particularly when they act as the service's dispatch.
1 - usually means the unit with the shortest response time to the patient
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
95-03
Date: 08/01/95
Re: ALSFR Service
Requirements
Page 1 of 6
REQUIREMENTS FOR
ADVANCED LIFE SUPPORT FIRST RESPONSE (ALSFR) SERVICES
I. Introduction
The 1993 amendments to Article 30 of the Public Health Law require that First
Responder (non-transport) EMS services, which provide ALS, be certified by the
Department (PHL 3005). To enable the certification of ALSFR services, this
policy sets forth the requirements that an ALSFR service must meet. Each
ALSFR service must have an operational plan (Section II a), specific BLS and
ALS equipment (Section V), policies and procedures relating to operations,
dispatch, and documentation (Section III), and reporting certain incidents
(Section IV). These requirements have been designed to compliment the typical
requirements that REMAC’s and local medical directors have required of ALSFR
services.
This policy statement will serve as interim direction for the minimum
requirements, conduct and competency in the operation of ALSFR services
under the provisions of Section 3012 of the Public Health Law, until final
regulations are adopted by the Department.
II. General Requirements
An ALSFR service shall:
a. develop and submit to the Department, for review and/or modification and
approval, a plan which demonstrates the manner in which the ALSFR
service will provide ALS care. This plan shall include but not necessarily
be limited to:
1. staffing patterns and level(s) of care;
2. vehicle configuration, type and use;
3. access, safeguarding, security and secure storage, including
environmental protection from temperature and other damage, of all
ALS equipment and supplies while in use and storage;
4. dispatch, ambulance and ALS communications;
5. ALS protocols and on-line medical control; and
6. Written approval of medical control for participation in the plan,
b. identify to the department all vehicles or other conveyances which will be
used as ALSFR vehicles;
c. display on each ALSFR vehicle when in service a valid Department of
Health certificate of inspection;
d. have and maintain each ALSFR vehicle in compliance with all applicable
federal or state agency (DMV, DOT, FAA, USCG, etc.) registration and
applicable requirements;
e. have for each ALSFR vehicle or conveyance any appropriate safety
inspection certificate from a federal or state agency (DMV, DOT, FAA,
USCG, etc.), unless specifically exempted by statute;
f. notify the department in writing when any designated ALSFR vehicle is
permanently removed from service as an ALSFR vehicle. Any department
certificate of inspection shall be removed at such time;
g. display on the exterior of both sides on any ALSFR vehicle the name of
the service in clearly legible letters not less than 3 inches in height;
h. equip any ALSFR vehicle placed in service with the minimum equipment
set forth in this part;
i.
have on each call when providing ALS care at least one individual who is
a certified advanced emergency medical technician attending the patient
at all times;
j. provide ALS care only at a level and in a manner authorized by medical
control;
k. only permit ALSFR conveyances to be operated by a duly licensed
individual;
l.
make available for inspection, with or without notice, to representatives of
the department all vehicles, conveyances, materials, equipment, records,
procedures, and facilities;
m. maintain current and accurate personnel files for all certified first
responders and emergency medical technicians, showing qualifications,
training and certifications and health records including immunization
status. Employee health records shall be maintained separately and in
compliance with all applicable requirements. Information contained in such
personnel files shall be reviewed no less frequently than annually, and
may be disclosed only to authorized individuals;
n. maintain a record of each EMS call in compliance with the requirements of
800.32 of this part;
o. maintain adequate, secure and safe storage facilities for all equipment,
supplies and oxygen. Separate storage and disposal shall be maintained
for soiled supplies and waste in accordance with applicable requirements;
p. maintain all equipment and supplies in a clean and sanitary condition,
secure and environmentally protected;
q. have a written agreement with one or more ambulance services which
describes dispatch criteria and procedures and which requires the
ambulance service to transport any patients in the care of the ALSFR
service and ALSFR service personnel, to a hospital;
r. operate only within its primary territory except:
1. in response to a request for mutual aid in accordance with the
service’s written mutual aid plan; or
2. in response to a mutual aid plan implemented by a central dispatch
agency on behalf of an ambulance or ALSFR service or on behalf
of a county or city emergency management office; or
3. by approval of the department and the appropriate regional
emergency medical services council for up to 60 days if the
expansion of territory is necessary to meet an emergency need;
III. Required Policies
a. have and enforce written policies concerning:
1. mutual aid, including any required authorizations and agreements,
to request the response of the nearest, appropriate, available EMS
service(s). The written plan shall consider the incident location and
access to it, location of the mutual aid agency, primary service
area, level of service, staff availability and any other pertinent
information when identifying the mutual aid agency;
2. coverage of the service’s response area when it is unable to
respond to emergency calls for assistance;
3. the maximum call receipt interval for all emergency calls for
assistance, except for MCI or disaster situations;
4. actions to be taken if the maximum call receipt interval determined
in (3) is exceeded and an ALSFR vehicle has not yet started toward
the incident location;
5. authorization and protocols for a central dispatch agency to send a
mutual aid service when the service does not or cannot respond;
6. minimum qualifications and job descriptions for all patient care
providers, drivers and EMS dispatchers;
7. physical, health and immunization requirements for all patient care
providers and drivers, including provisions for biennial review and
updating of such requirements;
8. preventive maintenance requirements for all authorized EMS
response vehicles and patient care equipment;
9. cleaning and decontamination of authorized EMS response
vehicles and equipment, in accordance with currently accepted
practices;
10. equipping and inspection of all authorized EMS response vehicles;
11. reporting by the agency of suspected:
i. crimes;
ii. child abuse;
iii. patient abuse; and/or
iv. domestic violence, including any directed toward elderly
persons;
12. responsibilities of patient care providers when:
i. a patient cannot be located
ii. entry cannot be gained to the scene of an incident
iii. a patient judged to be in need of medical assistance refuses
treatment and/or transportation;
iv. patients seek transportation to a hospital outside the area in
which the service ordinarily transports patients;
v. a receiving hospital requests that a patient be transported to
another facility before arrival at the hospital;
vi. treating minors;
vii. treating or transporting patients with reported psychiatric problems;
and
viii. confronted with an unattended death.
13. infection control practices and a system for reporting, managing and
tracking exposures and ensuring the confidentiality of all
information that is in compliance with all applicable requirements;
14. by July 1, 1995, have an EMS response plan for hazardous material
incidents. Participation in a county or regional plan will meet this
requirement.
15. By July 1, 1996, have a response plan for multiple casualty incidents.
Participation in a county or regional MCI plan will meet this
requirement.
IV. Required Reporting
a. upon discovery by or report to the governing authority of the service,
report to the Department’s Area Office by telephone no later than the
following business day and in writing within 5 working days every instance
in which:
1. a patient dies, is injured or otherwise harmed due to actions of
commission or omission by a member of the ALSFR service;
2. an authorized EMS response vehicle operated by the service is
involved in a motor vehicle crash in which a patient, member of
the crew or other person is killed or injured to the extent
requiring hospitalization or care by a physician;
3. EMS personnel are killed or injured to the extent requiring
hospitalization or care by a physician while on duty;
4. patient care equipment fails while in use, causing patient harm;
5. it is alleged that any member of the service has responded to an
incident or treated a patient while under the influence of alcohol
or drugs;
b. On or in a form approved by the Department, maintain a record of all
unexpected authorized EMS response vehicle and patient care equipment
failures that could have resulted in harm to a patient and the corrective
actions taken. A copy of this record shall be submitted to the Department
with the EMS service’s biennial recertification application.
V. ALS First Response Vehicle Equipment Requirements
Every ALS first response vehicle shall be equipped, meeting all requirements of
800.23 and shall be supplied as follows:
a. Emergency care equipment and supplies consisting of:
1. twelve sterile 4"x4" gauze pads;
2. adhesive tape, 2 rolls assorted sizes;
3. six rolls conforming gauze bandage, assorted sizes;
4. two universal dressings, minimum 10 by 30 inches;
5. six 5"x9" (minimum size) sterile dressings or equivalent;
6. one pair of bandage shears;
7. six triangular bandages;
8. sterile normal saline in plastic container (1/2 liter minimum)
within the manufacturer’s expiration date;
9. one air-occlusive dressing;
10. one liquid glucose or equivalent;
11. disposable sterile burn sheet;
12. one emergency childbirth kit, with sterile supplies;
13. blood pressure cuff(s) in adult and pediatric sizes;
14. one stethoscope
15. rigid extrication collars capable of limiting movement of the cervical
spine. These collars shall include one each pediatric and small,
medium
and large adult sizes;
16. carrying case for essential equipment and supplies;
17. one set or personal protective mask and goggles or equivalent for
each
crew person;
18. four pairs of disposable gloves in two sizes;
19. one pen light or flashlight; and
20. one blanket.
b. Oxygen and resuscitation equipment consisting of:
1. portable oxygen with a minimum 360 liter capacity with pressure
gauge, regulator and flow meter (medical "D" size or larger) and
one spare cylinder. The oxygen cylinders must contain a
minimum of 2,000 psi between them, and each cylinder shall
contain a minimum of 500 psi;
2. manually operated self-refilling bag valve mask ventilation
devices in pediatric and adult sizes, each with a system capable
of operating with oxygen enrichment and, as appropriate, two
sizes each of clean adult and pediatric masks with air cushion;
3. six oropharyngeal airways, one each in a range of sizes child
through adult, packaged so as to be individually identifiable and
maintained sanitary;
4. two each: disposable non-rebreather oxygen masks, and
disposable nasal cannula individually wrapped;
5. one each, pediatric non-rebreather mask and nasal cannula;
6. portable electric suction equipment capable, according to the
manufacturer’s specifications, of producing a vacuum of over
300 mm Hg when the suction tube is clamped, including one
wrapped plastic Yankauer pharyngeal suction tip, one 8 fr.
Catheter and one pediatric suction device;
7. one pen light or flashlight; and
8. one blanket.
c. Two-way voice communications by radio or equivalent enabling reliable,
direct communication with the ALSFR service dispatcher, the responding
ambulance vehicle and, as required, on line medical control throughout
the duration of the call on frequencies other than citizens band.
d. Safety equipment consisting of:
1. six flares or three U.S. Department of Transportation approved
reflective road triangles;
2. one battery lantern in operable condition; and
3. one Underwrites’ Laboratory rated five-pound ABC fire
extinguisher or any extinguisher having a UL rating of 10BC.
e. Provide one or more of the following categories of advanced life support
equipment as defined by medical control for the level of ALS care
authorized:
1. fluid administration equipment and supplies;
2. airway management equipment and supplies;
3. a defibrillator and supplies;
4. medication administration equipment and supplies;
5. other equipment and supplies to provide ALS care as authorized
by medical control, the Commissioner and the State EMS
Council.
f. Maintain all equipment and supplies in such a manner as to:
i. prevent damage or deterioration from environmental changes;
ii. limit access and maintain security at all times; and
iii. be secure and packaged so as to prevent physical damage.
g. An ALSFR service may make application to the Commissioner for
modification or exceptions to the vehicle or equipment requirements of this
part if the nature of the EMS operation justifies such modification. Such
application must clearly demonstrate that the ALSFR service plan meets
the requirements as set forth in section 800.30(a) of this part, and provide
specific justification for any exemptions requested.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
92-02
Date: 05/06/92
Re: Tuberculosis
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 4
The incidence of tuberculosis (TB) has increased substantially in the last few years. EMS
providers should be aware of this infectious disease and the procedures for protecting
themselves.
As with all infectious diseases, no precaution is 100% effective; rather, these precautions
are designed to reduce the probability that the disease can be transmitted from person to
person.
TB is spread when small droplets from the respiratory tract of an infected person enter
the air and are inhaled by another person. Precautions can be taken in three areas to
reduce the danger.
First, the patient's mouth should be covered with a mask. A disposble micron surgical
mask (#M "Aseptix" sub-micron molded surgical mask, Catalog #1812; or equivalent) is
best, but a standard surgical mask or even an oxygen mask is helpful. The nature of the
medical treatment required by the patient should determine which mask is used.
Second, a disposable micron mask or disposable particulate respirator (PR), should be
worn by the provider. It should fit snugly on the face. A beard or mustache will markedly
reduce the effectiveness of such protection.
Third, the number of infectious droplets in the air can be reduced by ensuring good
ventilation in the patient compartment of the ambulance. Thus, the ventilation system
should be maximized and/or side windows opened to provide a steady source of clean air.
Which patients should receive respiratory precautions?
Patients with respiratory symptoms of more than 2 weeeks duration or any patient with a
respiratory symptom of any duration who is a member of a higher risk group. The CDC
defines high risk groups as follows:*
•
•
•
•
•
•
•
•
Alcoholics
IV drug users
Contacts of patients known to have active TB
Low income populations
Prisoners
HIV infected persons
Nursing home residents
Refugees
Persons with other pre-existing medical conditions which compromise the ability to fight
infection are also at increased risk. Such conditions include:
• Chemotherapy
• Diabetes
• Steroid Therapy
• Renal failure
• Some cancers
(source: CDC)
Clearly, TB patients receiving nebulized aerosols of Beta-agonists are likely to spread
infectious droplets. In such patients, as well as those presenting with respiratory
symptoms such as a persistent cough, special attention should be given to these
precautions by EMS providers.
Since air-borne droplet spread is the only means of TB transmission, there is no need to
decontaminate or disinfect the ambulance or equipment.
The following sections from the CDC Mortality and Morbidity Weekly Report
(December 7, 1990) summarize the CDC recommendations for control of TB in prehospital settings:
1. Other source-control methods
A simple but important source-control technique is for infectious
patients to cover all coughs and sneezes with a tissue, thus
containing most liquid drops and droplets before evaporation can
occur. A patient's use of a properly fitted surgical mask or
disposable, valveless particulate respirator (PR) (see below) also
may reduce the spread of infectious particles. However since the
device would need to be worn constantly for the protection of
others, it would be practical in only very limited circumstances
(e.g., when a patient is being transported within a medical facility
or between facilities).
2. For persons exposed to tuberculosis patients.
Appropriate masks, when worn by health-care providers or other
persons who must share air space with a patient who has infectious
tuberculosis, may provide additional protection against
tuberculosis transmission. Standard surgical masks may not be
effective in preventing inhalation of dropley nuclei, because some
are not designed to provide a tight face seal and to filter out
particulates in the droplet nueclues size range (1-5 microns). A
better alternative is the disposable PR. PRs were originally
developed for industrial use to protect workers. Although the
appearance and comfort of PRs may be similar to that of cupshaped surgical masks, they provide a better facial fit and better
filtration capability. However, the efficacy of PRs in protecting
susceptible persons from infection with tuberculosis has not been
demonstrated.
PRs may be most beneficial in the following situations:
a) when appropriate ventilation is not available and the patient's
signs and symptoms suggest a high potential for infectiousness, b)
when the patient is potentially infectious and is undergoing a
procedure that is likely to produce bursts of aerosolized infectious
particles or to result in copious coughing or sputum production,
regardless of whether appropriate ventilation is in place, and c)
when the patient is potentially infectious, has a productive cough,
and is unable or unwilling to cover cough.
Comfort influences the acceptability of PRs. Generally, the more
efficient the PRs, the greater is the work of breathing through them
and the greater the perceived discomfort. A proper fit is vital to
protect against inhaling droplet nuclei. When gaps are present, air
will preferentially flow through the gaps, allowing the PR to
function more like a funnel than a filter, thus providing virtually no
protection.
3. For tuberculosis patients.
Masks or PRs worn by patients with suspected or confirmed
tuberculosis may be useful in selected circumstances (see below).
PRs used by patients should be valveless. Some PRs have valves to
release expired air, and these would not be appropriate for patients
to use.
4. Emergency medical services
When emergency-medical-response personnel or others must
transport patients with confirmed or suspected active tuberculosis,
a mask or valveless PR should be fitted on the patient. If this is not
possible, the worker should wear a PR (see above). If feasible, the
rear windows of the vehicle should be kept open and the heating
and air conditioning system be set on a nonrecirculating cycle.
Emergency-response personnel should be routinely screened for
tuberculosis at regular intervals. They should also be included in
the follow-up of contacts of a patient with infectious tuberculosis.
(End of CDC recommendations).
Treatment of Exposed Providers
PPD testing should be conducted for pre-hospital providers who are exposed to TB
patients for whom adequate infection control measures (outlined above) were not taken.
Unless a negative skin test has been documented within the preceding three months, each
exposed worker (except those who are already known to be positive reactors) should
receive a PPD (Mantoux) skin test as soon as possible.
If the skin test is negative, the test should be repeated within twelve weeks after
the exposure ended.
Persons with skin test reaction of 5mm induration (swelling) or greater, or with
symptoms suggestive of active TB, should receive chest x-ray examinations.
Persons with previously known positive skin test reactions who have been
exposed to an infectious patient should be evaluated for active TB, but do not
require a repeat skin test or a chest x-ray examination, unless they have symptoms
suggestive of active TB.
Optimally, arrangements for treatment should be made by each agency in advance of an
exposure. Possible sources of care include: personal physician, receiving hospitals or
County Health Departments.
*Core Curriculum on Tuberculosis; Centers for Disease Control, April 1991: p. 11
Issued by: J. Lawrence Mottley, M.D.
Senior Medical Advisor
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates: 86-3
89-14
Date: 07/05/89
Re: Out of Service
Vehicles
Page 1 of 2
SUBJECT: Out-of Service Vehicles
Once the Emergency Medical Services Program has been notified that an
ambulance has been placed in service and the appropriate sticker is affixed, it is
considered in service unless removed from service. An ambulance is removed
from service either temporarily or permanently. The following procedure must be
followed in either case. The procedure to follow when returning to service an
ambulance which had been temporarily removed from service is also included.
TEMPORARY REMOVAL FROM SERVICE
A. When an ambulance is removed from service, whether for vehicle
maintenance reasons or lack of patient care equipment, and it is believed
that this removal will be temporary, the following procedure is to be used:
1. Place on the outside of the windshield, over the State Certification
sticker, a State "Out of Service" sticker.
RETURN TO SERVICE OF AN AMBULANCE TEMPORARILY REMOVED
FROM SERVICE
A. When an ambulance that has been temporarily removed from service is
returned to service, the ambulance service operator will perform the
following:
1. Assure that the vehicle is in compliance with Part 800 of the codes
of the New York State Department of Health.
2. Remove the "Out of Service" sticker from the vehicle windshield.
AMBULANCE PERMANENTLY REMOVED FROM SERVICE
A. When an ambulance is permanently removed from service the ambulance
service operator will perform the following:
1. Notify in writing, on official letterhead, the appropriate State EMS
Representative of the following information:
•
•
•
•
Make
Year
Vehicle/Radio ID
License Plate Number
2. Remove ALL New York State EMS logos from the sides and rear of
the vehicle.
3. Remove the Department of Health Certificate of Inspection sticker
from the windshield.
If there are any questions concerning this policy, please contact the appropriate
EMS Representative or Associate Director of Operations at (518) 402-0996.
Approved by: Michael Gilbertson, Director
No.
New York State
Department of Health
Bureau of Emergency Medical Services
89-06
Date: 03/15/89
Re: Part 18 Permits
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 1
SUBJECT: Part 18
Part 18 of the New York State Sanitary Code requires specific emergency
medical services (EMS) planning and coverage for all events likely to attract
5,000 persons or more, at any given time. It is the Department’s position that
such coverage must provide for care of participants as well as spectators.
All Applications for a Permit for a Public Gathering (DOH-44) must include a plan
which encompasses EMS protection for the participants (including athletes) as
well as spectators. Following are methods by which this coverage may be
addressed.
When a physician, trainer, or coach is responsible for care of the participants
(generally athletes), the EMS plan must include an interface between the
responsible person and the EMS system. This interface must include a written
understanding, protocols, and two-way communication via radio or telephone.
For high risk events, the permit issuing official may require additional EMS
personnel and equipment dedicated to care of the participants.
For other events, EMS coverage for participants may be included with the
general coverage for spectators.
Issued by: George L. Johnson, Associate Emergency Medical Care
Representative
Authorized by: Michael Gilbertson, Director
No.
89-04
Date: 03/15/89
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
Re: Sample Standard
Operating Procedure to
Follow in Respect to
Backing and Parking the
Ambulance
Page 1 of 2
SUBJECT: Sample Standard Operating Procedure to Follow in Respect to
Backing and Parking the Ambulance
Policy
In response to the often questioned concerns of ambulance operators on
procedures for backing and parking ambulances and in preparation for the
Ambulance Accident Prevention Seminar (AAPS), the following guidelines have
been prepared so they could easily be adapted into each service’s standard
operating procedures.
Backing the Ambulance
1. Backing of the ambulance should be avoided whenever possible. Where
backing is unavoidable, a spotter or an assistant outside the vehicle
should be used.
2. In addition, a spotter should be used when vehicles must negotiate
forward turns with restrictive side clearances and where height clearances
are uncertain. The purpose of the spotter is to expand the driver’s sense
for the right, left, front and rear space cushions.
3. Under circumstances where the ambulance is staffed by only the driver
(e.g., all other personnel are inside the residence with the patient), the
driver should attempt to utilize any available emergency services
personnel to act as spotters. Where no personnel are available to assist,
the driver shall park the vehicle, get out, and make a complete survey of
the space cushion around all four sides of the vehicle to determine if any
obstructions are present before proceeding to back the ambulance.
4. Spotters are never permitted to ride the tailboard or running boards while
the vehicle is in motion. The spotter should be in a visible safe zone
positioning him/herself ten (10) to fifteen (15) feet at the left rear of the
ambulance.
5. The vehicle should not be backed until the spotter is in position in the safe
zone and has communicated his/her approval to begin backing by way of
a hand signal, and voice, when possible. Spotters should remain visible to
the driver in the safe zone. Anytime the driver loses sight of the spotter,
the vehicle should be stopped immediately until the spotter is again visible
and the communication to continue backing is processed. This is definitely
not a high-speed maneuver. It should be done very slowly and cautiously.
Parking the Ambulance
1. Always park the ambulance in a hazard-free area to protect the crew,
patient and the ambulance (e.g., at a motor vehicle accident pull past the
accident, avoiding fuel spills, and park the vehicle off the road on the
shoulder).
2. When parking to the driver’s blind side a spotter should be used.
3. When parking in a parking space or driveway, back into the parking area
so that you have a safe and efficient exit.
General Rules for Drivers and Spotters
1. Never be in a rush when backing or parking!
2. Do not start to back or park when unsure of the area.
3. Do not put the ambulance into reverse gear until it has come to a
complete stop.
4. When it is dark outside use the side and rear spotlights when backing to
light the area.
5. If the vehicle has a backup alarm that can be disengaged, it should always
be in the on position before backing the vehicle.
Standard Signals for Spotters
1. Straight Back – One hand above the head with palm toward face, waving
back. Other hand at your side.
2. Turn – Both arms pointing the same direction with index fingers extended.
3. Stop – Both arms crossed with hands in fists. Be sure to reinforce the
signal by yelling the stop order loud enough so the driver can hear.
4. Night Backing – Signals are the same. The spotter should assure that the
spotlights on the rear of the ambulance are turned on before allowing the
vehicle to be backed. A flashlight, wand type is useful, maybe carried but
at no time will it be directed towards the mirrors.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
89-02
Date: 3/1/89
Re: EMS Mutual Aid
Planning Guidelines
POLICY STATEMENT
Supercedes/Updates:
Page 1 of 7
On March 1, 1989, the New York State EMS Council approved these Guidelines
for the Development of EMS Mutual Aid Plans. This planning guide is a
voluntary, educational document designed to assist local communities as EMS
Mutual Aid Plans are developed, reviewed or refined.
PURPOSE:
To establish a guideline for the development of uniform agreements between
ambulance and other emergency medical response agencies, making available a
methodology to obtain the resources needed to manage medical emergency
incidents in a defined and reliable way.
Mutual aid plans for Emergency Medical Services should be incorporated in, or
appended to, county and local public safety emergency planning documents.
OBJECTIVE:
To create an interest in, and foster, a climate to encourage development of EMS
mutual aid plans in all communities, particularly where no such plans currently
exist. All EMS agencies, regardless of sponsorship or type, need written plans
that are individual or a part of a fire mutual aid plan to facilitate EMS operations
and to provide a logical extension into major operations. Pre-planned EMS
mutual aid will facilitate daily dispatch and improve the response to all patients.
These plans can be written in most jurisdictions within the current legislative
structure and with existing authorities.
DEFINITIONS:
"*" indicates definition referenced from NYS Public Health Law, Article 30 or Part
800, The State EMS Code.
* AMBULANCE – means a motor vehicle, airplane, or boat or other form of
transport especially designed and equipped to provide emergency medical care
during transit.
* AMBULANCE SERVICE – means an agency engaged in providing emergency
medical services and the transportation of sick, disabled or injured persons by
motor vehicle, aircraft or other form of transportation to or from facilities providing
hospital services. (As used here "PERSON" means an individual, partnership,
association, corporation or any other entity.)
* EMERGENCY MEDICAL SERVICE – means a service engaged in providing
initial emergency medial assistance including but not limited to rescue &
extrication, the treatment of trauma, burns, respiratory, circulatory and obstetrical
emergencies.
MULTIPLE CASUALTY INCIDENT (MCI) – means any incident which produces
a number of casualties necessitating assistance from outside the normal
jurisdiction. This may be in the form of simple mutual aid for a localized incident
or a more extensive response involving county or regional resources in the case
of large scale incidents.
MUTUAL AID – means the preplanned and organized response of emergency
medical services, and other emergency personnel and equipment, to a request
for assistance in an emergency when local resources have been expended. The
response is predicated upon formal agreements among participating agencies or
jurisdictions.
MUTUAL AID PLAN – means a written agreement between two or more
jurisdictions which lists responding agencies, personnel and equipment, and
delineates command responsibilities. The plan must define the primary role(s) of
all responding agencies and personnel.
* PRIMARY OPERATING TERRITORY – means that geographic area stated on
a DOH ambulance service certificate or certificate of registration which defines
the usual or normal operating area of an ambulance service.
EMERGENCY RESPONSE AREA – means geographic boundaries used to
define emergency medical services response capability by one or more EMS
agencies. This can be an EMS district, fire district, village, town, city, an area
defined by local statute or contract or any combination thereof.
PRIMARY RESPONSE AGENCY(S) - means the initial EMS agency(s)
responsible for answering calls for service in a specific emergency response
area.
CONSIDERATIONS FOR THE DEVELOPMENT OF MUTUAL AID PLANS
When EMS agencies or other local groups begin to develop or review mutual aid
plans, a coordinated approach to the process is necessary. The process must
involve all possible organizations, take into account local needs and resources
and then follow a systematic approach to create a response concept and a
written plan.
In the following two sections, plan development and review considerations are
presented. The first section contains those elements which a local or county EMS
plan should consider in the development phase. In the second section are factors
which a county or regional review body can assess to insure that local plans are
developed with a regional consistency.
All plans need to be common in concept and in a form that allows integration into
a regional approach that crosses geo-political boundaries.
While no specific EMS legislation currently exists to mandate plan development
locally, SARA Title 3 and Executive Law 2-B are examples of existing authorities
and initiatives which involve emergency medical services and therefore EMS
mutual aid plans.
EMS MUTUAL AID PLAN DEVELOPMENT:
All plans shall:
•
Be consistent with the Incident Command System and the NYSEMS MCI Management Model.
•
Include a system for training all participating agencies to carry out
their designated role as defined in the plan.
•
Include a scheduled annual review of the plan and the supporting
resources as well as providing a method for updating the plan and
familiarizing all participants with any changes.
•
Take into account geography, demographics, medical resources,
emergency response personnel, any identified hazards or other
unique local needs.
•
Include for each EMS agency the provision of day to day back-up
from one or more agencies as needed. This daily response plan will
usually provide the basis for the larger MCI response. Agency
location, level of care, staffing, actual response time and usual
number of vehicles must be considered. This daily mutual aid plan
may vary by day, time, or season.
•
Provide for mutual aid services to be furnished first by agencies
serving the same emergency response area. Additional
ambulances or other EMS resources are obtained from adjacent
service areas as needed.
•
Insure that during mutual aid operations, emergency response
areas or other defined areas are not left without EMS or ambulance
coverage for routine needs. EMS resources must remain in zone or
be brought in by the plan. Methods of coverage, local personnel
and agencies to be utilized shall be detailed in the plan.
•
Be designed to expand and contract the resources on site or on call
as the nature and size of an incident changes.
•
Include participation by non-EMS agencies which may have a
function in certain EMS emergency operations. Such agencies may
include: police, fire, rescue, haz-mat teams, utility companies, Red
Cross, church groups, heavy construction equipment operators,
amateur radio groups, etc.
•
Insure that EMS operations and mutual aid plans are provided for in
all local emergency response plans. This must include command as
well as resource management concerns.
•
Insure that EMS operations and mutual aid plans are appropriately
included in county fire mutual aid plans to facilitate specific EMS
responses.
•
Address the communication needs of response agencies including
command interface between agencies. Regional EMS Councils in
their planning and review function should insure that a coordinated
interagency radio network is available to facilitate command and
tactical operations.
•
Include a comprehensive system for organized mobilization and
deployment of manpower and equipment.
•
Include mandatory considerations for the safety and protection of
all personnel at all times during any emergency operation. The
designation of a safety officer and mandatory use of personnel and
equipment staging areas are strongly recommended. This is
normally the responsibility of the Incident Commander and must be
provided for by EMS operations if not otherwise provided for.
•
Provide for on-scene administration, coordination, record keeping
and retrospective evaluation of the operation, including providing
the on-scene personnel and documents necessary to implement
the system.
•
Address liability protection and compensation coverage for all
participants.
•
Address medical issues such as triage, the use of BLS vs. ALS in
large scale operations, disaster protocols that differ from day to
day, protocols, hospital capability and capacity, hospital and
medical communication capability, etc.
•
Address post-incident critical stress management to be utilized as
needed.
•
Include an incident critique for all participants and a plan review.
SEE APPENDED BIBLIOGRAPHY FOR REFERENCES TO FACILITATE
PLANNING
EMS MUTUAL AID PLAN REVIEW:
** Pursuant to PHL Article 30 each Regional EMS Council has "the responsibility
to coordinate Emergency Medical Services programs within its region". Therefore
every Regional EMS Council should take a leadership role to ensure the
development, coordination and maintenance of EMS mutual aid plans within its
region.
** Any plan developed by a county or local EMS council or other official should
be submitted to the appropriate Regional EMS Council for review of content and
for coordination with existing plans and planning objectives.
** Each Regional Council should develop objectives to ensure that plans
developed in the region are consistent and capable of being integrated with
adjacent plans. Regional Councils need to coordinate planning objectives with
those of adjacent agencies.
** Where county government has the planning responsibility for emergency
response plans, the county should include Emergency Medical Services mutual
aid as one component. Plans developed and administered by county government
should be submitted to the appropriate Regional EMS Council for review.
** Each Regional EMS Council should develop objectives to insure annual review
of all plans developed in its area.
LIABILITY CONSIDERATIONS IN MUTUAL AID PLANNING:
The issues of liability and associated responsibility for coverage must be
addressed completely for the protection of all jurisdictions and participants.
As a rule, an assumption is made that if you respond on a mutual aid call, as part
of a mutual aid plan, you assume full responsibility for your equipment, personnel
and their actions in the very same manner as in day to day operations. This rule
stands unless some other liability coverage can be documented.
Under some circumstances, state or local statutes or agreements may modify the
assumption of liability.
As plans are developed or refined a detailed review of all applicable Federal,
State and local statutes must be undertaken with the assistance of expert legal
counsel.
In certain circumstances the following may apply: Executive Law Section 2-B,
General Municipal Law, NYS County, Town and Village Law, Public Health Law
and local laws or policies.
A contract with a municipality may provide certain protections when acting on
behalf of that municipality.
Additionally, liability insurance policies, self-insurance coverage and other locally
implemented liability plans, including each individual’s personal liability coverage,
should be reviewed.
Plans must address liability protection, the assumption, transfer or carry over of
coverage including all those provided for by statute. All participants, equipment
and supplies that will be utilized damaged or otherwise requiring replacement in
any mutual aid plan must be taken into account.
In addition to operational reviews, all mutual aid agreements should be reviewed
by the appropriate legal counsel and insurance underwriters.
Ambulance/EMS Unit Mutual Aid Dispatch Pre-plan
Adopted from the NYS-EMS MCI Management Model
AMBULANCE
AGENCY
Amb A
NUMBER OF
PATIENTS
Daily
10
20
30
40
FIRST CALL
AMBULANCES
Amb B
Amb B
Amb C
Amb D
Amb E
SECOND CALL
AMBULANCES
Amb C
Amb F
Amb G
COVER/RELOCATION
AGENCIES
Amb B
Amb H
Amb A
Amb B
Amb B
50
Amb B
Daily
10
A preplanned mutual aid response system is established to insure an appropriate
and orderly response of resources to an incident. The use of the increasing
diameter (concentric circle) or ring approach to define the response allows a plan
to be developed with realistic response times. Revisions can easily be made
either to the plan or an operation as the need, situation size, availability of
resources, or back-up coverage changes. Participants’ familiarity with local
geography makes this concept easily implemented.
Each EMS agency needs to establish a plan for an incident in its primary service
area based on incident type, immediate response needs, types and levels of
service needed and/or available (i.e. BLS, ALS, etc.), neighboring agencies
availability to respond, and the need to cover the primary service area for other
calls.
The agency mutual aid plan needs to be reviewed and coordinated at county and
regional levels to insure overall consistency and integration with adjacent plans.
BIBLIOGRAPHY AND REFERENCES
NY State Public Health Law, Article 30
NY State Rules and Regulations, The State EMS Code, Part 800
NYS DOH Memorandum, Public Health Series – 85-31, 3/13/85
NY State General Municipal Law, Section 209.e
NY State Executive Law, Section 2-B
Emergency Planning and Community Right To Know Act of 1986 (SARA Title III)
NYS Emergency Medical Services, MCI Management Model, NYS Dept. of
Health, Albany, NY 1982
National Incident Command System Fire Publications, Oklahoma State
University 1983
Resources Compilation for Planning and Response to a MCI, ASTM Task Group
F30.03.07 1985
NYS Dept of State, Office of Fire Prevention and Control, Statewide Mutual Aid
Plan
"Fire Command", Alan F. Brunacini; NFPA Quincy, Mass.
Medical Incident Command, JEMS April 1982
Mass Casualty Planning, A Model for In-Hospital Disaster Response
Hospital Disaster Planning and Emergency Preparedness, The Joint Commission
on Hospital Accreditation 1987PSTM
Issued by:
John J. Clair
Senior EMS Representative
Andrew W. Stern
Associate Director
Authorized by:
Michael Gilbertson
Director
No.
88-22
Date: 12/06/88
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
Re: Barrier Precautions
and Reprocessing
Recommendations for
Prehosptial Providers
Page 1 of 3
SUBJECT: Barrier Precautions and Reprocessing Recommendations for
Prehosptial Providers
The New York State Emergency Medical Services Program has received
numerous requests for guidance on the topic of infection control for EMS
personnel, specifically dealing with the issues of proper barrier protections and
reprocessing of equipment or supplies commonly used in the field.
Following are recommendations developed with the assistance of the New York
State Department of Health’s Division of Epidemiology.
RECOMMENDATIONS FOR REPROCESSING MEDICAL EQUIPMENT
USED IN THE PREHOSPITAL HEALTH CARE SETTING
HIGH LEVEL
TYPE OF EQUIPMENT
STERILIZATION
GENERAL DISINFECTION
DISINFECTION
Reusable devices that contact
mucous membranes: (e.g.,
Yes
Yes
No
laryngoscope, EOA mask and
tube, ET stylette)
thermometers*
No
Yes
No
Reusable, noninvasive
equipment that contacts intact
No
skin: (e.g., splints,
stethoscopes)
No
Yes
Reusable materials which
may be laundered: blood
pressure cuffs, linen, MAST
(with bladders removed)
No
Yes
No
(Follow recommended laundry
procedures for the material bei
washed and the detergent bein
used)
Other ambulance equipment:
stretchers, stairchair, head
No
immobilizers, etc.
No
Yes
*Clean, then soak in alcohol or tincture of iodine.
SPECIAL NOTE: Dispose of all disposable equipment after single use, e.g., oral
and nasal airways, suction catheters and tubing, bite sticks, oxygen masks and
cannulae, disposable pocket masks and bag valve masks.
Sterilization
Destroys: All forms of microbal life.
Methods: Steam (autoclave), gas (ethylene oxide), dry heat, immersion in
EPA approved chemical "sterilant" for period specified by product
manufactuer (e.g. 10-18 hours).
Use: Disposable invasive equipment eliminates need to sterilize many
items in EMS setting. When indicated, arrangements should be made with
a health facility for this level of reprocessing.
High Level
Disinfection
Destroys: Most forms of microbial life, some spores may not be eliminated
by this method.
Method: Immersion in an EPA approved chemical "sterilant" (e.g., 2%
activated glutaraldehyde) for the shorter contact time specified by the
product manufacturer (e.g., 30-45 minutes).
Use: Reusable devices that contact mucous membranes.
General
Disinfection
Destroys: Most viruses, bacteria, and fungi; may not be as effective against
M. tuberculosis and does not kill spores.
Methods: Application of or immersion in any of the following:
1:10 to 1:100 dilution of sodium hypochlorite (bleach)
phenol products
quaternary ammonium chlorides
2% gluteraldehyde (10 minutes)
Environmental surfaces which have become soiled should be cleaned and
Environmental disinfected using any cleaner/disinfectant agent which is intended for
Disinfection
environmental use.* Such surfaces include floors, woodwork, ambulance
seats, countertops, etc.
*Do not use 1:10 dilution on plexiglass, i.e., cabinet doors or EKG monitor
screens. It will fog them permanently. Use a 1:100 solution or preferably another
disinfectant recommended by the manufacturer.
RECOMMENDED BARRIER PRECAUTIONS FOR INFECTION CONTROL
IN THE PREHOSPITAL HEALTH CARE SETTING
PROCEDURE OR TYPE OF
CONTACT
DISPOS
GOWN
ABLE
GLOVES
MASK
PROTECTIVE
EYEWEAR
Artificial respiration
Yes
No
**
No
Blood drawing or starting an IV
Yes
No
No
No
For direct contact with feces or
urine
Yes
Yes, if soiling
No
is likely
No
Endotracheal intubation, EOA,
EGTA
Yes
No
Bleeding control procedures with
spurting blood/emergency
childbirth
Yes
Yes, if soiling
Yes
is likely
Yes, if
splashing is
likely
Bleeding control procedures with
minimal bleeding
Yes
No
No
No
Oral/nasal suctioning, manually
cleaning airway
Yes
No
Yes, if
splashing is
likely
Yes, if
splashing is
likely
Taking a temperature
No*
No
No
No
Giving an injection
No*
No
No
No
Handling and cleaning soiled
instruments
Yes
(utility)
Yes, if soiling
No
is likely
No
Taking a blood pressure
No*
No
No
Yes, if
splashing is
likely
No
Yes, if
splashing is
likely
*While gloves are not necessary for these procedures, it is likely they will be worn
because of other activities which require their use.
**Ambulance and first response agencies should use either bag valve mask,
resuscitators or a pocket mask with a one-way valve on all patients.
Issued by: Robert Elling, Assistant Director for Program Development
Authorized by: Michael Gilbertson, Director
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
88-01
Date: 02/09/88
Re: Patient Carrying
Devices
Page 1 of 2
SUBJECT: Patient Carrying Devices
There are many patient carrying devices in the EMS inventory, including
orthopedic stretchers, stair chairs, canvas slings, spine boards, soft or rigid
stretchers (such as the Reeves and the SKED) and single or multiple level
ambulance cots.
Each of these carrying devices has been designed by the manufacturer for a
specific use. The orthopedic stretcher to lift or move patients with orthopedic
injuries; the long spine board to immobilize patients with potential spinal column
injuries; the stair chair to move on stairs and around narrow hallways; the
"Reeves" to facilitate moving individuals in a semi-rigid but flat position. There
are overlaps in the capabilities of many of these devices. However, it is important
to recognize that each of these devices has specific limitations which restricts its
use in certain circumstances. In other words, no device can be used all of the
time on all patients.
The State Emergency Medical Services Program recently investigated several
circumstances where patient carrying devices were inappropriately used. It
appears that the reason for the use is that the ambulance crew uses a particular
device for every patient. Examples of inappropriate uses of devices include
transporting a non-traumatized chest pain patient on an orthopedic or Reeves
stretcher, thus preventing the patient from sitting up, and attempting to
immobilize the spine of an injured patient on a Reeves or other soft stretcher.
While there are sometimes extenuating circumstances in the field, routine use of
these devices for the purposes given is clearly inappropriate.
EMTs have an obligation to weigh carefully the decision to use a specific piece of
EMS equipment, including carrying devices, in order to assure that the
equipment is appropriate for the patient, the problem, and the situation.
All providers should assure that patients transported by ambulance are strapped
to the stretcher or crew bench. No patient should ever be transported strapped to
a Reeves or long backboard but not to the stretcher. Strapping to the stretcher is
the only way to prevent movement of the initial carrying device in the event the
ambulance comes to a sudden stop. Patients should never be transported within
the ambulance in a chair since these can not be secured. Children, however,
may be transported in their car seats if strapped to the stretcher or crew bench,
assuming that their injuries do not require them to lay flat.
Your attention to these issues is expected in the interest of improving patient
care.
Issued and Authorized by: Michael Gilbertson, Director
98-18
12/30/98
87-41 Reissued
*
* Distributed in 1987
Several EMS vendors supply the kits, their components and other items related to MCI management.
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
87-39
Date: 12/15/87
Re: Changes to Definition
of "School"
Page 1 of 1
Policy Update: CHANGES TO DEFINITION OF "SCHOOL"
The regulations to the Commissioner of Motor Vehicles were amended October
26, 1987, to expand the definition of the term "school" as it relates to junior
operator (Class 6 and 8) driving restrictions. The term "school" now includes:
1. Classes conducted or approved by the New York State Office of Fire
Prevention and Control for the purpose of training volunteer firefighters.
2. Classes conducted by the New York State Department of Health for the
purpose of training emergency medical technicians, advanced emergency
medical technicians and paramedics.
3. Classes conducted or approved by the New York State Department of
Health for the purpose of providing training in any ancillary emergency
medical services (e.g. emergency medical first responder training.)
The term "school" also includes classes conducted by the National Guard, or any
other active reserve group of the U.S. Armed Forces, for the purpose of training
members of such groups.
A junior operator who is driving to or from such classes should carry a letter from
the class administrator or instructor stating the name, date of birth and motorist
identification number of the student, the hours, location and duration of the
course, and an address and phone number at which the administrator or
instructor may be contacted by a police officer to verify information.
The specific regulation of the Department of Motor Vehicles has been attached to
this policy update.
Issued by: Robert Elling, Assistant Director for Program Development
Authorized by: Michael Gilbertson, Director
No.
New York State
Department of Health
Bureau of Emergency Medical Services
POLICY STATEMENT
Supercedes/Updates:
86-02
Date: 01/14/86
Re: Infection Control –
CPR Manikins
Page 1 of 2
SUBJECT: Infection Control – CPR Manikins
(The following recommendations for decontaminating manikins used in CPR
training were furnished to the Emergency Medical Services Program by the
United States Center for Disease Control, Atlanta, Georgia.)
1. The manufacturer’s recommendations and provision for sanitary practices
should be thoroughly examined.
2. Students should be told in advance that the training sessions will involve
"close physical contact" with their fellow students.
3. Students should not actively participate in training sessions if they have
dermatologic lesions on the hands or in oral or circumoral areas; are
known to be hepatitis B carriers; have upper-respiratory-traction infections
or AIDS (or evidence of HTLV III/LAV infection); or the student has reason
to believe that he or she has been exposed to or is in the active stage of
any infectious process.
4. If more than one CPR manikin is used in a class, students should be
assigned in pairs, with each pair having contact with only one manikin.
This limits possible exposures.
5. All persons responsible for CPR training should be thoroughly familiar with
hygienic concepts, as well as the procedures for cleaning and maintaining
manikins and accessories. Manikins should be inspected routinely for
signs of physical deterioration, such as cracks or tears in plastic surfaces,
which prevent thorough cleaning. Manikin’s clothes and hair should be
washed periodically or whenever visibly soiled.
6. In order to limit the potential for disease transmission during the tworescuer "switching procedure", the second student taking over ventilation
should simulate it instead of blowing into the manikin.
7. When practicing the "obstructed airway procedure", the finger sweep
should either be simulated or done on a manikin whose airway was
decontaminated before the procedure and will be decontaminated
afterwards.
8. Each time a different student uses the manikin, the individual protective
face shield, if used, should be changed. After a potentially contaminating
procedure, the manikin face and inside the mouth should be wiped
vigorously with clean absorbent material (e.g., 4" X 4" gauze pad) wetted
with hypochlorite solution or with 70% isopropanol, or ethanol. The
surfaces should remain wet for at least 30 seconds before they are wiped
dry with a second piece of clean absorbent material. Although highly
bactericidal, alcohols are not broad-spectrum agents; their use here is
recommended primarily as an aid in mechanical cleaning and because
some persons find the odor or hypochlorite objectionable. Little viable
microbial contamination is likely after the cleaning procedure.
9. At the end of class, the procedures listed below should be followed to
avoid drying of contamination on manikin surfaces:
•
Disassemble the manikin as directed by manufacturer.
•
As indicated, thoroughly wash all external surfaces (also reusable
protective face shields) with warm soapy water and brushes.
•
Rinse all surfaces with fresh water.
•
Wet all surfaces with a sodium hypochlorite solution having at least
500 ppm free available chlorite (e.g., ¼ cup (approximately 60 ml)
liquid household bleach (approximately 5% sodium hypochlorite)
per gallon (approximately 4 liters) of tap water) for 10 minutes. This
solution must be made fresh at each class and discarded after each
use.
•
Rinse with fresh water and immediately dry all external and internal
surfaces.
10. Persons responsible for the use and maintenance of CPR manikins should
not totally rely on disinfectants for protection from cross-infection.
Emphasis should be placed on thorough cleaning (scrubbing, wiping).
Microbial contamination is easily removed from smooth, nonporous
surfaces by using disposable cleaning cloths moistened with a detergent
solution. There is no evidence that a soaking procedure alone in any liquid
is as effective as the same procedure accompanied by vigorous
scrubbing.
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