Section 515.220  EMS Regional Plan Content

a)         The EMS Medical Directors Committee portion of the Regional Plan shall address at least the following (Section 3.30(a) of the Act):

1)         Protocols for inter-System/inter-Region patient transports, including protocols for pediatric patients and pediatric patients with special health care needs, identifying the conditions of emergency patients that may not be transported to the different levels of emergency department, based on the emergency department classifications and relevant Regional considerations (e.g., transport times and distances);

2)         Regional standing medical orders;

3)         Patient transfer patterns, including criteria for determining whether a patient needs the specialized service of a trauma center, along with protocols for the bypassing of or diversion to any hospital, trauma center or regional trauma center, Comprehensive Stroke Center, Primary Stroke Center, Acute Stroke-Ready Hospital or Emergent Stroke Ready Hospital, which are consistent with individual System bypass or diversion protocols and protocols for patient choice or refusal;

4)         Protocols for resolving regional or inter-System conflict;

5)         An EMS disaster preparedness plan which includes the actions and responsibilities of all EMS participants within the Region for care and transport of both the adult and pediatric population;

6)         Regional standardization of CE requirements;

7)         Regional standardization of Do Not Resuscitate (DNR) and Practitioner Orders for Life-Sustaining Treatment (POLST) policies, and protocols for power of attorney for health care;

8)         Protocols for disbursement of Department grants (Section 3.30(a)(1-8) of the Act);

9)         Protocols for the triage, treatment, and transport of possible acute stroke patients developed jointly with the Regional Stroke Advisory Subcommittee (Section 3.30(a)(9) of the Act).  Regional Stroke Data will be considered as it becomes available regarding development of stroke transport protocols;

10)         Regional standing medical orders shall include the administration of opioid antagonists.  (Section 3.30(a)(10) of the Act);

11)         Protocols for stroke screening;

12)        Development of protocols to improve and integrate EMS for children (or EMSC) into the current delivery of emergency services within the Region; and

13)         Development of a policy in regard to incidents involving school buses, which shall include, but not be limited to:

A)        Assessment of the incident, including mechanism and extent of damage to the vehicle;

B)        Passenger assessment/extent of injuries;

C)        A provision for transporting all children with special healthcare needs and those with communication difficulties;

D)        Age specific issues; and

E)        Use of a release form for non-transports.

b)         The Trauma Center Medical Directors or Trauma Center Medical Directors Committee portion of the Regional Plan shall address at least the following:

1)         The identification of regional trauma centers and identification of trauma centers that specialize in pediatrics;

2)         Protocols for inter-System and inter-Region trauma patient transports, including identifying the conditions of emergency patients which may not be transported to the different levels of emergency department, based on their department classifications and relevant Regional considerations (e.g., transport times and distances);

3)         Regional trauma standing medical orders;

4)         Trauma patient transfer patterns, including criteria for determining whether a patient needs the specialized services of a trauma center, along with protocols for the bypassing of or diversion to any hospital, trauma center or regional trauma center which are consistent with individual System bypass or diversion protocols and protocols for patient choice or refusal (These policies must include the criteria of Appendix C.);

5)         The identification of which types of patients can be cared for by Level I and Level II Trauma Centers;

6)         Criteria for inter-hospital transfer of trauma patients, including the transfer of pediatric patients;

7)         The treatment of trauma patients in each trauma center within the Region;

8)         A program for conducting a quarterly conference which shall include at a minimum a discussion of morbidity and mortality between all professional staff involved in the care of trauma patients.  (Section 3.30(b)(1-9) of the Act) 

A)        This shall include but not be limited to all cases that have been deemed potentially preventable or preventable in the trauma center review using Resources for Optimal Care of the Injured Patient.  This review should exclude trauma patients who were dead on arrival.

B)        In addition, the review shall include all patients who were transferred more than two hours after time of arrival at the initial institution and who meet one or more of the following criteria at the receiving trauma center:

i)          Admitted to an intensive care unit;

ii)         Admitted to a bed with telemetry monitoring;

iii)        Went directly to the operating room;

iv)        Went to the operating room from the emergency department;

v)         Discharged to a rehabilitation or skilled care facility;

vi)        Died following arrival.

C)        The Region shall include a review of morbidity/audit filters that have been determined by the Region.

D)        Cumulative regional reports will be made available upon request from the Department; and

9)         The establishment of a regional trauma quality assurance and improvement subcommittee, consisting of trauma surgeons, that shall perform periodic medical audits of each trauma center's trauma services, and forward tabulated data from those reviews to the Department. (Section 3.30(b)(9) of the Act)

c)         The Regional Stroke Advisory Subcommittee portion of the Region Plan shall address at least the following:

1)         The identification of Comprehensive Stroke Centers, Primary Stroke Centers, Acute Stroke-Ready Hospitals and Emergent Stroke Ready Hospitals and their incorporation in the Region Plan and the System Program Plan;

2)         In conjunction with the EMS Medical Directors, development of protocols for identifying and transporting acute stroke patients to the nearest appropriate facility capable of providing acute stroke care. These protocols shall be consistent with individual System bypass or diversion protocols and protocols for patient choice;

3)         Regional stroke transport protocols recommended by the Regional Stroke Advisory Subcommittee and approved by the EMS Medical Directors Committee; and

4)         With the EMS Medical Directors, joint development of acute stroke patient transfer patterns, including criteria for determining whether a patient needs the specialized services of a Comprehensive Stroke Center, Primary Stroke Center, Acute Stroke-Ready Hospital or Emergent Stroke Ready Hospital, along with protocols for the bypassing of, or diversion to, any hospital, that are consistent with individual inter-system bypass or diversion protocols and protocols for patient choice or refusal.

d)         The Director shall coordinate with and assist the EMS System Medical Directors and Regional Stroke Advisory Subcommittee within each EMS Region to establish protocols related to the assessment, treatment, and transport of possible acute stroke patients by licensed emergency medical services providers.  These protocols shall include regional transport plans for the triage and transport of possible acute stroke patients to the most appropriate Comprehensive Stroke Center, Primary Stroke Center or Acute Stroke-Ready Hospital, unless circumstances warrant otherwise.  (Section 3.118.5(f) of the Act)

e)         The Region's EMS Medical Directors and Trauma Center Medical Directors Committees shall appoint any subcommittees that they deem necessary to address specific issues concerning Region activities. (Section 3.30(c) of the Act)

f)         Internal Disaster Plans

1)         Each System hospital shall submit an internal disaster plan to the EMS Medical Directors Committee and the Trauma Center Medical Directors Committee.

2)         The hospital internal disaster plan shall be coordinated with, or a part of, the hospital's overall disaster plan.

3)         The plan shall be coordinated with local and State disaster plans.

4)         The hospital internal disaster plan shall be developed by a hospital committee and shall at a minimum:

A)        Identify the authority to implement the internal disaster plan, including the chain of command and how notification shall be made throughout the hospital;

B)        Identify the critical operational elements required in the hospital in an internal disaster;

C)        If the facility needs to go on bypass or resource limitation status, identify the person responsible for notification and the persons both outside and within the hospital who should be notified;

D)        Identify a person or group responsible for ensuring that needed resources and supplies are available;

E)        Identify a person to communicate with representatives from other agencies, organizations, and the EMS System;

F)         Identify a person who is responsible for procuring all supplies required to manage the facility and return the facility to the pre‑incident status;

G)        Identify the plan and procedure for educating facility employees on their role and responsibilities during the disaster;

H)        Designate a media spokesperson;

I)         Establish a method for resource coordination between departments and individuals to address management of staff, patients and patient flow patterns;

J)         Designate a person (safety officer) with responsibility for establishing safety policies to include, but not be limited to, decontamination operations, safety zones, site safety plans, evacuation parameters, and traffic patterns;

K)        Designate a location where personnel, not actually committed to the incident, will report for assignments, as needed (i.e., a staging area);

L)        Include notification procedures to EMS Systems, area ambulances, both public and private, and police and fire authorities of the type of incident that caused the hospital to implement its internal disaster plan and of any special instructions, e.g., use of a different driveway or entrance;

M)       Establish a designated form of communication, both internal and external, to maintain two-way communication (e.g., Mobile Emergency Communications of Illinois (MERCI), ham radio, walkie talkies);

N)        Include a policy to call in additional nursing staff when an identified staffing shortage exists;

O)        Include the policy developed pursuant to Section 515.315(f);

P)         Include contingency plans for the transfer of patients to other facilities if an evacuation of the hospital becomes necessary due to a catastrophe, including but not limited to a power failure (Section 3.30 of the Act); and

Q)        Address biological and chemical incidents and the availability of decontamination.

(Source:  Amended at 42 Ill. Reg. 17632, effective September 20, 2018)