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CQI_Policy_2008

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					   Scott County EMS
   Continuous Quality Improvement
      Policy Manual




General Purpose:
       This CQI Policy establishes guidelines for the implementation of a program to
support EMS providers as they strive to provide excellent patient care. These policies
intend to provide direction to set measurable goals and define minimum performance
standards for the individuals and service. This consistent, fair evaluation practice will
provide the routine feedback every provider deserves.
       This policy meets or exceeds the requirements of Iowa Code Chapter 147A:
Emergency Medical Care– Trauma Care and the Iowa Administrative Code (IAC): 641—
132.8(147A) Service program levels of care and staffing standards and 641—132.9(147A)
Service program—off-line medical direction.
General Procedure:
       The interaction of the physician, service leadership and providers is critical for the
success of this CQI program. All staff must understand their role, responsibilities and
duties as part of the CQI team. Every team member shall receive an initial orientation to
this policy and be provided with an opportunity for input and updates when amended.
.
                           EMS Service CQI Policy
EMS Service Name

Service Location

Policy Approval      Print Name                             Signature                    Date
Medical Director

Service
Representative


Section Policy Description          Form                  Title                             Pages
1        Scope of Practice          Appendix G            Training Roster and Skill
                                                          Maintenance Log
2        Protocols                  Appendix G            Training Roster and Skill
                                                          Maintenance Log
3        CQI Assistant              Appendix A            Continuing Education, Skills
         Appointment, CEH                                 Competency and CQI
         and Skills                                       Appointment Form
         Competency
         Definition
4        Credentialing and          Appendix E            EMS Provider Orientation Form
         Competency
                                    Appendix F            EMS Skills List
5        Written Medical            Appendix B            Patient Care Report Audit Form
         Audits
                                    Appendix C            Written Audit Activity Log
6        Follow-up and Loop         Appendix D            CQI Follow-up and Action Plan
         Closure
7        Measurable                 Appendix H            Measurable Outcomes
         Outcomes
                                    Appendix I            Measurable Outcomes Report
8        Equipment/Vehicle          Appendix J            Equipment Checklist
         Maintenance
                                    Appendix K            Post-Run Checklist
                                    Appendix L            Vehicle and Equipment
                                                          Maintenance Record
9        Pharmacy                   Appendix M            Pharmacy Agreement
         Agreement and
         Policies &                 Appendix N            EMS Pharmacy Policies &
         Procedures                                       Procedures
                                    Appendix O            Drug Inspection Form
                                    Appendix P            Drug Inventory Control Log

                                                 Page 2 of 39
                             This sample is provided by the Iowa Bureau of EMS.
                           It is not mandatory that you use this sample document.
                          EMS Service CQI Policy
Section 1: Scope of Practice                                             IAC: 641--132.8(3) c.
Policy:
EMS providers shall function within the current Scope of Practice and as authorized, in
writing, by the medical director.
Procedure:
1. EMS providers shall review the Scope of Practice for Iowa EMS Providers during initial
    orientation to the service and whenever the scope is officially amended.
2. The service shall maintain an EMS Training Roster that documents initial and periodic
    staff reviews of the Scope of Practice.
3. EMS providers shall function within the Scope of Practice for their certification level
    limited by the service program level of authorization.
Supporting Document: Scope of Practice for Iowa EMS Providers at
www.idph.state.ia.us/ems
Implementation Form: APPENDIX G: Training Roster and Skill Maintenance Log

Section 2: Protocols                                        IAC: 641--132.8(3) b., 132.9(2) a.
Policy:
EMS providers shall function as directed in the medical director authorized protocols.
Procedure:
1. Annually, the medical director and service shall review and authorize updated
   protocols.
2. The service shall ensure the Iowa EMS Bureau Regional Coordinator receives the
   medical director signed authorization and change pages.
3. EMS providers will receive initial and annual protocol education.
4. The service shall maintain an EMS Training Roster that documents protocol education.
5. EMS providers shall function as directed in the medical director approved patient care
   protocols.
6. Treatment rendered that deviates from the approved protocols must be documented on
   the patient care report (PCR) and brought to the attention of the appointed auditor.
Supporting Documents: Iowa EMS Protocols. The complete set of protocols and annual
updates are published every August and posted at www.idph.state.ia.us/ems
Implementation Form: APPENDIX G: Training Roster and Skill Maintenance Log

Section 3: CQI Assistant Appointment, Continuing Education Hour (CEH) and Skill
Competency Definition                     IAC: 641--132.8(3) m.(2), 132.9(2) d. 132.9(3) a.- e.
Policy:
The medical director shall conduct CQI activities or appoint individual(s) to perform written
audits of the patient care reports; conduct and document CEH and skill training.
Procedure:
1. The medical director shall appoint, in writing, staff to assist with CQI policy
   implementation including: CEH, skill competency training, written audits, action plans,
   follow-up, loop-closure and resolution.
2. The medical director shall define, in writing, personnel CEH requirements.
                           EMS Service CQI Policy
Section 3: (continued)
3. The medical director shall identify, in writing, the minimum number and type of skills
   personnel shall practice.
4. The medical director shall define, in writing, the types of responses and number of
   patient care reports to be audited by the appointees.
5. The medical director shall define, in writing, the minimum requirements for CEH for
   PA/RN exception(s), which may include proof of skills competency up to the level of
   authorization of the service program.
6. Appointees shall implement duties as assigned by the medical director.
Implementation Forms: APPENDIX A: Continuing Education, Skills Competency and
CQI Appointment Form

Section 4: Initial Skill Credentialing & On-Going Competency IAC: 641--132.8(3) m. (2)
Policy:
New staff shall complete a standard credentialing orientation process that includes
baseline medical competencies. All staff shall maintain and document ongoing-
competencies as defined by the physician medical director and service director.
Procedure:
1. New staff shall be required to complete the EMS Provider Orientation Form under the
   direction of the assigned preceptor.
2. The completed EMS Provider Orientation Form shall become part of the employee’s
   personnel file.
3. All staff will promptly complete and document ongoing skill competencies as defined by
   the medical director.
Implementation Forms: APPENDIX E: EMS Provider Orientation Form; APPENDIX F:
   EMS Skills List

Section 5: Medical Audit                                  IAC: 641--132.8(3) m.(1), 132.9(4)
Policy:
The medical director and the EMS service representative shall describe the audit process
in writing defining the type and frequency.
Procedure:
1. Within 24 hours, the responding staff shall complete and file a written patient care
    report.
2. Any significant deviation from approved protocol or standard of care will be brought to
    the attention of the assigned CQI auditor.
3. Any discussion of EMS responses shall be confidential and limited to current staff.
4. Assigned CQI auditors shall perform written audits as designated in writing by the
    medical director.
5. The medical director shall review the written audits as designated in writing.
6. An audit shall be complete when it is signed by the PCR author, reviewed by
    responding staff and the auditor is satisfied with the loop closure.
7. The completed written audit shall be recorded into the Written Audit Activity Log.
8. Written audits shall be destroyed after 12 months or when the audit process is
    complete.

                                                 Page 4 of 39
                             This sample is provided by the Iowa Bureau of EMS.
                           It is not mandatory that you use this sample document.
                          EMS Service CQI Policy
Section 5: (continued)
Implementation Forms: APPENDIX B: Patient Care Report (PCR) Audit Form;
APPENDIX C: Written Audit Activity Log

Section 6: Follow-Up and Loop Closure                IAC: 641--132.8(3) m. (3), 132.9(2) g.
Policy:
The medical director and the service director shall utilize the written action plan, as
needed, to address personnel, vehicle, equipment and system challenges.
Procedure:
1. The action plan shall be implemented (but not limited to) when the following occur:
   a)       Significant deviation from written protocol or standard of care.
   b)       Delay of response or treatment
   c)       Vehicle or equipment failure
   d)       System difficulty
2. The medical director and service director shall develop and implement a written action
   plan and monitor the situation until the desired improvement is achieved.
Implementation Form: APPENDIX D: CQI Follow-Up and Action Plan

Section 7: Measurable Outcomes                                            IAC: 641--132.9(2), c.
Policy:
The medical director, in consultation with the staff, shall establish measurable outcomes
consistent with strategic planning goals and unique needs of the local EMS system to
appraise the overall effectiveness and efficiency of the EMS system.
Procedure:
1) At least twice a year, the service director or CQI designee shall measure the following
   times for all emergency responses:
   a) Average time from first page to enroute
   b) Average time from first page to arrival at scene
   c) Average scene time for medical
   d) Average scene time for trauma
2) In addition to response and scene times, the staff and medical director shall select at
   least one additional indicator to measure and report.
3) Annually, the service CQI designee shall report outcomes (in writing) to the EMS staff
   and medical director.
Implementation Forms: APPENDIX H: Measurable Outcomes;
APPENDIX I: Measurable Outcomes Report

Section 8: Equipment & Vehicle Checklist / Maintenance IAC: 641--132.8(3) o., 132.8(5)
Policy:
All EMS staff shall share the duty of performing vehicle and equipment checks and
documenting these on the appropriate forms within the pre-determined timeframe. Vehicle
and equipment maintenance shall, at a minimum, follow the manufacturer’s
recommendations.


                                                 Page 5 of 39
                             This sample is provided by the Iowa Bureau of EMS.
                           It is not mandatory that you use this sample document.
                          EMS Service CQI Policy
Section 8: (continued)
Procedure:
1. The Post Run Checklist shall be completed following every response.
2. Equipment and the vehicle cleaned and supplies replaced following each response..
3. Detailed vehicle and equipment checks shall be conducted at a minimum of once every
   month.
4. All staff shall be responsible for performing and completing the monthly checklist as
   assigned.
5. Any deficiencies shall be documented on the checklist and brought to the attention of
   management for corrective action(s) and resolution shall be documented.
6. Completed vehicle and equipment checklists and documentation of maintenance shall
   be kept on file for ten years.
Implementation Forms: APPENDIX J: Equipment Checklist; APPENDIX K: Post-Run
Checklist; APPENDIX L: Vehicle Maintenance Record

Section 9: Pharmacy Policies and Procedures                        IAC: 641--132.8(4) c., d., e.
Policy:
Certified EMS providers shall read and function within the service program’s Pharmacy
Policies and Procedures, as authorized in writing.
Procedure:
1. All EMS providers are directed to follow all policies and procedures as set forth in the
   Pharmacy Policies and Procedures document.
2. Any deviations from the service program pharmacy policies and procedures shall be
   brought to the attention of the CQI designee and service program director.
Implementation Forms: APPENDIX M: Pharmacy Agreement; APPENDIX N: Pharmacy
Policies and Procedures; APPENDIX O: Drug Inspection Form; APPENDIX P: Drug
Inventory Control Log




                                                 Page 6 of 39
                             This sample is provided by the Iowa Bureau of EMS.
                           It is not mandatory that you use this sample document.
                                             APPENDIX A

     Continuing Education, Skills Competency and
   Continuous Quality Improvement (CQI) Appointment
                         Form
Type or print service name:



                                PERSONNEL APPOINTMENTS
As Medical Director I hereby appoint the following to act on my behalf for these EMS CQI activities:
 Appointee Name                     CQI Activity                          Yes          No CQI Activity    Yes   No
                                    Medical audits, action                                Skill
                                    plan,                                                 Competency
                                    follow-up, loop closure,                              and CEH
                                    and resolution
                                    Medical audits, action                                 Skill
                                    plan,                                                  Competency
                                    follow-up, loop closure                                and CEH
                                    and resolution
                       TYPE OF RESPONSES FOR WRITTEN AUDIT
At least quarterly, the above named appointee(s) will complete written audits of the following types
of EMS responses:

Type of Response                               Yes         No        Type of Response                    Yes    No
Cardiac arrest/CPR                                                   Death at scene
Unstable or potentially unstable                                     Refusal of transport
trauma
Medication administration other than
O2
Deviation from approved protocol
Unconsciousness
                         PHYSICIAN REVIEW OF WRITTEN AUDITS
As Medical Director, I will review the written audits performed by the above named appointees
quarterly.

             EMS PERSONNEL CONTINUING EDUCATION REQUIREMENTS
To remain an active participant of this EMS service program, EMS providers shall maintain the
following:
   A. Continuing education hours (CEH) as required for renewal of the Iowa EMS
      certification.
                                                    Page 7 of 39
                                This sample is provided by the Iowa Bureau of EMS.
                              It is not mandatory that you use this sample document.
   B. Continuing education hours (CEH) for RN/PA exception (select one):
      same as certified EMS providers _____ OR other (describe)_________________
   C. Documentation of course completion in any or all of the following nationally
      recognized courses:
        Course Description                                                         Acronym   Yes   No
        CPR, AED, obstructed airway procedures for all age                         CPR
        groups
        Advanced Cardiac Life Support                                              ACLS
        Pediatric Advanced Life Support                                            PALS
        Basic Trauma Life Support                                                  BTLS
        Basic Trauma Life Support-Pediatrics                                       BTLS-P
        Pre-hospital Trauma Life Support                                           PHTLS
        Advanced Medical Life Support                                              AMLS
        Pediatric Pre-hospital Care                                                PPC
        Pediatric Education for Pre-hospital Professionals                         PEPP


                     EMS SKILL MAINTENANCE REQUIREMENTS
As a minimum, the CQI appointee(s) shall ensure and document that the certified EMS
providers maintain competency in the following skills as allowed by protocol and within
their Scope of Practice:
                        Indicate level of provider and frequency of practice:
               Q = Quarterly B = bi-annually A = annually N/A = not-applicable
SKILL DESCRIPTION                                                Level of Provider Q B A                N/A
Cardiac arrest management:
CPR; AED; BVM; suctioning; oral/nasal, double-lumen,
bridge, and/or ET airways; Rx
Immobilization devices:
cervical collars, long and short backboard, extremity
splints including traction
Medication administration:
patient assisted and/or per protocol
ADULT airway devices: double-lumen, bridge, endotracheal :
Write # of successful attempts: _________
Circle method: patient OR manikin OR both
ADULT – IV/IO access:
Write # of successful attempts: ____________
Circle method: patient OR manikin OR both
PEDIATRIC airway devices: double-lumen, endotracheal:
Write # of successful attempts: ____________
Circle method: patient OR manikin OR both
PEDIATRIC - IV/IO access:
Write # of successful attempts: __________
Circle method: patient OR manikin OR both
Needle cricothyrotomy and/or Needle thoracostomy




                                                Page 8 of 39
                            This sample is provided by the Iowa Bureau of EMS.
                          It is not mandatory that you use this sample document.
The complete list of skills is available in the Scope of Practice for Iowa EMS Providers
document at www.idph.state.ia.us/ems >>Providers>>Scope of Practice.
                     APPOINTEE STATEMENT OF AFFIRMATION
I acknowledge that I am appointed, by the medical director, as an official CQI designee. I
understand my duties and will implement and maintain this CQI program as directed.
Type or print name, sign and date:



Type or print name, sign and date:


                  MEDICAL DIRECTOR STATEMENT OF AFFIRMATION
As medical director, I reserve the right to audit any patient care report, skill competency log,
continuing education file or compliance with this CQI directive at any time. I hereby direct
those acting on my behalf to promptly bring to my attention any significant deviation from
written protocol and/or standard medical practice.
Type or print name, sign and date:




                                                   Page 9 of 39
                               This sample is provided by the Iowa Bureau of EMS.
                             It is not mandatory that you use this sample document.
                                               APPENDIX B

Patient Care Report (PCR) Audit Form
Incident Date:__________________________ Record Number:____________________
Report Author:_________________________ Additional Staff:_____________________
Auditor:_______________________________ Audit Date:_________________________

S = satisfactory (element included, clear, and understandable)          NA = not applicable to this situation
I = improvement needed (element omitted, vague or unclear)               UN = unknown (unable to obtain this info.)

PROVIDE WRITTEN COMMMENT BELOW FOR ALL “IMPROVEMENT NEEDED” OR “NO”
NOTATIONS
DOCUMENTATION ELEMENTS:     S    I    N/A UN COMMENTS:
Service/staff identification
Patient identification
Scene and time information
Chief complaint: documented or obvious
Safety equipment used by patient
History including MOI or NOI
Vital signs and physical exam findings
Care rendered prior to arrival
Procedures and treatments
Change in status

CLINICAL AUDIT MEASURES:                     YES       NO         N/A              COMMENTS:
Response time acceptable
Scene time acceptable
Transport time acceptable
Destination decision appropriate
Tiered response appropriate
Appropriate protocol followed
Overall documentation adequate
Treatment/procedures appropriate
Overall performance adequate
Patient outcome as expected
Medical Director review needed
Follow-up necessary (attach action plan)

AUDITOR
COMMENTS:_____________________________________________________________

________________________________________________________________________

STAFF
COMMENTS:___________________________________________________________

________________________________________________________________________

                                                     Page 10 of 39
                                  This sample is provided by the Iowa Bureau of EMS.
                                It is not mandatory that you use this sample document.
________________________________________________________________________
AUDITOR SIGNATURE       DATE         MEDICAL DIRECTOR SIGNATURE
DATE

________________________________________________________________________
STAFF SIGNATURE          DATE        STAFF SIGNATURE
DATE




                                          Page 11 of 39
                       This sample is provided by the Iowa Bureau of EMS.
                     It is not mandatory that you use this sample document.
                                                       APPENDIX C

                                 Written Audit Activity Log
Service:_______________________________ Jan-March ____ April-June____ July-Sept____ Oct-Dec____ Year:_____

Response    Chief Complaint   Docu-        Clinical     Vehicle or   Deviation   Delay of     System       Follow-up   Follow-up
ID –                          mentation    Accept-      Equipment    From        Response,    Difficulty   Recom-      Action Plan
Number or                     Acceptable   able         Problem      Protocol    Treatment,                mended      Date of
Date                                                                             Transport                             Completion
                              Yes or No    Yes or No    Yes/No       Yes/No      Yes/No       Yes/No       Yes/No      MM/DD/YY
                                    APPENDIX D

                   CQI follow-up and action plan
Response ID Number:                                           INCIDENT Date:
RECOMMENDED BY:          auditor   physician medical director     other_______________
RECOMMENDED FOR:          report author   staff involved with the incident   case review
with all staff
FOLLOW-UP TO BE COMPLETED BY:              Service Director     CQI Appointee_________
TIMEFRAME: Begin process:      today or within    7days    14 days    30 days    at next
staff meeting
TARGET FOLLOW-UP PLAN COMPLETION DATE:

PERSONNEL: (describe opportunity for improvement; i.e. number, location and type
of clinical or field hours, CEH topic, practical skill type, number of ACLS runs, what
protocol to review, etc.)
  not applicable      in-hospital clinical  protocol review    policy review   CEH
  skill practical    equipment practical   field internship     other_________________




VEHICLE /EQUIPMENT: (list item and describe problem)
  not applicable repair  replace    other __________________________________




SYSTEM: (describe difficulty)
  not applicable  protocol change required       policy change required dispatch
  tiered response on-line medical direction      other____________________________




ACTION PLAN COMPLETION: (comment, sign and date)
MEDICAL DIRECTOR:



SERVICE DIRECTOR:
STAFF:


DESIRED IMPROVEMENT ACHIEVED?                  YES       NO (IF NO, ATTACH NEXT PLAN
OF ACTION)




                                       Page 14 of 39
                  This sample form is provided by the Iowa Bureau of EMS.
                           It is not mandatory you use this form.
                                              APPENDIX E

                 EMS Provider Orientation Form
Service Name:_________________________________Location:_______________________________

Provider Name:_____________________________________________ Date Hired:________________

Preceptor(s) Name:_____________________________ Date Orientation Complete:________________

The preceptor will date and initial each task when satisfactorily completed.


Provide current copies of the following documents
DATE & INITIAL
__________ Iowa Driver License
__________ BLS course completion card (all levels)
__________ Course completion cards as required by the Medical Director (i.e; ACLS,PALS, PEPP, PHTLS, etc.)
__________ Emergency driving and communications training
__________ Hepatitis B vaccination and tuberculosis status
__________ Dependant Adult and Child Abuse training
__________ NIMS (IS-700) and Incident Command (100-200-195-300 or equivalent)


Explain the location & purpose of the following items
DATE & INITIAL                                             DATE & INITIAL
______ ______ Blank Patient Care Reports                   ______ ______ Protocols
______ ______ Bulletin board(s)                            ______ ______ Provider skill maintenance logs
______ ______ Charge Sheets                                ______ ______ Reference books
______ ______ Computer / printer / copier                  ______ ______ Run log book
______ ______ EMS Standing Orders and Protocols            ______ ______ Schedule
______ ______ File cabinets                                ______ ______ Schedule requests
______ ______ Important phone numbers                      ______ ______ Policies and procedures manual
______ ______ Magazines and catalogues                     ______ ______ Service Program uniform policy
______ ______ Mail boxes                                   ______ ______ Spare equipment storage
______ ______ Medicare supplement forms                    ______ ______ Station phone(s)
______ ______ Memo book                                    ______ ______ Time cards (book)
______ ______ Radio/pager batteries and chargers           ______ ______ Vehicle & equipment check lists


Service Program Response Area
DATE & INITIAL
_____ ______ Map of service area
______ ______ Maps of cities, towns, mobile home parks, schools and businesses in the service area
______ ______ 911 map of service area
______ ______ Frequent locales: clinics, nursing homes and hospitals
Response Vehicle(s)
DATE & INITIALVehicle cab & engine compartment
______ ______ Cab area /starting procedures                ______ ______ Vehicle and equipment check lists
______ ______ Emergency brake                              ______ ______ Vehicle cleaning procedures
______ ______ Radio ops/procedures                         ______ ______ Vehicle safety check (tire pressure,
______ ______ Location of map books                        all lights, wiper blades, exhaust system, mirror
______ ______ Use of siren and emergency lights            adjustment)
______ ______ Fueling procedure/credit card use            ______ ______ Emerg vehicle operations policies
______ ______ Location of crank case & proper              dip-stick, windshield washer fluid reservoir, power
inspection of the crank case oil dip stick, transmission   steering reservoir, brake fluid reservoir, belts & hoses
DATE & INITIAL   Vehicle Patient care and/or equipment storage area
______ ______ Inventory the contents of equipment storage compartments and test all equipment
______ ______ Location and contents of medication drug box/bag
______ ______ Review medication exchange IV solution checks and exchange policies and procedures
______ ______ Location and operation of cardiac monitor/AED’s

              Vehicle Patient care and/or equipment storage area (continued from page 1)
DATE & INIITIAL
______ ______ Location of on-board & portable oxygen tanks
_____________Review oxygen tank replacement policy and procedure
______ ______ Location, operation and cleaning of on-board and portable suction units
______ ______ Location and operation of AC power inverter
______ ______ Safe operation and cleaning procedure of the ambulance cot
______ ______ Review the restocking cabinet/closet & required stocking levels

Communications
DATE & INITIAL
______ ______ Use, responsibility and access of pagers
______ ______ Use of and access to portable radios
______ ______ Use of cellular phones for patient report
______ ______ Use and intent of internal communications staff memo book
______ ______ Procedure for schedule changes

Documentation
DATE & INITIAL
_____ ______ Proper completion and filing of patient care report
______ ______ Use of supplemental patient care report forms
______ ______ Patient transfer authorization form
______ ______ Proper documentation of patient refusal of treatment
______ ______ Proper documentation in run log
______ ______ Proper documentation of skills maintenance

Security
DATE & INITIAL
______ ______ Proper operation of overhead doors and side doors
______ ______ Assign new employee a key and/or door combinations (if applicable)
______ ______ Policies regarding vehicle security at the scene

Roles and Responsibilities
DATE & INITIAL                                                    DATE & INITIAL
______ ______ Be on time, in uniform (if applicable)              ______ ______ Clean vehicle inside/out after calls
______ ______ Response priorities in order                        ______ ______ Chain of command
______ ______ Review policies for being on call                   ______ ______ White light permit/blue light permit
______ ______ Restocking rigs after calls                         ______ ______ Monthly staff/training meetings
______ ______ Protocols and scope of practice                     ______ ______ Critical Incident Stress Management

   Demonstrate Skill Competencies
   DATE & INITIAL
   ______ ______ Demonstrate an appropriate assessment of and formulate a proper treatment plan for:
                  ___ medical patients, ___trauma patients, ____pediatric patients.
   ______ ______ Demonstrate competency in performing all of the skills listed in the current “Iowa EMS Scope
                of Practice” document within the level of certification and service authorization and as
                 approved by the medical director.
   ____________ Demonstrate the ability to find and write directions to 10 locations randomly selected by the
                 trainer, using the maps located in the response vehicle
   ______ ______ Demonstrates proper documentation of 10 patient care events
   ______ ______ Demonstrates proper lifting techniques/methods for two rescuer carry, two rescuer cot, one
                                                       Page 16 of 39
                                  This sample form is provided by the Iowa Bureau of EMS.
                                           It is not mandatory you use this form.
                  rescuer assist cot, bed/cot to chair, bed/cot to bed & use of slide board
New Employee Statement of Affirmation: I hereby affirm and declare that I have actively
participated in the orientation. I have read the policies and procedures and protocols and will work diligently
to comply.

________________________________________________________________________
Print Name                     Signature                         Date




                                                     Page 17 of 39
                                This sample form is provided by the Iowa Bureau of EMS.
                                         It is not mandatory you use this form.
                                              APPENDIX F

                                  Iowa EMS Skills List
         The Iowa EMS Skills List can be used as a tool for the medical director to assign type and frequency
          of skill competencies for EMS providers and/or for the RN/PA exception orientation.
         The shaded box indicates the skill is within the provider scope of practice. An “X” within the box
          means that skill is allowed with medical director approval and documentation of the training must be
          maintained.
         Select skills (check provider level box) to be demonstrated by EMS providers within their individual
          scope of practice and as approved by the medical director within written protocols.
         Skills for legacy certifications not listed here, (FR ‘79, FR-G, EMT-A, EMT-D, EMT-I ’85) may be
          found at www.idph.state.ia.us/ems >>Providers>>Scope of Practice>>Iowa EMS Scope of Practice
                                              Provider Level:
        FR=First Responder B=EMT-B I=EMT-I P=EMT-P PS=Paramedic Specialist CCP=Critical Care
                                            Paramedic
                                                 Frequency:
                                       Q=quarterly B=biannually A=annually
Skill                                                              FR B       I   P    PS    CCP    Q    B   A
Airway techniques: head-tilt chin-lift, jaw-thrust, modified jaw-
thrust, cricoid pressure, mouth-to-mouth-nose-barrier-mask-and
stoma, suction (upper airway)
Airway devices: oral, nasal, esophageal/tracheal-multi lumen,
bag-valve-mask
CPR and manual relief of airway obstruction
Defibrillation: AED (automated or semi-automated)
Pacing: transcutaneous (automated)
Oxygen delivery: humidified, nasal cannula, non-rebreather,
partial rebreather, regulator, simple face mask, Venturi mask
Pulse oximetry
Cardiac monitoring: single lead (non-interpretive)
Hemorrhage control: direct pressure, pressure point, tourniquet
Spinal immobilization: manual, cervical collar
Splinting: manual
Blood pressure: manual and automated
Eye irrigation
Over-the-counter medicines
Assisted delivery (childbirth)
Airway devices: oxygen-powered demand valve
Cardiac monitoring: multi-lead (non-interpretive)                        X    X
Activated charcoal, epinephrine, medicated inhaler, nitroglycerin
EPI-Pen: carry and administer
Pneumatic Anti-Shock Garment (MAST,etc.)
Mechanical CPR device
Spinal immobilization: seated (KED,etc.), longboard
Splinting: rigid, soft, traction, vacuum
Non-medicated IV maintenance (D5W, Ringer’s Lactate, Normal
Saline)
Blood glucose monitoring
Automated transport ventilators
IV initiation: peripheral
IV initiation: at central port                                                X
Crystalloid: D5W, Ringer’s Lactate, Normal Saline
Blood sampling: obtain (capillary and venous)
Airway device: bridge
Chest Decompression: needle
Cricothyroidotomy: needle
End tidal CO2 monitoring/capnometry
Gastric decompression: NG or OG tube
Skill                                                             FR B I                     P   PS   CCP     Q    B   A
Intubation: orotracheal, lighted stylet, medication assisted-non-
paralytic
Obstruction relief: direct laryngoscopy
Suctioning: tracheobronchial
Cardiac monitoring: single lead (interpretive)
Cardioversion: electrical
Carotid Massage
Defibrillation: manual
Pacing: transcutaneous (manual)
Blood/ blood by-products
Intraosseous: initiation
Maintenance: medicated IV fluids
Medication administration routes: aerosolized/nebulized, buccal,
endotracheal tube, intramuscular, intranasal, IV piggyback &
push, nasogastric, oral, rectal, subcutaneous, sub-lingual
Eye irrigation: Morgan Lens
Thrombolytic therapy: monitoring
Urinary catheterization
CPAP
Intubation: nasotracheal
Intubation: medication assisted-paralytic (RSI)
PEEP: therapeutic (> 6 cm H20 pressure)
Spinal immobilization: assessment-based
Colloids: albumin, dextran
Umbilical access: initiation
Thrombolytic therapy: initiation
Cardiac monitoring: multi-lead (interpretive)
BiPAP
Chest tube placement: assist mode only
Chest tube: monitoring and management
Cricothyroidotomy: surgical
Intubation: digital, retrograde
Ventilators: automated (assessment and mgmt.)
Pacing: internal (monitoring)
Arterial line: (monitoring and access)
Central line: (monitoring and access)
Arterial blood sampling: radial site (obtain)
Hemodynamic monitoring
ICP monitoring
                                 APPOINTEE STATEMENT OF AFFIRMATION
I acknowledge that I am appointed, by the medical director, as an official CQI designee. I understand my duties and will
implement and maintain this CQI program as directed.

Type or print name, sign and date:


Type or print name, sign and date:


                            MEDICAL DIRECTOR STATEMENT OF AFFIRMATION

                                                        Page 19 of 39
                                   This sample form is provided by the Iowa Bureau of EMS.
                                            It is not mandatory you use this form.
As medical director, I reserve the right to audit any patient care report, skill competency log, continuing
education file or compliance with this CQI directive at any time. I hereby direct those acting on my behalf to
promptly bring to my attention any significant deviation from written protocol and/or standard medical practice.

Type or print name, sign and date:




                                                     Page 20 of 39
                                This sample form is provided by the Iowa Bureau of EMS.
                                         It is not mandatory you use this form.
                                       APPENDIX G

      EMS Training Roster and Skill Maintenance Log
Service: ___________________________ Location:______________________

Date:_____________ Start Time:________________ End Time:_____________

Describe Training Conducted:________________________________________

________________________________________________________________

________________________________________________________________

Instructor: ________________________________________________________

CEH (check only one):  Formal Number ___________________or  Optional

Print or Type Name        Certification Number                    Signature




I affirm and declare that the above signed were present and participated in this EMS
training.


Instructor/Proctor Print Name                         Signature                   Date
                                             Page 21 of 39
                        This sample form is provided by the Iowa Bureau of EMS.
                                 It is not mandatory you use this form.
                                           APPENDIX H

                    EMS Service Measurable Outcomes
Measurable outcomes are an important component of every Continuous Quality Improvement
(CQI) program. Proactive measurement can improve patient care and documentation practices;
identify training needs and assist with decision making for equipment, personnel and capitol needs.
The medical director and service should consider annual review of the measurements and set
goals to support continuous improvement. When consistently meeting goals, select or develop
new measurements. These sample Measurable Outcomes have been developed to assist Iowa
EMS service programs as they comply with physician directives as defined by:
Iowa Administrative Code 641—132.9(2) The medical director’s duties include, but need not
be limited to…
c. Monitoring and evaluating the activities of the service program and individual personnel
performance, including establishment of measurable outcomes that reflect the goals and
standards of the EMS system.

EMS Service Program
Name:__________________________________________________
No.   Indicator                                                                   Yes No
1.    100% of EMS providers on the roster are annually trained to new
      protocols within 45 days of physician approval of the protocols or by
      October 31.
2.    One full set of vital signs and the GCS will be completed 95% of
      patients.
3.    Multiple, complete sets of vital signs and the GCS will be documented on
      75% of the patients with transportation times greater than 15 minutes.
4.    Eligible chest pain patients will receive aspirin (ASA) per protocol before
      transport 90% of the time.
5.    75% of suspected stroke patients will receive a neurological examination
      per protocol.
6.    EMS will arrive at the side of the patient within 10 minutes of the first
      page 75% of the time.
7.    Time of arrival at the patient’s side will be documented on 80% of the
      patient care reports
                  MEDICAL DIRECTOR STATEMENT OF AFFIRMATION
As physician medical director, I establish the above measurable outcomes to assist with evaluation
of system performance. Annually, as a minimum, the appointees shall report measurable
outcomes, in writing, to the EMS staff and medical director.
Type or print name, sign and date:



                        APPOINTEE STATEMENT OF AFFIRMATION
I acknowledge that I am appointed, by the medical director, as an official CQI designee.



                                                 Page 22 of 39
                            This sample form is provided by the Iowa Bureau of EMS.
                                     It is not mandatory you use this form.
I understand my duties and will implement and maintain this CQI program as directed. Annually,
as a minimum, the appointees shall report measurable outcomes, in writing, to the EMS staff and
medical director.
Type or print name, sign and date:



Type or print name, sign and date:




                                                 Page 23 of 39
                            This sample form is provided by the Iowa Bureau of EMS.
                                     It is not mandatory you use this form.
                                         APPENDIX I

            EMS Service Measurable Outcomes Report
EMS Service Name:________________________ Location:________________________
Report compiled by:________________________________________________________
For the period of:  January - June  July - December         Year: ________________
                               For Emergency Dispatches:
Total number of transports for the period: _______Record the average times for the
following:
1st page to enroute:         _____ minutes                       Medical scene time: _____ minutes
1st page to arrival at scene: _____ minutes           Trauma scene time: _____ minutes
Indicator # 1: 100% of EMS providers on the roster are annually trained to the new
protocols within 45 days of physician approval of the protocols or by October 31.
Number on Roster: ______ Number Trained: ________ Date(s):____________________
Comments/Action Plan/Follow-up: ____________________________________________
Indicator # 2: One full set of vital signs and the GCS will be completed 95% of patients.
   Criteria                     (circle          Jan Feb Mar Apr May Jun %
   month)                                        Jul  Aug Sep Oct Nov Dec
   Total number of eligible patients
   BP, pulse, resp and skin documented
   Missing/incomplete: BP
   Missing/incomplete: pulse
   Missing/incomplete: resp.
   Missing/incomplete: skin
   (color/temp/moisture)
   Missing/incomplete: Glascow Coma Scale
   Missing 2 or more vital signs
Comments/Action Plan/Follow-up_____________________________________________
Indicator # 3: Multiple, complete sets of vital signs and the GCS will be documented on
75% of the patients with transportation times greater than 15 minutes
   Criteria                (circle month)        Jan Feb Mar Apr May Jun %
                                                   Jul   Aug Sep Oct Nov Dec
   Total number of eligible patients
   Initial: BP, pulse, resp skin, GCS
   documented
   Next set : Missing/incomplete: BP
              Missing/incomplete: pulse
              Missing/incomplete: resp.
              Missing/incomplete: skin
                                              Page 24 of 39
                         This sample form is provided by the Iowa Bureau of EMS.
                                  It is not mandatory you use this form.
            Missing/incomplete: GCS
  Missing 2 or more vital signs

Comments/Action Plan/Follow-up:_____________________________________________
Indicator # 4: Eligible chest pain patients will receive aspirin (ASA) per protocol before
transport 90% of the time.
 Criteria                 # of pts. by month             Jan      Feb       Mar     Apr   May   Jun   %
                             (circle month)              Jul      Aug       Sep     Oct   Nov   Dec
 Number of eligible patients (probable cardiac
 pain, no allergy to ASA, not taken PTA)
 Received ASA
 Received ASA on scene
 Received ASA enroute facility
 Eligible patients that did not receive ASA
Comments/Action Plan/Follow-up:_____________________________________________
Indicator # 5: 75% of suspected stroke patients will receive a neurological examination
per protocol.

Criteria                                                                                   Number or
                                                                                            Percent
Number of suspected stroke patients
Number with documented neurological assessment per protocol
Percent of stroke patients that received the examination
Comments/Action Plan/Follow-up:_____________________________________________
Indicator # 6: EMS will arrive at the side of the patient within 10 minutes of the first page
75% of the time.

 Criteria                      (circle                   Jan      Feb       Mar     Apr   May   Jun   %
 month)                                                  Jul      Aug       Sep     Oct   Nov   Dec
 Total number of eligible responses
 Not documented
 1-5 minutes
 6-10 minutes
 11-20 minutes
 > 21 minutes
Comments/Action Plan/Follow-up_____________________________________________
Indicator # 7: Time of arrival at the patient’s side will be documented on 80% of the
patient care encounters.

 Criteria                      (circle                   Jan      Feb       Mar     Apr   May   Jun   %
 month)                                                  Jul      Aug       Sep     Oct   Nov   Dec
 Total number of eligible responses
                                                Page 25 of 39
                           This sample form is provided by the Iowa Bureau of EMS.
                                    It is not mandatory you use this form.
Not documented
Comments/Action Plan/Follow-up_____________________________________________




                                          Page 26 of 39
                     This sample form is provided by the Iowa Bureau of EMS.
                              It is not mandatory you use this form.
                                            APPENDIX J

                   Monthly Equipment Checklist
Equipment              Write Quantity             Portable Suction                   Yes   No
Main Oxygen                                 PSI   Clean and undamaged?
Portable Oxygen                             PSI   Wand, tubing, canister?
O2 Masks (2 ea)        Adult Child Infant         Operates well?
Nasal Canula (2 ea)    Adult Child                Defibs                             Yes   No
Pocket Mask (1)                                   Clean and undamaged?
Bag-Valve-Mask (1)                                Scissors and towel?
Oral Airway (7)                                   Battery okay?
Nasal Airway (4)                                  Write expiration dates:
Cervical Collars (6)                              Adult Defib Pads (3)
Soft Roller Bdg. (4)                              Peds Defib Pads (2)
Trauma Dsg. (2)                                   Aspirin
Occlusive Dsg (2)                                 Glutose Paste (2)
Triangular Bdg. (6)                               Adult Epipens (2)
Scissors (2)                                      Peds Epipens (2)
Stethoscope (2)                                   Combitube (2)
BP Cuff (all sizes)    XL L   Child Infant        Protocols (current year)
Penlight (2)                                      Drug box tag #
OB Kit (1)                                        IV box tag #
KED (1)
Longboard/straps(2)                               Write Comments Below:
Head Immobilizer (2)
Scoop Stretcher (1)
Stair Chair (1)
Traction Splint (1)
Splints
Pillows (1)
Blankets (2)
Gloves
BSI Kit (2)




                                                  Inspector                                Date
                                                  Print Name:
                                                  Signature:

                                                Page 27 of 39
                           This sample form is provided by the Iowa Bureau of EMS.
                                    It is not mandatory you use this form.
         Quarterly Equipment Maintenance Checklist
                      Use this form to document equipment maintenance.
              All maintenance should follow the manufacturer recommendations.

Vehicle
Date
Mileage
Inspector
Stretcher: strap
wear, lock bar,
moving parts
Suctions: clean,
stocked and
functions well
Oxygens: tanks
above 300 psi,
regulators tight,
flow-meters work
BP cuffs: work
well, clean, hose
wear
Stair chair: works
smooth, straps
okay
Backboards/KED:
clean, no rough
edges, straps and
head immobilizers
present
Vacuum
splints/mattress
and MAST: clean,
pump works, no
leaks




                                              Page 28 of 39
                         This sample form is provided by the Iowa Bureau of EMS.
                                  It is not mandatory you use this form.
                                          APPENDIX K

                             Post-Run Check List
 Complete this checklist following every response and submit with the patient care
                                      report.
  This checklist does not substitute for a periodic detailed check of the vehicle and equipment.

Inspector(s): __________________________________Date: __________Time:________

ITEMS TO BE INSPECTED AFTER EVERY RESPONSE                                           COMMENTS
Fuel: Tank # 1: ¼ ½ ¾ F Tank # 2: ¼ ½ ¾ F
Windshield washer fluid: ¼ ½ ¾ F
Clean:      Interior      Exterior
Oxygen: (record PSI and bleed lines)
D:            PSI                  PSI              PSI
E:            PSI                  PSI             PSI
M:            PSI                  PSI              PSI
Other tank size:                   PSI             PSI
List Supplies:                      # Used # Replaced
1.
2.
3.
4.
5.
6.
7.
8.
Was all the equipment needed available?       Yes  No
Did all the equipment you used work properly? Yes   No
Were all necessary supplies available?        Yes   No
Did the vehicle start okay?                   Yes   No
Did the vehicle stop okay?                    Yes   No
Did the vehicle shift with ease?              Yes   No
Do the lights/warning devices work properly?  Yes   No
Do the tires look okay?                       Yes   No
Did radios, cell, etc. work okay?             Yes   No
Did you note any unusual noises?               Yes  No
Did the vehicle sustain any body damage?      Yes   No
Does this vehicle need to be out-of-service?   Yes  No
Describe any problems or concerns noted regarding vehicle operations, equipment or
supplies.
________________________________________________________________________
________________________________________________________________________
                                                Page 29 of 39
                           This sample form is provided by the Iowa Bureau of EMS.
                                    It is not mandatory you use this form.
                                         APPENDIX L

                     Vehicle Maintenance Record
               Use this form to document vehicle and equipment maintenance.
          All maintenance should follow the vehicle manufacturer recommendations.

Service Name:________________________________ Model:_____________

Make:_________________ Year:_________________VIN:_________________

Date
Mileage
Where Serviced
  Write cost in column
Change Oil
Change Oil Filter
Lubricate Chassis
Change Air Filter
Service Transmission
Flush Cooling System
Add Antifreeze
Align Wheels
Rotate Tires
Replace Tires
Adjust/Fix Brakes
Tune Engine




                                              Page 30 of 39
                         This sample form is provided by the Iowa Bureau of EMS.
                                  It is not mandatory you use this form.
                      Vehicle Maintenance Checklist
                Use this form to document vehicle and equipment maintenance.
               All maintenance should follow the manufacturer recommendations.


Vehicle
Date
Mileage
Inspector
Lights:
inside and outside
Latches: inside
and outside
Tires:
tread, pressure,
damage
Damage:
Body or interior
Test:
Horn, siren, wipers
Visual
inspection:
Belts, hoses, fluid
levels, battery
terminals
Communications:
Radios, cell
phones




                                               Page 31 of 39
                          This sample form is provided by the Iowa Bureau of EMS.
                                   It is not mandatory you use this form.
                                          APPENDIX M

 EMS Pharmacy Agreement: 657—Chapter 11(124,147A,155A)
Service Name: _____________________________City of Operation:_________________
Circle Level: EMT-B EMT-I EMT-P                 Paramedic Specialist                 Critical Care Paramedic
657—11.2(124,147A,155A) Ownership of Drugs—Option:
Select one option: MEDICAL DIRECTOR OR PHARMACY
Exclude the Pharmacy contact information if the MEDICAL DIRECTOR OPTION is
selected.
For PHARMACY OPTION, provide all of the following information. Please print or type.
Medical Director Information:
Name                                     Day Phone Number                 Evening Phone Number

Fax Number                               Email Address



Base Pharmacy Information:
Name                                     Street or Box                    City, State, Zip Code

Day Phone Number                         Fax Number                       Email Address

Pharmacist-in-Charge Name                License Number                   License Expiration


For the purposes of this agreement, the terms “drugs” shall refer to only those drugs or
intravenous infusion products as allowed within the EMS provider scope of practice, within
the level of authorization of the EMS service program AND as approved by the physician
medical director in writing.
   1. All drugs provided shall be the ultimate responsibility of the above designated owner.
      Under this agreement, all drugs shall remain the property of the designated owner.
      Whenever necessary and appropriate, the owner may consult with a pharmacist in regard
      to all matters relating to the proper use, storage, and handling of drugs.
   2. For purposes of this agreement, the service director or other individual (designated in
      writing by signature on this agreement) shall be the responsible individual for the service
      program.
   3. The service director or designee shall be responsible for accountability, distribution,
      expiration dates and storage condition of the drugs.
          a. All drugs shall be stored at the proper temperatures as defined by USP/NF.
          b. Any drug bearing an expiration date may not be administered after the expiration
              date.
          c. Outdated drugs shall be quarantined together until such time as the items can be
              lawfully disposed.
                                                Page 32 of 39
                           This sample form is provided by the Iowa Bureau of EMS.
                                    It is not mandatory you use this form.
           4. The service director or designee shall establish a periodic inspection program as required
              by pharmacy rule.
                  a. The service director or designee shall ensure proper inspection of the drugs on a
                     periodic basis.
                  b. Proof of periodic inspection shall be in writing and made available upon request of
                     the board or department.
                  c. Drugs used by the service program, as well as records, shall be subject to
                     inspection and audit by the Pharmacy Board of Examiners, Iowa Department of
                     Public Health and the federal Drug Enforcement Administration.
           5. Pharmacies shall provide drugs limited to the drugs listed in the service program’s written
              protocols.
           6. An EMS provider shall not administer a drug without the verbal or written order of a physician,
              physician designee, or by written protocol. The service program director or designee is
              responsible for ensuring proper documentation of orders given and drugs administered.
           7. The service program director or designee shall be responsible for developing and
              implementing policies and procedures for the security and control of the service program’s
              drug products, including provisions for adequate safeguards against theft or diversion of
              drugs. The following conditions must be met to ensure appropriate control over the drugs.
                  a. Policies and procedures shall identify who will have access to the drugs.
                  b. Drugs shall be secured at all times in a manner that limits access to authorized
                     personnel only.
           8. This agreement shall be effective the date of signing and shall continue in force thereafter
              until expiration date of the service program’s authorization as issued by the Iowa
              Department of Public Health, unless the authorization is sooner suspended or revoked.
              Additional means of termination include:
                  a. At any time upon the mutual agreement of the parties;
                  b. By either party, without cause, upon thirty days prior written notice to the other;
                  c. Immediately, upon written notice given by either party to the other party in the event
                     of any action or threatened action by local, state, or federal government or
                     accrediting bodies, or any opinion by legal counsel to the effect that the provision of
                     state or federal law or regulation creates a serious risk of assessment, sanction,
                     penalty or other significant consequence to the party giving such notice.
Statements of Affirmation and Agreement:
      I affirm and declare that I have read Iowa Administrative Code 657—Chapter 11 Drugs in
      Emergency Medical Service Programs. I understand that I am ultimately responsible for the drugs
      provided to this service. I will ensure that the service named in this agreement will comply with all
      applicable requirements set forth.
Medical Director Option:
_________________________________ ______________________________                              ________
Medical Director Print Name       Medical Director Signature                                  Date
Pharmacy Option:
_________________________________             ______________________________                  ________
Pharmacist in Charge Print Name               Pharmacist in Charge Signature                  Date

I affirm and declare that I have read Iowa Administrative Code 657—Chapter 11 Drugs in Emergency
         Medical Service Programs. I understand I am responsible for the service program implementation
         of this agreement, including, but not limited to, policy and procedure development and
         implementation in conjunction with the designated service owner.


Service Program Director:
                                                         Page 33 of 39
                                    This sample form is provided by the Iowa Bureau of EMS.
                                             It is not mandatory you use this form.
_________________________________            ______________________________               ________
Service Director Print Name                  Service Director Signature                   Date

Service Program Designee (optional):

_________________________________          _______________________________                ________
Designee Print Name                        Designee Signature                             Date




                                               APPENDIX N
                                                     Page 34 of 39
                                This sample form is provided by the Iowa Bureau of EMS.
                                         It is not mandatory you use this form.
     EMS Pharmacy Policies and Procedures
Service Name: ________________________ City of Operation: _____________________

These policies and procedures implement the EMS Pharmacy Agreement dated
_________________. The EMS service director or individual designated in writing within
the Pharmacy Agreement shall ensure these policies are implemented and the procedures
enacted as defined herein.
For the purposes of these EMS Pharmacy Policies and Procedures, the terms
“drug” or “drugs” shall refer to only those drugs or intravenous infusion products
as allowed within the EMS provider scope of practice, within the level of
authorization of the EMS service program AND as approved by the physician
medical director in writing.
For the purposes of these EMS Pharmacy Policies and Procedures, the term
“owner” shall refer to the medical director or base pharmacy as designated in
writing on the pharmacy agreement.
   1. Administration of drugs: An authorized EMS provider shall not administer or
      assist with the administration of a drug without the verbal or written order of a
      physician, physician assistant, physician designee or by written protocol.
   2. Controlled substances prescribing: Controlled substances shall be prescribed
      only by a person who is authorized by state law. Verbal orders for controlled
      substances may be given by the receiving hospital’s authorized staff. The
      controlled substance prescriber must document the verbal order and the drug use.
   3. Storage: All drugs shall be stored at the proper temperature as defined by the
      USP/NF. The temperature in the storage compartment shall be recorded during
      routine inspections on the EMS Drug Inspection Form.
   4. Expiration dates: Any drug bearing an expiration date may not be administered
      after the expiration date. All drug kits will be labeled with the earliest expiration date
      of any product contained within and that date shall be record during routine
      inspections.
   5. Drug disposal or destruction:
          a. Controlled substance disposal or destruction shall be documented in
              writing on the EMS Drug Inventory Control Log and signed by the EMS
              provider responsible for administration and witnessed by an EMS provider or
              a licensed health care provider.
          b. Outdated drugs shall be removed from service until they are disposed of by
              the owner or designee. The disposal or destruction of the outdated drug
              shall be documented on the EMS Drug Inventory Control Log and signed
              by two EMS providers or by one EMS provider and a licensed health care
              provider.
   6. Inventory control: Drugs carried by the service shall be only those that meet the
      appropriate scope of practice of the service EMS providers. In addition, the quantity
      of drugs carried by the service shall be based on the protocol requirements as
      determined by the service program medical director. Any use, breakage, loss, theft,
                                                Page 35 of 39
                           This sample form is provided by the Iowa Bureau of EMS.
                                    It is not mandatory you use this form.
              or other decrease in inventory shall be recorded on the EMS Drug Inventory
              Control Log.
          7. Inspections: At a minimum, monthly inspections will be conducted and
              documented on the EMS Drug Inspection Form.
                  a. Records of routine inspection and inventory control shall be submitted every
                      six months to the owner.
                  b. Records will be made available upon request of the Iowa Board of Pharmacy
                      Examiners, Iowa Department of Public Health or the federal Drug
                      Enforcement Agency.
                  c. As a minimum, all pharmacy records shall be maintained for a period of four
                      years.
          8.  Security: Access to the drugs will be limited to authorized EMS personnel. The
              drugs shall be kept in a secure compartment and remain locked until needed for
              administration. Drug kits found not locked in accordance with these policies and
              procedures will be subject to immediate inventory and have a variance report
              completed.
          9. Adverse drug reaction: Any unanticipated or undesired response directly
              attributable to the administration of a drug shall be reported by the EMS personnel
              to the receiving hospital emergency department staff and to the service program
              medical director.
          10. Drug defects: Any defects in a drug will be reported, in writing, by EMS personnel
              to the drug owner.
          11. Drug recalls: The drug owner is responsible for ensuring that the EMS service
              program is included in any recall.
Statements of Affirmation and Agreement
       I affirm and declare that I have read Iowa Administrative Code 657—Chapter 11 Drugs in
       Emergency Medical Service Programs. I understand that I am ultimately responsible for the drugs
       provided to this service. I will ensure that the service named in this agreement will comply with all
       applicable requirements set forth.
Medical Director Option:

___________________________                 ______________________________                    _________
Medical Director Print Name                 Medical Director Signature                        Date

Pharmacy Option:

___________________________                ______________________________                     __________
Pharmacist in Charge Print Name            Pharmacist in Charge Signature                     Date

I affirm and declare that I have read Iowa Administrative Code 657—Chapter 11 Drugs in Emergency
         Medical Service Programs. I understand I am responsible for the service program implementation
         of this agreement, including, but not limited to, policy and procedure development and
         implementation in conjunction with the designated service owner.
Service Program Director:




                                                         Page 36 of 39
                                    This sample form is provided by the Iowa Bureau of EMS.
                                             It is not mandatory you use this form.
___________________________           ______________________________                   _________
Service Director Print Name           Service Director Signature                       Date

Service Program Designee (optional):

___________________________           ______________________________                   _________
Designee Print Name                   Designee Signature                               Date




                                                  Page 37 of 39
                             This sample form is provided by the Iowa Bureau of EMS.
                                      It is not mandatory you use this form.
                                               APPENDIX O


                         EMS Drug Inspection Form
               Submit a copy of this form to the owner every 6 months.
Service Name:______________________________ City of Operation:_________________________

Name of Owner:_____________________________ Next Date to Submit:______________________
                  Base Pharmacy or Medical Director
                       Record the following parameters monthly, as a minimum.
Month/Day/Year
Print First Name
Print Last Name
Initials or Signature
Rig name/number
Box number
Box secure ?
Tag number
Next Expiration Date
Temperature
Over the Counter Rx Quantity and      Quantity and    Quantity and   Quantity and   Quantity and   Quantity and
                      Outdate         Outdate         Outdate        Outdate        Outdate        Outdate
Activated Charcoal
Aspirin
Oral Glucose
Auto-inject Epi
(adult)
Auto-inject Epi
(pediatric)
                                           APPENDIX P

                   EMS Drug Inventory Control Log
Submit a copy of this form to the owner every 6 months. Date to submit:_______


Date    Report Drug Name & Dose   Prescribed by: Protocol Amount    EMS Provider:           Witness:
        Number                    or Practitioner Name     wasted   (print and sign name)   (print and sign name)
                                  OR describe reason for
                                  decrease: (i.e.,outdate,
                                  breakage, loss, theft)

				
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