Lenox Ambulance Service Operations

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               Lenox Ambulance Service Operations
                                      Revised September 2006

Section 1 - General Information:

   1.   It is the responsibility of each member of the crew to make himself/herself familiar with
        this manual, including the Appendices, the Service Protocols, and the Laws and Rules
        governing EMS in Iowa. It is the responsibility of the Director to assure new members
        have a copy or access to each, and to assure all members have access to all materials
        listed. A binder will be located in the ambulance station with all pertinent documents.

   2.   Patient care is provided to all patients without regard to race, sex, color, ethnicity,
        religion or insurance / financial status.

   3.   Chain of Command: Personnel  Director  Ambulance Board  City Council
        Representatives  City Council. See Appendix M for current list of Board Members.

   4.   Call sheet: A new call sheet is made every two weeks by the director. Crew members
        should notify the director of available times for the next call sheet, by 6 p.m. on the
        Sunday prior to when a call sheet expires. For instance, the call sheet ends on a Tuesday,
        and call times should be given to the Director by the Sunday before. This allows time for
        the sheet to be distributed and mailed as necessary so that personnel have it prior to the
        beginning of the call period.

   5.   Call shifts: If a crew member finds he/she cannot fill a shift he/she is scheduled to cover,
        he/she should try to find a replacement, or someone to trade the shift with him/her. It is
        essential that at least one EMT is on each shift. The Director, City Hall, and the person’s
        shift partner should be notified of the change. If unable to find someone to cover the shift,
        the crew member should notify the Director, the other person scheduled on the shift,
        and/or City Hall.

   6.   Meetings: Meetings are held on a regular basis, as posted at the ambulance station, on the
        call sheet, and through other communications. Special meetings may be called as needed.
        All members are expected to attend regular and special meetings, as the communication at
        the meetings is vital to the teamwork and working basis of the Service.

   7.   Alcohol use: As stated in the By-Laws of the Lenox Ambulance Service, personnel are
        not to consume any alcoholic substances within 8 hours of going on call or at any time
        during a call shift. Heavy drinking raises the blood alcohol level to a degree that it can’t
        return to normal within 8 hours. Personnel should wisely consider the consumption of
        alcohol, especially in large amounts. At any time a person is suspected of being under the
        influence, the person suspecting this should call for someone to replace the crew member
        on the response, and the Director should be notified immediately of the situation. An
        incident report should be completed as well. Use of any controlled substances (except
        medications for which the person has a prescription, taken when not on call or going on
        call) will not be tolerated. See the By-Laws (App. N) for more information.


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8.   Confidentiality: Patient confidentiality is of the utmost importance.

       a. Crew members shall not discuss runs with those who were not on the run.
       b. Discussing the call is a “need to know” situation, and limited to discussing the
          patient’s condition with personnel assuming care for the patient.
       c. Even if not mentioning a patient’s name, in a small town, it is not difficult for a
          person to figure out who is being talked about. We are privileged to be invited a
          person’s personal space, and we learn private details that we have a duty to regard
          with respect and extreme care. Breach of confidentiality will not be tolerated.
       d. This policy does not prevent run data from being used or discussed for run audits,
          call reviews, case studies, and billing purposes. Confidentiality is expected of all
          involved in such cases.
       e. Each member of the service is required to sign a Confidentiality Agreement. (App.
          A)
       f. Students who are doing ride time with the ambulance service must sign a
          Confidentiality Agreement.

9.   Ambulance Crew Health Issues:
      a. The Director is also the designated Safety Officer and Infection Control Officer.
      b. The ambulance service will provide Hepatitis B vaccinations for each member. Any
         personnel who decline the vaccinations must sign a declination form.
      c. All personnel should have a TB test yearly, arranged and paid for by the service. If
         a member of the service receives TB testing at his/her place of employment, a
         record of the test should be submitted to the Director.
      d. Records of immunizations and TB testing will be kept in the personnel files of each
         member.
      e. The Exposure Control Plan (Appendix C) outlines the methods for prevention of
         communicable diseases, and the process for reporting an exposure.
      f. An injury that occurs while a crew member is on a call should be reported
         immediately to the Director.
              i. The injured person must complete an incident report. (App. Q)
             ii. The Director may require the crew member be seen by a physician.
            iii. The injured person may choose to be seen by a physician for the injury, even
                 if not required to by the Director.
            iv. Ambulance personnel are covered under Workman’s Compensation.
      g. A crew member who has a medical condition which prevents him/her from meeting
         the physical or mental requirements of the job has the responsibility of notifying the
         Director of this. Examples include such things as a broken bone, recent surgery, or
         conditions that interfere with reading, writing, speaking, performing medical
         procedures such as CPR, lifting, and driving. A functional job analysis is found in
         Appendix U of this manual, and contains the physical and mental expectations
         when functioning on the ambulance service.
              i. This crew member should not take call or go on calls until the condition is
                 resolved.
             ii. Specific details of the person’s medical condition are not required. A simple



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                     statement of “I am not physically / mentally able to fully function as an
                     EMT / driver at this time,” is adequate.
                iii. To return to duty, the member must provide a release statement from his/her
                     doctor. (See App. T)
                iv. Simple illnesses such as the flu or a cold do not qualify as a physical
                     impairment under this policy.

   10. New members of the Service, whether trained drivers or EMS personnel, shall complete
       an orientation process within 30 days of being approved as a member of the department.
       See Appendix B for the Orientation Checklist. A confidentiality statement and application
       must be completed (App. A).

   11. Individual responses to calls for help: In the event an EMS provider is asked personally
       to give advice, provide assessment, or care for an individual without the ambulance being
       called, it is recommended that the provider declines to give advice, except to recommend
       the person seek advice from his/her doctor.

          a. EMS providers responding as individuals are not covered by the insurance of the
             ambulance service, and should act within the role of a bystander/citizen.
          b. Documentation of any help rendered is recommended for the provider’s personal
             liability reasons.
          c. If an EMT receives a personal call from someone wanting an ambulance response,
             that person should be advised to call 911 or the EMT should call 911 for the person.
             Response should go through dispatch, so that the on-call personnel may respond.

   12. Uniforms: The Service does not have a uniform, however, crew is encouraged to wear
       clothing that identifies them as a member of the Service whenever appropriate.

          a. Clothing should be clean and appropriate to patient care.
          b. It is understood that people may be called away from jobs or other activities that
             would prevent personnel from always meeting this standard.
          c. Crew members may keep a shirt or other items at the station to quickly change into
             before going on a call..
          d. Safety is to be considered. Long pants provide more protection than short ones, and
             sturdy shoes provide better protection, especially on trauma calls, or calls that
             involve motor vehicle crashes, as terrain could be rough, wet, or include sharp
             objects produced by the crash.

Section 2 – Ambulance Calls

   13. Responding to a call: When the pager sounds, the on-call personnel should go
       immediately to the ambulance station.
         a. Safety while driving to the station is of the utmost importance and is the
            responsibility of the responding person.
         b. It should be noted that responding to the station does not give the legal right to
            disobey speed limits, traffic signs, or other laws. The minimal amount of time that



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          is saved by speeding to the station is not worth the risk of injury to self or others.
       c. Maps: There is a 911 map on the wall of the garage at the station, and maps in each
          ambulance for the Service response area. BEFORE leaving for a call, the crew
          should assure knowledge of the location of the call. Time spent looking at a map
          can shorten overall response time. For calls that a possibility for more assistance
          may be needed, the location on the map should be circled with a dry erase marker.

14. White light / blue light use: Lenox Ambulance Service does not have a white light policy
    for members at this time.
       a. Service members who are also on the fire department, and have a blue light in their
          vehicle, are NOT allowed to use the blue light to respond to an ambulance call.
       b. Blue lights are for fire department responses only.

15. Entering the station:
      a. Responders may use the code number on the remote key pay to enter the north
         garage door, or a key to the small door on the north side of the building.
      b. The code number shall not be given to anyone who is not a member of the crew,
         except as needed by the Supervisor of city personnel.

16. Choosing which ambulance to use:
      a. In all emergency responses 87-65 will be used if available.
      b. If 87-65 is on a call or otherwise out of service, 87-64 should be used.
      c. 87-64 should be used for transfers from a hospital to a nursing home and for other
         non-emergency transfers.
      d. The crew should be careful in determining a non-emergency call, and if there is any
         doubt, 87-65 should be taken.
      e. If 87-64 is chosen over 87-65, documentation of the reason should be made.

17. Upon reaching the ambulance, the extension cord should be unplugged, and once inside
    the ambulance, the cell phone and radio should be turned on immediately.

18. The times given by dispatch for being paged, going in service, en route times, scene
    times, etc., should be recorded by ambulance personnel. If not written down at the time
    given, dispatch can be contacted after the call to obtain the times.

19. The mileage reading at the scene and upon arrival at the destination should be recorded.

20. Staffing: The ambulance shall be staffed at least at the minimum staffing requirements as
    set forth by the State Department of Public Health, Bureau of EMS.

       a. Minimum staffing for the Lenox Ambulance is at least one EMT-B, and one other
          person who has a current BLS for Healthcare Providers card, and has completed
          training in emergency driving and radio communications.
       b. A lone staff member should not take the ambulance to the scene of a call.
               i. Exception 1 – If mechanical problems require another ambulance be
                  dispatched to the scene, one person may drive the ambulance there for the



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                   initial crew to utilize.
               ii. Exception 2 – If an on-call staff member is already at the scene, his/her
                   partner may drive the ambulance to the scene, provided the member at the
                   scene intends to go on the call.

21. Seatbelts: Seatbelts are required for all personnel and citizens who are in the ambulance.
    The only exception is the patient attendant giving patient care that can’t be given while a
    restraint is worn. In this case, the patient attendant(s) should replace their seatbelt(s) as
    soon as possible after the particular care is completed.

22. No smoking is allowed in the ambulance at any time.

23. Tiering: Professional cooperation and courtesy to members of other services is essential
    in the continuation of quality patient care.
       a. When tiering with a service to provide a higher level of care for the patient, the
           tiering agency should be notified as soon as possible through dispatch, noting the
           direction of travel you will be using to go to the hospital.
       b. When seeing the approaching tiering ambulance, the driver should carefully pull off
           of the road, or onto a side road, to meet the other ambulance.
       c. Personnel from the other ambulance will board the Lenox ambulance with
           equipment and supplies.
       d. The tier should be made in an efficient manner to cause as little time as possible
           stopped for the tier.
       e. To decide whether or not a tier should be requested, refer to the patient care
           protocols. Some examples of when tiering would be appropriate are: Chest pain,
           shortness of breath not quickly relieved with oxygen, diabetic reactions with altered
           mental status not responding to basic treatment, severe trauma, an unconscious
           patient with an unstable airway, and cardiac arrest.

24. Transporting patients:

       a. Patients should be secured with a minimum of three straps when on the cot during
          movement to and from the ambulance, in a facility, or during transport.
       b. The harness straps should be used whenever possible.
       c. If a strap must be removed to facilitate treatment procedures, it should be replaced
          as soon as possible.
       d. Pediatric patients should be secured safely with proper restraints, and should not be
          held by parents or others during transport.

25. Transport of non-patients:
      a. Occasionally, a family member of a patient will want to ride to the hospital in the
         ambulance with the patient. This is allowed at the discretion of the crew.
      b. Unless the patient is a child, the family member should be seated in the front of the
         ambulance and must wear the seatbelt.
      c. If the patient is a child, if there is room, the family member – unless disruptive –
         should be allowed in the patient compartment, and should wear a seatbelt.



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   26. Destination of patients:
         a. The patient or the patient’s family has the right to choose which hospital transport
             will be made to, unless distance to that facility would jeopardize the patient’s
             condition.
         b. This decision on transport should be documented in the run report.
         c. If the patient or patient’s family is unable to choose a facility or wants the
             ambulance crew to decide, the patient attendant will make the decision based on
             distance to the closest hospitals and the patient’s needs.
         d. Doctor or hospital orders are needed to take a patient to an Omaha, Des Moines or
             Iowa City hospital, and especially to a Veteran’s hospital.
         e. Common destinations: A book with phone numbers and directions to the most
             common destinations utilized by patients of the Service is located in each
             ambulance.

Section 3 – Patient Care Issues

   27. Refusal of care:
         a. A mentally competent adult has the right to refuse care.
         b. When this occurs and it is felt that medical treatment is important, the EMS
            provider should give the patient a thorough explanation of why the patient should
            accept care, and encourage such. Risks of refusing treatment and/or transport should
            be explained, and documented on the Refusal of Care form.
         c. If unsuccessful, the EMS provider should explain risks of refusing care, the
            importance of seeking care on his/her own, and give the patient any appropriate
            information regarding his/her possible condition.
         d. The EMS provider may contact Medical Control for advice, (and in some cases is
            required to contact MC) and may decide with the advice of MC, to enlist the help
            from law enforcement to begin procedures for a compulsory transport. Examples
            may include a patient who is suicidal, a minor patient suspected of being abused,
            and other situations.
         e. Enough information should be obtained to complete the Refusal of Care form,
            including the patient’s signature and the signature of a witness. Thorough
            documentation of any extenuating circumstances should be completed. See
            Appendix D, Refusal Form.
         f. A supply usage sheet, which is attached to the refusal form, should be completed.

   28. Resuscitation Decisions: All members of the service should be familiar with the three
       protocols that deal with resuscitation decisions and death in the field. These protocols are:
       “Determination of Death in the Field,” which helps the EMS provider know when
       resuscitation efforts are appropriate; “Cease-Efforts Protocol,” which explains how efforts
       can be halted in the field; and “Death in the Field Protocol,” which explains the
       procedures that should be followed if death in the field is determined, and no resuscitation
       is being attempted. Whenever resuscitation efforts are started, the crew should use the
       current BLS standards set forth by the AHA; this includes CPR and AED use, and calling
       for ALS. You can review the DNR protocol, and the above mentioned protocols in the



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        patient care protocols AND in Appendix W of this manual.

   29. Living Wills: A Living Will is different than a Do Not Resuscitate order, and may only be
       enforced by the attending physician at the receiving facility. A family member can refuse
       care on behalf of a patient, if the family member has Power of Attorney, or is the next of
       kin. In this case, contact Medical Control immediately.

   30. Organ Donors: A person who is a potential organ donor should receive treatment as any
       other patient. The EMS provider may initiate organ donation assessment according to the
       protocol found in the patient care protocols. A patient’s wishes, if known, should be made
       known to the receiving facility. Refer to Organ Donation information in PC protocols.

Section 4 – After the Call

   31. The ambulance interior and any equipment used should be cleaned and disinfected as
       needed following each call.

   32. Both the driver and the patient attendant have responsibilities after a call is
       completed. The attendant needs to write his/her report. While this is being done, his/her
       partner should begin the process of cleaning the cot, replacing the linens, cleaning the
       ambulance interior as needed, and putting supplies and equipment back in order. Working
       as a team will help the crew get back in service as soon as possible after a call. The
       personnel should follow infection control guidelines when cleaning, to avoid the
       transmission of disease.

   33. Linens: Most hospitals exchange linens with ambulance services. When leaving a patient
       at a hospital, be sure to replace linens as needed. Be sure to retain the pillow from the cot
       when leaving a patient, or replace the pillow with another one from the facility. The linen
       cabinet in the ambulance should have a ready supply of sheets, towels, blankets and
       pillowcases.

   34. Preparing the cot: After each patient use, the cot should be cleaned and fresh linens
       should be placed. This includes a flat sheet over the mattress, a draw sheet, blanket, pillow
       with clean pillowcase, and during cold weather, the heavy blanket/wrap.

   35. Some incidents may cause excessive stress reactions of the responders. Each member
       should be familiar with CISM information (App. P) and initiate contact if appropriate.

Section 5 – Scene Issues

   36. Calling for more help: If the responding crew determines the need for more help at a
       scene, the dispatcher should be informed immediately of the need. Specify if lifting help,
       medical help, the fire department, or some other specialized assistance is needed.

   37. General Scene Safety and Crime Scenes: Scene safety (for the crew, patient, and
       others) is of utmost importance. Refer to Appendix R for guidelines.



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   38. Hazardous materials: Any situation found to involve hazardous materials should be
       handled with extreme caution. Remember the “rule of thumb” and locate yourself and the
       ambulance a safe distance from the incident.
         a. Request the Fire Department if not already notified, and notify CHEMTREC as
             appropriate.
         b. The ambulance crew will not enter an unsafe scene.
         c. The Fire Department, if present, is in charge of the scene and will determine safety
             for EMS personnel. A HazMat book is in the pocket of the passenger side door of
             each ambulance, and should be used to interpret information from any placards that
             may be visible within the safe distance.

   39. Helicopter transport: The ambulance crew can call for a helicopter transfer if this would
       provide faster transport of the patient to the appropriate facility. Instances when air
       transport may be appropriate include prolonged extrication of a seriously injured patient,
       or seriously ill patient a long distance from a hospital. Additional information regarding
       helicopter safety and landing zones is found in Appendix O.

          a. The Iowa Trauma System Out of Hospital Treatment and Transport Protocol (See
             Appendix E) should be utilized for all trauma patients. The closest helicopter
             services available are Life Flight, St. Josephs Hospital, Omaha; Life Flight, IMMC,
             Des Moines; and Mercy One, Mercy, Des Moines.
          b. To call for a helicopter, notify the dispatcher which service is requested, and where
             the helicopter will be landing – the scene or another specified site. The helicopter
             pilot will contact the service via radio when in range to finalize landing zone issues
             and allow a patient report from the patient attendant to flight personnel.
          c. If wanting to meet a helicopter at a hospital, that hospital must be contacted for
             permission. The hospital must request the helicopter. In this situation, the hospital
             has the option of assessing the patient first prior to air transport.


Section 6 – Equipment and Supplies

   40. Pagers: Each member of the crew is issued a pager and will be responsible for its care,
       which includes keeping the battery and extra battery (if supplied) charged as needed.
         a. The Director should be notified if the pager malfunctions.
         b. A member should carry the pager at all times when on call, being careful to keep
            the pager clean and dry.
         c. There is a pager test each evening at approximately 1800 hours. If a pager does not
            go off, an inquiry should be made to another crew member to find out if their pager
            sounded. If a problem is suspected, the Director should be contacted.

   41. Supplies used should be replaced immediately following a call as needed.
         a. Some items may be replaced by the receiving tiering agency, or the receiving
            hospital, while others must be replaced from the supply cupboards at the station.
         b. When an item is in low supply or depleted from the cupboards, the Director should



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           be notified by phone or e-mail, and a “supply / equipment” form should be
           completed and left in the Director’s inbox at the ambulance station.

42. Equipment malfunctions:
      a. If equipment pertinent to patient care malfunctions in the course of a call, the
         malfunction should be documented in the run report, noted on the “supply /
         equipment” form, and the Director should be notified by phone or e-mail as soon as
         possible.
      b. If equipment is found to have a malfunction when not in the course of patient
         treatment, it should be noted on the “supply / equipment” form, and the Director
         should be notified by phone or e-mail as soon as possible.

43. If equipment is left with a patient at a receiving facility, or sent with the patient via air
    transport, the equipment should be replaced by the receiving agency if possible. If not
    possible, note on the “supply / equipment” form what equipment needs to be retrieved,
    and from where.

44. It is the responsibility of each member of the service to be familiar with and operate all
    equipment (within his/her scope of practice) carried on the ambulances.

       a. In-services will be held when new equipment is acquired.
       b. If a member misses an in-service, he/she should initiate a meeting with the Director
          or another member, to become trained on the new piece of equipment.
       c. When new equipment is obtained, the crew will be informed via the call sheet or
          other appropriate means.

45. Inventory of supplies and equipment will be made on a regular basis as assigned. This
    task is a valuable learning tool to become accustomed to where items are located
    throughout the ambulance, and for assuring that everything is accounted for and available
    for patient care use. Inventory forms are provided to record findings when an inventory is
    completed. See Appendix F for Inventory Forms.

46. Locked cabinets: Each ambulance has a locked cabinet for pharmacy / IV supplies. The
    key is secured to the cabinet handle with a break-away lock. This lock number is to be
    recorded on the appropriate form (see appendix L) after opening the cabinet, and a new
    lock is to be placed.

47. Oxygen: Oxygen bottles should be turned off, and lines bled, after use.
     a. When a small bottle reaches 500 or less PSI, the bottle should be replaced with a
         new bottle. The empty bottle should be placed in the holding area at the northeast
         corner of the station. When only two new bottles remain in the holding area, this
         should be noted on a “supply/equipment” form.
     b. When a large bottle of oxygen reaches approximately 300 PSI, the tank should be
         replaced. The empty bottle should be placed in the holding area with a note attached
         reading “empty.”
     c. Oxygen tanks in the ambulance should be secured at all times.



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Section 7 - Communications

   48. Radio communications: Use of the radio is the responsibility of the driver when talking
       to the dispatcher, and the patient attendant when talking to Medical Control or when
       giving a patient report. Close contact with the dispatcher should be maintained. Taylor
       County utilizes a 10-code system for communications, however, if the radio operator does
       not know the proper code to use, simple plain language should be used instead.

          a. Radio communications should be professional, calm, and clear. Hold the key on the
             mike for a full second before speaking. Profanity is prohibited, and patient names
             should not be used over the radio.
          b. The common communications with the dispatcher include:
                   i. 10- 8 – In service (at least one person on call has arrived – can note if
                      awaiting crew, or if you know more crew is needed)
                  ii. 10-76 – En route to the scene.
                 iii. 10-23 – Arrived at the scene.
                 iv. 10-76 – En route to the receiving facility.
                  v. 10-6 – Arrived, and busy at the receiving facility.
                 vi. 10-24, 10-76 – Assignment completed, and en route back to the station.
                vii. 10-7 – Out of service at Station 6.
          c. The type of call will dictate if a variation of the above is necessary. For calls that a
             tier is requested, dispatch should be notified of when stopping for the tier, and when
             the trip en route is continued.

   49. Cellular phone communications: The patient attendant may use the radio to call in a
       patient report, however, cellular phone communication may provide more confidentiality
       and ease of contacting the receiving facility. Numbers are programmed into the phone for
       the most common facilities transport is made to. Other numbers are in a book in each
       ambulance.

Section 8 – Vehicle Operation and Maintenance

   50. Driving: Members of the service should be familiar with the laws governing the use of
       lights and sirens, and other driving issues that face a driver of an emergency vehicle.
       Extreme caution should be used whenever driving an ambulance, especially when using
       lights and sirens, as the reactions of other drivers is unpredictable when confronted with
       an emergency vehicle.
          a. An emergency vehicle operator must always exercise “due regard” for his/her crew,
              the patient, and other drivers.
          b. The person driving must remember that he/she is responsible for the lives of
              himself/herself, his/her crew, other drivers, and the patient. Distractions from
              focused driving should be avoided. En route to the scene, it is recommended that if
              radio or cell phone traffic is necessary, the person not driving takes this
              responsibility. Radio music should also be avoided on emergency responses.



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      c. Speed should be limited to no more than 10 mph over the posted speed limit when
         that posted limit is 30 mph or over, and no more than 5 mph over the posted speed
         limit when that posted limit is less than 30 mph. When road conditions are
         deteriorated due to weather or other hazards, the driver should adjust speed
         accordingly. Safe arrival at the scene and at the destination of the ultimate goals of
         driving the ambulance.
      d. When driving in excess of the speed, lights and sirens must be used. (If the call is
         during the night when there is no traffic, sirens are not always necessary.)
      e. Intersections provide the greatest risk for collision when driving an emergency
         vehicle. The driver should stop at all stop signs, and at all red lights, and clear the
         intersection before proceeding.
      f. In cases when it would be impossible or unsafe for other drivers to pull off the road
         or pull over to allow you to pass, lights and sirens should be turned off.
      g. Siren (when appropriate) and lights should be used on emergency responses to calls.
         Lights and sirens are unnecessary, and increase risk to the patient and crew, if used
         on the way to the hospital when a patient does not have a life-threatening condition.
         Lights and sirens should be reserved for true emergencies.
      h. When using the siren, do not wait until following closely behind another car before
         turning the siren on, as this could cause the driver of the car ahead to be startled and
         hit the brakes.
      i. In Nebraska, whenever lights are used, the siren MUST be used as well.
      j. The headlights should always be “on” when the ambulance is being driven.
      k. When transporting a critical patient, the crew may request law enforcement’s
         assistance in safe passage through intersections. If this request is to be made, it
         should be done early enough to allow time for the officers to get in position. Escorts
         are discouraged, as this provides a greater risk to the following emergency vehicle,
         especially at intersections.
      l. When passing another vehicle, the ambulance should pass on the left of the vehicle,
         and abide by safe passing zones. Only in extreme cases, or when a vehicle pulls to
         the left, should the ambulance pass on the right, but caution should be exercised.
      m. Speeding when the ambulance is not being used for an emergency is not condoned.
         Drivers are responsible for any traffic tickets received while driving the vehicle.
      n. It is up to the responding crew who will drive and who will attend the patient, based
         on qualifications and patient needs.
      o. Seatbelts should be worn by all personnel when responding to a call. Seatbelts are
         required for the driver at all times, and for any riders in the ambulance. The patient
         attendant should wear a seatbelt whenever the patient care situation allows.
      p. The back-up alarm is required whenever backing up. Do not turn it off.

51. Ambulance vehicle maintenance:

      a. The Director is responsible for assuring that regular vehicle maintenance is
         completed, or appointing someone to be responsible, however, all personnel are
         responsible for reporting any suspected problems. All vehicle maintenance shall be
         logged on the appropriate forms.
      b. Fuel should be added anytime the fuel gauge indicates the tank is less than ¾ full.



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          c. The ambulance should be washed as needed following a call.
          d. Operation problems:
                 i. All suspected problems with the operation of either ambulance shall be
                    immediately reported to the Director.
                ii. If operational problems interfere with a response or patient transport, the
                    driver will call for the back-up unit, or for a tier with another service as soon
                    as possible.
               iii. The transfer of the patient should be as efficient as possible.
               iv. Complete documentation of the event should be made.
                v. Dispatch should be notified when there are major operational problems, or
                    when a unit is out of service.

Section 9 – Records and Reports

   52. Records and reports: A pre-hospital patient care report shall be completed for each call.
         a. Runs will be logged as appropriate, including all requested information.
         b. Each run in which a patient is assessed will receive a run number.
                  i. If, after arriving on scene, the person refuses assessment, treatment, and
                     transport, and did not make the call for help, this is considered a public
                     assist call. This should be noted on the refusal form.
                 ii. If a patient is treated, but refuses transport, the refusal form must be
                     completed in its entirety (as appropriate). See Section 3, #27.
                iii. If more than one patient from the SAME event is being transported at the
                     same time, ONE run number, with letters following for each patient shall be
                     used. Example 07-101A, 07-101B, for two patients from one MVC.
                iv. If more than one patient from unrelated events is transported at the same
                     time, the run will receive two numbers. Example, two patients from the
                     nursing home need transported at the same time – each patient would
                     receive a different run number. Note – personnel are only paid for one run.
         c. The names of all responding personnel should be printed on the report.
         d. The report writer should sign the report.
         e. It is important that the report be complete. All sections should either be filled in or
            marked out with an “x” if the section is not applicable. Many sections have “not
            applicable” as an option to check.
         f. The patient attendant should complete the report immediately following the call
            unless an extreme situation prevents it.
         g. A copy of the report should be left at the receiving facility (this is not necessary
            when transporting a patient from a hospital to home or nursing home). Extra pages
            for the patient care report are available if more space is needed. Never shorten a
            narrative based on space available on the report form.
         h. Reports MUST be legible.
         i. The report shall be filed appropriately at the ambulance station
         j. Once a report is filed, if the author wishes to add something or correct a mistake, an
            addendum must be written, then signed, dated, and attached to the original run
            report.
         k. Patient reports are legal documents, and are protected by confidentiality laws. The



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            ambulance service is the legal custodian of the run reports and no one is to release a
            report to anyone without written permission by the patient or a subpoena. If a report
            is requested by subpoena, the original report will then be placed in a locked file for
            safekeeping, and written documentation of any release of information will be kept
            on file.
       l.   Any paperwork that is not needed, that has patient information on it, must be
            shredded.
       m.   Stand-by calls in which no patients were treated should be recorded on a “Stand-by
            Record” form instead of a run report. Stand-By calls do not need a run number if no
            one was treated. Refusal forms should be used as appropriate.
       n.   To assist billing personnel, there is a form to complete for all patients who have
            Medicare coverage. This should be filed with the run report at the station.
       o.   After transport is complete, the EMS provider should request a signature from the
            patient, patient’s family, or power of attorney, on the Assignment of Benefits/
            HIPAA Form, otherwise known as the Consent Form, and a Privacy Notice should
            be given to the patient or patient’s family if they request it.
       p.   The ABN (Advanced Beneficiary Notice) should be utilized when it is obvious a
            patient does not meet medical necessity for ambulance transport, or when a patient
            requests transport to a facility that is further away than the nearest appropriate
            facility. (A difference of just up to 10 miles is not usually an issue.) Examples of
            this are when a patient is being discharged from the hospital back to the nursing
            home, and could go by car or special wheelchair van, or if a patient has an isolated
            closed injury below the shoulder or knee.
       q.   The PCS (Physician Certification Statement) should be completed by the physician
            or nurse when a non-emergent transfer, scheduled or unscheduled, is requested for a
            patient. This statement certifies that the patient can’t be transported any other way
            than by stretcher, and is necessary for billing purposes. If the patient does not meet
            criteria for the PCS, an ABN form will be necessary. Examples of a patient
            requiring a PCS would be a patient who is a fetal position, always in bed, needing
            to go to the hospital for x-rays. If returned, a separate form is needed for the return
            trip. Though oxygen is listed as a condition, a patient on oxygen alone does not
            meet criteria – he/she must require continuous monitoring of the oxygen/
            respiratory status as well.
       r.   When a patient is transported to or from a medical facility, a demographic sheet, or
            “face sheet,” should be requested from the facility, and should be attached to the
            patient care report. If possible, get a copy of insurance card(s), front and back.
                 i. If unavailable, the patient’s full name, address, phone number, social
                     security number, and insurance information should be obtained if at all
                     possible, and recorded on the patient care report.
                ii. If a patient is flown from the scene before information has been obtained,
                     the receiving hospital should be contacted within 8 hours to request a
                     demographic sheet be faxed to the Service.

53. Run Audits – complete information regarding run audits is found in the CQI Plan. As
    part of the overall Continuous Quality Plan, run audits help identify concerns in patient
    care and documentation of care. Run audits are used as a means to improve patient care



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        documentation and patient care decisions, and should be recognized as a learning tool.
          a. Run audits are completed on a regular basis by the Medical Director and/or
             personnel appointed by the Medical Director.
          b. After an audit is complete, the report writer should review the audit and make
             comments as needed.
          c. Once all requirements of the audit findings are completed, the audit will be
             destroyed.

Section 10 – Special Situations

   54. Mandatory Reporting: All ambulance personnel are mandatory reporters for suspected
       cases of child abuse and dependent adult abuse. All personnel must renew training in
       mandatory reporting at least once every five years. When a person suspects child or
       dependent adult abuse, her or she should make a verbal report to the ER staff, and ER
       physician, then file a telephone report of the incident to the Department of Human
       Services, followed by a written report within 24 hours of the incident (or the first business
       day if on a weekend). See appendix H for a complete list of reportable events by Iowa
       Law, and for the proper forms to be used to report abuse. Sexual assault, rape, and
       dogbites are reportable to the receiving facility and/or law enforcement. Motor vehicle
       crashes must be reported to law enforcement.

   55. Law Enforcement: Back-up from law enforcement shall be requested on any call which
       by its nature may present an insecure or unsafe scene. (See Scene Safety, Section 5, #37)
       Cooperation with law enforcement is expected as long as patient care or patient / crew
       safety is not compromised. Patient information, including the written run report, shall not
       be given to law enforcement except for need-to-know information such as where the
       patient is being taken to, or the general impression of the scene. A subpoena is needed for
       the officer to receive patient information. This protects the rights of the patient, as well as
       the officer’s investigation.

   56. Rehab Services for Fire Department
         a. Emergency responder rehabilitation is designed to ensure that the physical and
            mental well being of members operating at the scene of an emergency don't
            deteriorate to the point where it affects the safety of any member.
         b. Fireground rehab is the term used for the care given to the emergency workers
            while performing their duties at an emergency scene.
         c. It includes monitoring of vital signs and lung sounds, rehydration and nourishment
            of workers and a place for workers to rest between assignments.
         d. When responding to structure fires with the fire department, EMS is requested to be
            available for rehab. Fire Department members’ records are in each ambulance and
            should be used to record and compare vital information.
         e. If a firefighter is found to have extremes in vital signs, the fire chief, or incident
            commander should be notified and a mutual decision made on whether the
            firefighter should continue to work the fire.




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57. Stand-By: There are times when the Ambulance Service is requested to respond in a
    “stand-by” status at specific events, some scheduled, and some unscheduled. Examples
    include football games, rodeo events, and fires.
       a. The ambulance should be parked north of the football field at the high school for
          stand-by purposes.
       b. The ambulance should parked in designated areas as specified by rodeo personnel
          for rodeo events.
       c. The ambulance should be parked in a safe area as requested by the Fire Chief or
          Incident Commander at other scenes.
       d. A stand-by form should be completed for all stand-by situations.
       e. A patient care report form should be completed for anyone transported from the
          scene.
       f. A refusal form should be completed for anyone treated but not transported. This
          report should receive a run number.
               i. If more than one patient is treated but not transported from the same event, a
                  patient number (A,B,C, etc.) should be added to the run number.
              ii. If a patient is transported from the event, and others are treated but not
                  transported, the transport will receive a separate run number.

58. Transport of Service Animals: The purpose of this policy is to provide guidance to EMS
    personnel who encounter individuals who are assisted by service animals, including guide
    dogs for the visually impaired and other types of service animals. However, because of
    the nature of the services we provide it can sometimes be difficult to accommodate a
    patient and a service animal in an ambulance. EMS personnel should be guided by this
    policy in determining whether service animals should be transported with the individual in
    the ambulance or wheelchair van, or whether alternate methods of transporting the service
    animal should be utilized. All Patients with Service Animals:

       a. Service animals, for example, guide dogs utilized by visually impaired persons,
          shall be permitted to accompany the patient in the ambulance or wheelchair van
          unless the presence of the service animal will disrupt emergency or urgent patient
          care or there is some basis for the crew members to believe that the safety of the
          crew, the patient or others would be compromised by the presence of the service
          animal in the ambulance or wheelchair van.

       b. EMS personnel should assess the level of care required to provide competent
          medical attention to the patient.

       c. When the presence of a service animal in the ambulance might interfere with patient
          care, jeopardize the safety of the crew, the patient or others, or cause damage to the
          ambulance or equipment, personnel should make other arrangements for
          simultaneous transport of the service animal to the receiving facility. Unless
          emergency conditions dictate otherwise, absolutely every effort must be made to
          reunite the patient with the service animal at the time of the patient’s arrival at the
          receiving facility or other destination.



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          d. Acceptable alternative methods of transporting a service animal to the receiving
             facility include, but are not necessarily limited to, family members, friends or
             neighbors of the patient, or a law enforcement official. Attempt to obtain and
             document the consent of the patient for transport of the service animal by such
             person. If no such individuals are available, contact the service base or PSAP and
             request that additional manpower respond to transport the service animal.

          e. Personnel should document on the patient care report instances where the patient
             utilizes a service animal, and should document on the patient care report whether or
             not the service animal was transported with the patient. If the service animal is not
             transported with the patient, a separate incident report should be maintained by the
             ambulance service describing the reasons that the service animal was not
             transported with the patient.


Section 11 – Benefits for Ambulance Personnel

   59. Pay: Lenox Ambulance crew are privileged to receive a stipend for ambulance calls, and
       for call shifts after meeting a minimum number of shifts for the fiscal year. See Appendix
       J for specific guidelines on personnel wages.
          a. Crew members are paid for runs made while on call, and other runs if the extra
              person was deemed necessary.
          b. New members running as a third person, for experience in the back with the patient,
              are not paid.
          c. Personnel running as students, for student requirements, are not paid.
          d. If no one is on call, and another transporting service arrives at a patient scene prior
              to Lenox personnel arriving, or at the same time, and Lenox personnel have not
              done an assessment or provided treatment for the patient, AND the patient is
              transported by the other service, this is not considered a run. No run report is
              necessary, and personnel are not paid.
          e. Paychecks are issued quarterly on the schedule of the City’s pay periods.

        Other Benefits that are available based on the “Service Participation-Based Benefits
        Chart, found in Appendix J:
                                a. IEMSA Membership.
                                b. Accidental Life Insurance (with low cost option for
                                   family/spouse)
                                c. Continuing Education as outlined in next section.
                                d. Upgrading to a higher level of EMS certification.

Section 12 – Education / Continuing Education

   60. Training costs: The ambulance service may reimburse training costs for new members,
       and continuing education costs for current members according to the Ambulance Board
       policies. See Appendix J for more details.




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61. It is the responsibility of each EMS provider to remain current in BLS certification at the
    Heatlhcare Provider Level (or its equivalent).

       a. Opportunities for renewal will be announced, but the provider is ultimately
          responsible for remaining current.
       b. Any member not current will be taken off the active roster until the member is
          current. Cost of the renewal will be paid by the service.

62. Renewal of EMS certification: EMS Certifications expire March 31 of each year. It is the
    responsibility of each member to 1) complete the required educational components for
    renewal, and 2) complete the application for renewal (which can be done on-line). Anyone
    whose certification expires will be taken off the active roster until the certification is
    current.

63. There are other educational requirements required both by the Bureau of EMS, and the
    Medical Director. The Ambulance Director will arrange for any special training, skills
    reviews, or in-services that need to be completed, but it is the individual EMS provider’s
    responsibility to attend the training or make arrangements to acquire the training at a
    different time. Examples include Mandatory Reporting, Bloodborne Pathogens, and
    requirements of Homeland Security programs.

64. Skills maintenance logs will be derived from the reporting software as much as possible.
    This is possible only if documentation on the run reports reflect the skills, what time they
    were done, whether successful, and who completed the skill. The Medical Director
    requires certain skills are routinely reviewed. Skills sessions to provide for these reviews
    will be scheduled.

65. The Service has equipment that can be utilized for training purposes, including CPR
    manikins. If a member wishes to use the manikins, he/she should “reserve” them by
    writing on the calendar how many of each “age” he/she needs on the dates they are
    needed. Training equipment should be cleaned after each use.




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