Fourth Quarter Report - Southwest Virginia EMS Council

Fourth Quarter Report
Fiscal Year Ended June 31, 2010
Southwest Virginia EMS Council, Inc.
1000 West Main Street
Abingdon, VA 24210
(276) 628-4151 PHONE
(276) 676-0800 FAX
southwest@vaems.org
www.southwest.vaems.org
Section 1: Meeting Agenda
BOARD OF DIRECTORS MEETING
6:30 P.M.—June 17, 2010
Southwest Virginia Higher Education Center, Abingdon, VA
PROPOSED AGENDA
I.
Call to Order
A. Approval of June 17, 2010 Meeting Agenda
B. Approval of March 18, 2010 Meeting Minutes
C. Approval of Financial Statements – 4th Quarter FY2010
II.
Reports and Action:
A. President and Executive Officers—Lonny Gay, President
B. Executive Director—Gregory Woods
1. Activity Report
2. Third Quarter FY 2010 Deliverable Report (OEMS)
3. OEMS 4th Quarter 2010 Quarterly Report
C. Regional Medical Director—Dr. Norman Rexrode/Dr. Paul
Phillips
D. EMS Advisory Board Representative—L.V. Pokey Harris
E. OEMS Program Representative(s)—Ron Kendrick/Paul
Fleenor
F. Committees
1. Training and Education
2. Public Information & Education
3. Performance Improvement
4. Critical Incident Stress Management Team
5. Communications & Transportation
6. Medical Direction Committee
7. Emergency Planning & Preparedness
III.
Public Comment
IV.
Unfinished Business
A. Vacant Board Positions
V.
New Business
A. Review/Revision of regional protocols
B. Review/Revision of hospital diversion plan
C. Personnel Issues
VI.
Adjournment
Section 2: Meeting Minutes
Southwest Virginia EMS Council, Inc.
Board of Directors
Southwest Virginia Higher Education Center
March 18, 2010
6:30 p.m.
Members Present:
Lonny Gay – President
J.C. Bolling – Vice-President
Maxie Skeen – Secretary
Delilah Long – Treasurer
Roger Burke
William Dub Ford
Dr. French Moore, Jr.
Pokey Harris
Freda Ayers
Lynn Weaks
Paul Phillips
Doug Testerman- Call In
Carol Barr
Dreama Chandler
Ron Kendrick
Topic/Subject
Call to Order
Approval of March 18, 2010
Meeting Agenda
Approval of December 17,
2009 Draft Minutes
Approval of Financial
Statements – 2rd Quarter 2010
Reports and Actions:
Members Absent:
Dr. Norman Rexrode
Earl Carter
Steve Wallace
Bryan Saunders
David Brash
Joe Roma
Dr. Gary Williams
Rhudy Keith
Jerry Bledsoe
Ronald Sexton
Rusty Osborne
Junior Keene
Ron Passmore
Todd Lagow
Charlie Smith
Staff:
Gregory Woods – Exe. Director
Theresa Kingsley – Lead Field Co.
Others:
Steve Harris
Discussion
Recommendations, Action/Followup; Responsible Person
The Treasurer, Delilah Long, called the meeting to order at 6:44 p.m.
A motion was made and carried to approve the March 18, 2010 meeting agenda as presented.
A motion was made and carried to approve the December 17, 2009 meeting minutes as presented.
A motion was made and carried to approve the Second Quarter 2010 financial statements as presented.
A.
President and
Executive Officers –
President, Lonny Gay, informed the Board of Directors that the Executive Officers had nothing to report
at this time.
B.
Executive Director-
Gregory Woods provided the Board with his report. He indicated that 2nd quarter feedback has not been
received, but he anticipates no deficiencies. He informed the Board that the Council is on track with all
the Contract Deliverables for the third quarter. Also, Mr. Woods discussed the Non-Contract Items –
EMS Council Designation, 3rd Annual EMS and Fire Symposium and the Office Relocation.
1
Topic/Subject
Discussion
C.
Regional Medical
Director
Dr. Norman Rexrode was absent from the meeting but Dr. Paul Phillips reported that the Regional
Medical Directors continues to work on updating protocols and drug box wish list for the southwest
region.
D.
EMS Advisory Board
Representative
Pokey Harris discussed with the Board of Directors the EMS System Funding, the Governor’s proposal
to reallocate EMS funding to the State Police, and the Amendments that saved the funding. Also, she
informed the Board that she was unable to attend the EMS Advisory Board meeting due to her job
obligations and that FARC will be testing a new VETA grading system.
E.
OEMS Program
Representative(s)
Ron Kendrick informed the Board that this region had no enforcement actions to report. Also, he
informed the Board that the Roll Out of the VPHIB will need a lot of assistance.
F.
Committees
1.
Training and
Education
Theresa Kingsley discussed with the Board all the training opportunities in the region and that this
committee continues to work to provide the region with the most update training possible.
2.
Public
Information and
Education
Mr. Woods informed the Board of the EMS Regional Awards program and asked for assistance in
advertising the program and getting nominations. Deadline will be May 7.
3.
Performance
Improvement
The Committee is scheduled to meet next week.
4.
Critical Incident
Stress
Management
Team
No report was given due to Clinical Coordinator Charlie Smith’s absence.
5.
Communications
& Transportation
RSAF reviews will likely be held on April 15, which is the regular date of the Executive Committee
meeting, depending on the number of applications received.
6.
Medical
Direction
Committee
The Committee did not meet this quarter.
7.
Emergency
Planning &
Preparedness
The Committee did not meet this quarter.
Recommendations, Action/Followup; Responsible Person
2
Topic/Subject
III. Public Comment
IV. Unfinished Business
V. New Business
A. Election of Board of
Directors
B. Review/Revision of
Regional Plans
1. Strategic EMS Plan
2. WMD/MCI Plan
3. Medication and EMS
Supplies/Medication Kit
Exchange
VI. Other
Adjournment
Discussion
Recommendations, Action/Followup; Responsible Person
No public comment was given.
A motion was made to appoint Lynn Meaks and David Brash to the vacant Hospital Administrator
director positions. The motion was approved. The PD-2 at large position and emergency nurse position
will be voted on at the next meeting.
Woods reviewed the three plans due this quarter. Staff member Theresa Kingsley had contacted Jim
Nogle at OEMS concerning the WMD/MCI Plan that was revised during the fourth quarter 2009 to see
if any items needed to be changed and if the format was acceptable. No comments were received from
OEMS. Woods commented that the EMS Kit and Supplies restocking programs within the region are
unchanged, but with protocol revisions it is likely that changes will be made. A motion was made to
accept these two plans as presented without any changes. The motion carried.
Woods discussed the regional EMS plan that had been distributed with the meeting notice. The floor
was opened to discuss changes to the plan and/or the SWOT analysis conducted earlier. Minor changes
were made to the SWOT analysis. A motion was made to approve the Strategic Plan with suggested
changes to the SWOT. The motion carried. A motion was made to schedule future separate work
sessions for more detailed planning. The motion carried.
No other business was discussed.
The meeting adjourned at 6:44 p.m.
3
Section 3: Financial Reports
11:24 AM
Southwest Virginia EMS Council, Inc.
06/15/10
Profit & Loss
April 1 through June 15, 2010
Accrual Basis
Apr 1 - Jun 15, 10
Ordinary Income/Expense
Income
401 · Interest Income
420 · Contributions-Local Government
430 · Contributions-Other
445 · State Inc-Consolidated Testing
447 · Other Inc.-Consolidated Testing
450 · State Operating Income
472 · State Training Inc.-ALS
475 · Training Inc.-Registration Fees
480 · Training Income-Textbooks
485 · United Way Revenue
Total Income
Gross Profit
Expense
501 · Salaries & Wages
505 · Fringe Benefits
506 · Rent-Office
508 · Telephone
510 · Supplies
511 · Equipment Purchased
512 · Travel
514 · Other Training Expense
516 · Training Expense-ALS
520 · Repairs & Main-Svc. Contracts
521 · Insurance
522 · Subscriptions/Dues
526 · Payroll Taxes
527 · Miscellaneous Expense
533 · Cell Phone
545 · Bank/Card Fees
550 · Consolid. Test Expense
800 · Paramedic Expenses
801 · Paramedic Supplies
802 · Misc. Expense
800 · Paramedic Expenses - Other
Total 800 · Paramedic Expenses
1.57
1,260.00
100.00
1,555.00
2,130.00
70,984.94
1,890.00
5,552.10
164.50
575.00
84,213.11
84,213.11
44,815.05
112.12
2,000.00
452.61
123.62
125.76
314.69
8,896.99
7,620.00
105.00
586.00
675.00
3,428.38
-431.01
742.62
13.06
4,275.00
12,081.65
2,059.50
-7,240.00
6,901.15
Total Expense
80,756.04
Net Ordinary Income
3,457.07
Net Income
3,457.07
Section 4: 3rd Quarter Deliverables Feedback
Virginia Office of EMS Subcontractor Deliverables Review Form
Subcontractor Agency:
Southwest Virginia EMS Council
Contract Quarter:
Third Quarter FY 2010 Contract
Contract Deliverable
Meets Deliverable
Comments
Section III A – Regional Infrastructure
Yes
No
N/A
None reported in Quarterly Report
Position Vacancy
Documentation & Reporting
Yes
No
N/A
Quarterly Report
Posted to LN
Yes
No
N/A
Minutes of Board Meeting
Mar minutes posted to LN
Yes
No
N/A
Minutes of Subcommittee Meetings
Posted to LN
Yes
No
N/A
Quarterly Financial Statements
Posted to LN
Fees For Service
Yes
No
N/A
Reported in Quarterly Report
State Committee Responsibilities
Yes
No
N/A
Reported in Quarterly Report
Section III B – Regional Medical Direction
Regional Medication & Supplies Exchange
Yes
No
N/A
Posted to LN
Program
Regional Medication Kit Exchange Program
Yes
No
N/A
Posted to LN
Section III C – Regional Planning
Regional EMS Plan
Yes
No
N/A
Posted to LN
Yes
No
N/A
Review of mandates
Yes
No
N/A
SWOT Analysis
Yes
No
N/A
Planning Committee
Yes
No
N/A
Mission Statement
Yes
No
N/A
4 Core Strategies/Initiatives
Yes
No
N/A
Documented review by Board/Cmte.
Reported in Quarterly Report
Yes
No
N/A
Post to web
Reported in Quarterly Report
Yes
No
N/A
Distribution of Plan
Reported in Quarterly Report to be
th
completed in 4 quarter.
Regional MCI Plan
Yes
No
N/A
Posted to LN
Pandemic & Continuity of Operations Planning
Yes
No
N/A
Proof of assistance to agencies related to
Reported in Quarterly Report
pandemic planning, conduit of information related
to pandemic event.
Section III D – Regional Coordination
Regional Information & Referral
Yes
No
N/A
Proof of assistance regarding EMS issues.
Reported in Quarterly Report
Yes
No
N/A
Maintain an interactive website
Reported in Quarterly Report
Regional PI Program
Yes
No
N/A
Agenda/Mins/Rosters of PI Mtgs.
Posted to LN
No
N/A
Yes
Reported in Quarterly Report
Technical Asst. Provided
Regional TPI Program
No
N/A
Yes
Agenda/Mins/Rosters of PI Mtgs.
Posted to LN
No
N/A
Yes
Reported in Quarterly Report
Technical Asst. Provided
RSAF Grant Program (All Items)
Yes
No
N/A
Reported in Quarterly Report
Regional EMS Instructor Network
Yes
No
N/A
Extension requested & granted
Agenda/Mins/Rosters of Meetings
Section III E – BLS CTS Administration
Yes
No
N/A
Submit CTS Schedule to OEMS
Reported in Quarterly Report
Yes
No
N/A
Publish CTS Schedule to Web
Reported in Quarterly Report
Yes
No
N/A
Distribute CTS Schedule to Instructors
Reported in Quarterly Report
Section III F – Regional Category 1 CE Program
No contract requirements for 3rd quarter.
Section 5: 4th Quarter Report
Regional Council Quarterly Reporting
As based on the Scope of Services contract between each Regional EMS Council in the Commonwealth
of Virginia, and the Virginia Department of Health, Office of Emergency Medical Services, each
Regional EMS Council is required to submit a Program Report, reflecting progress on the annual work
plan.
For the remaining quarterly reports for the 2010 Contract Year, the following format will be followed,
regardless of the method of reporting (Lotus Notes, e-mail, hard copy):
The following items will be reported upon, in the following order:
A. Regional Infrastructure
1. Regional EMS Council Office Hours
The Southwest Virginia EMS Council maintains a business office currently at 1000 West Main Street,
Abingdon, VA. The office is open Monday-Friday, 9:00 a.m. through 5:00 p.m.
2. Continuity of Operations Plan (COOP)
A Continuity of Operations Plan was developed in FY2008 in accordance with Council’s contract with
OEMS and remains in effect. The plan was, reviewed, revised, and approved by our Board of Directors
at their December 2009 meeting.
3. Employee Qualifications and Performance
Copies of position descriptions for all positions funded by the Office of EMS were included in the
first quarter report.
a. Position Title
b. Responsibilities/Duties
c. Number of hours per week worked
d. Percentage of work time allocated to contractual duties
e. Line of Supervision
f. Education/Training Requirements
g. Work Experience/Qualifications
4. Notification of position vacancy.
The Office of Emergency Medical Services was advised that Administrative Assistant Kathy White is no
longer employed by the Southwest Virginia EMS Council. The position will be filled within the next 90
days.
5. Organizational Information
Organizational information was submitted with the first quarter report including:
a. Agency wide organizational chart, including all employees/staff.
b. Names of all the members of the Board of Directors
c. List of Board Members paid through contract funds (not applicable).
d. Disclosure of board members, employees and/or staff relationships with service or entity
regulated by OEMS
6. Documentation and Reporting
a. Inclusion of appropriate parties in mailings
The OEMS EMS Systems Planner and regional Program Representatives are included in all
electronic correspondence sent from the Council to EMS agencies, providers, hospitals, or
localities within the service area. The Council has been asked not to include OEMS staff in
postal mailings and to reduce postal mailings to reduce costs and environmental impact.
b. Annual financial report by 12/31
This item is not required to be reported this quarter. The Council has contracted with SS &
Company, CPA, to conduct our yearly financial audit. The completed financial report was
provided to OEMS on December 29, 2009.
c. Program reports
Program reports are developed quarterly and submitted to OEMS no later than 30 days after the
last day of each quarter.
d. Final annual report
A final annual report was approved by the Executive Committee of the Board of Directors at
their January 28, 2010 meeting and included with the second quarter report.
e. Meeting minutes
Final approved minutes from every meeting of the governing board and committees will be
posted to the Council website within 30 days. OEMS will be provided meeting minutes using the
OEMS computer system “Lotus Notes” in the appropriate quarterly report.
f. Roster of all subcommittee members
A current roster of all committees was updated in September 2009 using the OEMS computer
system “Lotus Notes.” Committee structure will be updated quarterly as needed.
g. Regional policies, bylaws, procedures and protocols
Current regional policies, by-laws, procedures and protocols were submitted in the second
quarter report.
h. Three copies of educational materials purchased with state funds
Any information or educational materials developed in whole or in part with state funds will be
identified and copies provided. No such materials were developed this quarter.
i. Financial statements of revenue and expenditures
A quarterly financial statement is included in this report as Attachment A.
7. Fees
The Council charges a $50 registration fee for all candidates completing initial practical testing
at a regional Consolidated Test Site and $25 for retests.
8. State Committee Responsibilities
a. Directors Committee
b. Advisory Board
c. Assigned committees
Advisory Board representative Pokey Harris attended the EMS Advisory Board meeting on
May 14, 2010. Lead Field Coordinator Theresa Kingsley attended the FARC review meetings
on June 3 and 4. Executive Director Woods was unable to attend the RDG and Advisory
Board meetings due to his wife’s college graduation.
B. Regional Medical Direction
1. Regional Medical Director
a. Scope of Services
The Scope of Services was submitted to OEMS on July 1, 2008. This was a two-year agreement.
b. Signed contract
A two-year RMD contract was submitted electronically and via hard copy to OEMS on July 1,
2008. Secondary RMD contract with Dr. Paul Phillips was submitted with the first quarter report.
c. RMD compliance with Virginia EMS Regulations
The RMD complies with the Virginia EMS Regulations.
2. Regional Medical Protocols
Ongoing reviews of regional patient care protocols have been conducted throughout the fiscal
year. The Medical Direction Committee last met on May 27 and approved several changes to
regional medical protocols including the addition of specific triage protocols in the beginning
section and referral to the appropriate ACLS cardiac protocol instead of insertion of a region
protocol. These changes are included in this report as Attachment C. Realizing that AHA
guidelines will change in the near future, it is anticipated that further changes will occur at that
time as well. The protocol revisions were approved at the June 17, 2010 Board of Directors
meeting, and the changes were distributed electronically to all licensed EMS agencies and OMDs.
Protocols are available for download on the Council’s interactive website.
a. Revision of BLS and ALS medical protocols, post to website, proof of approval by Board.
b. Electronic copies of protocol revisions to OEMS
c. Proof of notification of protocol posting to regional stakeholders
d. Proof of distribution of Protocols to stakeholders and OEMS
3. Regional Medication and EMS Supplies Restocking Program
This item was reported in the Third Quarter. The Regional medication and EMS supplies
restocking plan was reviewed by the Board of Directors at their March 18 meeting. Due to
ongoing protocol revisions and possible impact on medication, no changes were recommended at
this time.
a. Update and revise medication and supplies restocking plan.
b. Provide OEMS with copy of plan, and supporting documentation of approval by Board.
4. Regional Medication Kit Exchange Program
This item was reported in the Third Quarter Report. The Regional medication kit exchange
program was reviewed by the Board of Directors at their March 18 meeting. Due to ongoing
protocol revisions and possible impact on medication kit contents, no changes were recommended
at this time.
a. Review, revise and coordinate exchange program for hospitals and agencies.
b. Provide OEMS with copy of plan, and supporting documentation of approval by Board
C. Regional Planning
1. Regional EMS Plan
This item was reported in the Third Quarter Report. A survey related to regional EMS system
strategic planning was distributed to EMS agencies and local governments as part of the
comprehensive review process. The Council Board of Directors reviewed feedback from the
survey at their March 18 meeting and discussed changes. The previous SWOT analysis was
reviewed, and changes to that analysis were made. The plan was approved with these changes.
a. Review and revise the Regional Strategic EMS Plan by 2/1.
1. Review of council mandates (Code of Virginia)
2. SWOT Analysis
3. Planning Committee work to vision for region.
4. Mission Statement
5. Core strategies, with strategic initiatives
6. If no changes, proof of review and approval of existing plan by Board.
b. Provide OEMS with copy of plan
c. Proof of notification of plan posting to web to regional stakeholders.
d. Proof of distribution of plan to stakeholders and OEMS.
2. Trauma Triage Plan (TTP)
This item was reported in the Second Quarter report. The trauma-triage plan was approved
by the Board of Directors at their December meeting and submitted with the second quarter
report. The plan was posted to the Council website and agencies notified of its posting.
a. Triennial review of TTP
b. Committee Composition
c. Submission of TTP to OEMS
d. Proof of notification of plan posting to web to regional stakeholders.
3. Regional MCI Plan
This item was reported in the Third Quarter Report. The MCI plan underwent comprehensive
revisions during the 2009 contract year. The revised plan was approved at the Board of Director
June 2009 meeting. OEMS Emergency Operations manager Jim Nogle was contacted by Council
staff for recommended updates. No suggestions were received from OEMS. Due to the recent and
extensive revision, the Board of Directors recommended no changes and approved the plan at
their March 18 meeting.
a. Option chosen by respective council.
a1. Primary – responsible for all aspects of plan – facilitates participation in review
process among stakeholders.
a2. Secondary – Shared partnership with other entity
a3. Attendance – no responsibility – collects and shares information.
b. Copies of agendas, attendance records, minutes and other documentation as proof of
participation and accomplishments.
c. Provide OEMS with copy of plan, and supporting documentation of approval by Board.
d. Proof of notification of plan posting to web to regional stakeholders.
e. Proof of distribution of plan to stakeholders and OEMS.
4. Hospital Diversion Plan
The Hospital Diversion Plan was reviewed during the fourth quarter. The draft plan was
submitted to EMS agencies and hospitals for review. A brief survey was created and a link sent
to stakeholders to foster involvement and feedback. The Board of Directors reviewed and
approved the draft plan at their June 17 meeting. The approved plan is included in Attachment
C.
a. Review/revise hospital diversion plan
b. Provide OEMS with copy of plan, and supporting documentation of approval by Board.
c. Notification of plan posting to web to regional stakeholders by 6/1.
d. Proof of notification of plan posting to web to regional stakeholders.
e. Proof of distribution of plan to stakeholders and OEMS.
5. Surge Capacity Plan
Council staff members routinely attend meetings of the Far Southwest Hospital Preparedness
Alliance. The Council was notified of no meetings of the group this quarter. No event required
activation of the EMS MCI plan or Regional Surge Plan this quarter; therefore, no after action
reports were required.
a. Provide OEMS with copy of plan, & documentation of participation in plan development, and
an after action report in event of activation of MCI or Surge Plan.
6. Pandemic and Continuity of Operations Planning
The Council has established and publicized a link on its website to information concerning
H1N1. The link also offers to assist EMS agencies with H1N1 planning activities. The Council
has acted as an information conduit distributing information from the VDH and OEMS
concerning H1N1 planning and preparedness activities. Council staff members are available to
assist agencies with planning activities, but no requests for assistance were received this
quarter. The Council distributed N95 fit test training session information to EMS stakeholders
via our listserv. In addition, fit test sessions are planned during the months of June and July.
a. Evidence of assistance to EMS Agencies in developing plan of action for H1N1, reporting of
unmet needs, planning activities, incidents and responses (if applicable). Evidence of assistance
to EMS agencies in developing plan/procedure for continuation of operations in the event of a
reduction or cessation of activities by that EMS agency.
D. Regional Coordination
1. Regional Information and Referral
a. Evidence of assistance regarding EMS issues to stakeholders.
The Council provides assistance to EMS agencies, providers, and stakeholders daily upon request.
Assistance is provided via telephone, email, or in person.
b. Maintaining website, posting of documents as required in the contract.
The Council maintains an interactive website that is updated routinely.
2. Regional PI Program
a. Develop/Revise/Maintain Regional PI Plan (PIP).
The regional Performance Improvement Committee met on September 17 and made revisions to
the EMS PI Plan. The plan and template (unchanged) were approved by the Board of Directors
on September 17. The plan is posted on the Council’s website and was distributed to EMS
agencies.
PIP Includes:
1. PI Program outline development
2. Schedule and Topics
3. Method of reporting significant events, including action plan, and resolution
plan.
4. PIP includes regional PI committee membership, objectives and rules of
committee meetings.
b. Coordination of PI program
The regional PI Template was approved by OEMS during the FY2008. The template was
reviewed by the PI committee as part of the EMS PI plan revision process and approved by the
Board of Directors at their September 17 meeting. Performance indicators for the year were
defined as outlined in the plan. Quarterly PI Tracking forms and topics were distributed to EMS
agencies in June 2009 and upon any changes. A PI Referral Form is included in the PI Plan
(which was distributed to EMS agencies) and is available from the Performance Improvement
section of the Council’s website. An agency address list was included in the second quarter
report.
1. Development of regional PI template, including:
a. Schedule and Topics
b. Method of submitting quarterly PI project results to committee.
c. Method of reporting significant events to regional PI committee.
c. Evidence of provision of technical assistance to agencies to comply with State regs related to
reporting. Encourage all agencies to submit data for regional PI initiatives, and to meet
requirements.
Reminders of Quarterly PI submission and data submission forms are placed on the Council’s
website and distributed via email. Technical assistance is provided as needed. Field
Coordinator Bryan Kimberlin assisted Glade Spring Lifesaving Crew, St. Charles Fire Rescue,
Washington County Fire Rescue, Damascus Rescue, Highlands Ambulance Svc., and Lifecare
Medical Transports with regional PI submission. Executive Director Woods assisted
Independence Rescue, Washington County Lifesaving Crew, and Carroll Co. EMS with regional
PI submission.
d. Conduct quarterly regional PI specific meetings, as defined in regional PI plans.
The regional Performance Improvement Committee met on ________________, with the
purpose of reviewing regional PI data and King Airway data received for the second quarter
2010. A quorum was not present to conduct business. __ EMS agencies submitted PI data.
Meeting documents are submitted as Attachment B. Due to attendance issues, a second meeting
will be scheduled, and the committee will be restructured to eliminate members who have not
actively participated in the PI process.
1. Committee should review findings of agency PI programs, and address
significant events.
2. Develop action plans to improve identified issues (e.g. training specific to
issue).
3. Develop a method of evaluating an action plan.
4. Demonstrate resolution of identified issues.
e. Submission of PI items for FY 10:
Meeting documents are included in this report in Attachment B. The next regularly scheduled
meeting of the PI Committee will be _______________ subject to change.
1. Agenda, rosters of attendees, and minutes for all quarterly PI meetings.
2. Copy of the PIP
3. Copy of the template PIP plan provided to EMS Agencies in the region.
4. Evidence of EMS Agency involvement in the PIP.
a. If agenda and minutes of meetings don’t reflect ID of PI issues, then evidence
of plans to correct the issues and resolution shall be submitted.
3. Regional Trauma Performance Improvement (TPI) Program
Meeting documents and the approved plan is submitted as Attachment E.
a. Develop/revise/maintain region wide TPI Plan (TPIP) for trauma related responses. Plan to
include the following:
The regional Trauma Performance Improvement Committee met on September 17 and made
revisions to the Trauma PI Plan. Performance indicators for the year were defined as outlined
in the plan. The plan and template (unchanged) were approved by the Board of Directors on
September 17. The plan is posted on the Council’s website and was distributed to EMS agencies.
1. Outline of organized TPI program to examine triage and care of trauma patients,
including:
a. Monitoring/assessing adherence to patient care protocols
b. Monitoring/assessing compliance with trauma triage plans.
c. Monitoring/assessing system issues
d. Identifying educational needs
e. Identifying methods of resolving issues
f. Report how identified issues were resolved or improved.
2. Schedule and topics for quarterly region wide PI project to be conducted by
contractor and individual EMS agencies
3. PI based method of reporting trauma related significant events. Includes method of
reporting to TPI committee, method of developing an action plan, and a method of
resolving the event.
4. TPIP to include the regional TPI committee membership, objectives of the committee
and rules for participation in meetings. Committee composition should include
representation from OMD’s, designated trauma centers, non-designated hospitals and
a diverse representation of EMS agencies in the region.
b. Coordinate a TPI program.
The regional PI Template was approved by OEMS during the FY2008. The template was
reviewed by the TPI committee as part of the EMS TPI plan revision process and approved by
the Board of Directors at their September 17 meeting. Performance indicators for the year were
defined as outlined in the plan. Quarterly PI Tracking forms and topics were distributed to EMS
agencies in June 2009 and will be distributed again in October 2009. A PI Referral Form is
included in the PI Plan (which was distributed to EMS agencies) and is available from the
Performance Improvement section of the Council’s website.
1. Develop and distribute a TPI template for agencies to use to establish or maintain
their own PI programs for trauma responses with OEMS approval for template.
Template includes:
a. Schedule and topic for TPI project each quarter
b. Method to submit quarterly results to regional TPI committee
c. Method of reporting significant events to TPI committee
c. Provide technical assistance to agencies to comply with State regs related to QI reporting.
Encourage all agencies to submit data for regional PI initiatives, and to meet
requirements.
d. Conduct quarterly TPI specific meeting, as defined in TPI
The regional TPI Committee met on _______________, with the purpose of reviewing regional
TPI data and King Airway data received for the second quarter 2010. A quorum was not present
to conduct business. __EMS agencies submitted TPI data. Meeting documents are submitted as
Attachment B. Due to attendance issues, a second meeting will be scheduled, and the committee
will be restructured to eliminate members who have not actively participated in the PI process.
1. Regional TPI committee should review the findings of individual agency trauma
related PI programs, as well as address any significant events that have occurred.
2. Develop action plans to improve identified issues
3. Develop method of evaluating action plan
4. Demonstrate resolution of identified issues.
e. Submission of TPI related items:
Meeting documents are included in this report in Attachment B. The next regularly scheduled
meeting of the TPI Committee will be ________________.
1. Agenda, rosters of attendees, and minutes for all quarterly TPI meetings.
2. Copy of the TPIP
3. Copy of the template TPIP plan provided to EMS Agencies in the region.
4. Evidence of EMS Agency involvement in the TPIP.
a. If agenda and minutes of meetings don’t reflect ID of TPI issues, then evidence
of plans to correct the issues and resolution shall be submitted.
f. Regional PI/TPI may be addressed by the separate or combined committees.
4. RSAF Program
a. Promote grant writing and review assistance services to agencies one month prior to
submission deadline with electronic/hard copy notifications. Assist agencies to review and
write RSAF grant applications upon request, and request assistance from grants administrator
when appropriate.
Notices of the upcoming RSAF cycle deadline and offers of assistance were distributed by mail
to all EMS agencies in the region in February 2010. Notices were also placed on the Council
website and distributed via email. A regional Grant Review meeting was held on April 15, 2010,
at the American Red Cross building in Bristol, VA. The committee ranked the top grant requests,
and the committee recommendations were approved by the Executive Committee of the Board of
Directors. Grades and rankings were submitted to OEMS on April 25.
b. Promote services to assist agencies to submit grants electronically.
Notice of the upcoming grant cycle and assistance offered by the Council was mailed to EMS
agencies in February 2010, with additional notices being sent via our email distribution list and
posted on our website on February 15.
c. Conduct regional reviews and grading of grants as per regulations and policies governing the
RSAF program.
1. Conduct two review and grading sessions during the contract period, and submit
grades
2. Notify submitting agencies of review meeting time and agenda
a. Meeting is open to public
Grant reviews were held on April 15, 2010, at the American Red Cross in Bristol, VA.
b. Minutes recorded and kept on file for 5 years.
3. Ensure that each application is reviewed consistently by grant review committee and
assigned grade, using OEMS criteria.
4. Rank no less than top 3 applications in order of priority for each regional council area,
and submit by e-mail to grants administrator.
Grades, comments, and regional priorities were submitted to OEMS on April 25, 2010.
Theresa Kingsley attended RSAF review meeting in Richmond on June 3-4. Advisory Board
member Pokey Harris represents our region on that committee and attended meetings on
those dates as well.
5. CISM Program
a. Maintain an OEMS accredited regional CISM team as per policy manual guidelines by 10/1
The CISM Team regular meeting was held on June 22, 2010. Meeting minutes are included in
Attachment B.
b. Statistical reports:
1. 1/1 to 6/30 to OEMS by 7/31
No statistical reports were required to be submitted during this quarter. The Team held a
quarterly meeting on March 23, 2010.
2. 7/1 to 12/31 to OEMS by 1/31
c. Updated CISM team operating policy to OEMS by 10/1, using OEMS approved template.
The CISM Team met on September 22, 2009 and reviewed the team operating guidelines. The
revised CISM Team Operating Policy and draft minutes were submitted with the 1st Quarter
report.
6. Regional EMS Awards Program
a. Conduct Regional EMS Awards Program
Notice of the 2010 Awards Program was distributed by mail during February 2010. Notice of
the awards nomination deadline was posted on the website along with a web-based
submission form, and email reminders are being distributed. The anticipated nomination
deadline, subject to change, is May 7 with the awards banquet being held in July.
1. Title is Southwest Virginia EMS Awards Program.
2. Regional Awards Program has same 11 categories and criteria as Governor’s Awards,
including scholarship.
3. Use of OEMS nomination form.
4. Schedule and publicize the awards program.
5. Award to each first place winner.
b. Assure that regional nominations are judged and forward first place winners information to
OEMS by 8/2.
Regional nominations will be judged and submitted to OEMS by 8/2.
1. Appoint a committee to select regional winners.
2. Provide information to Advisory Board Selection Committee.
3. Submit news release to local media and OEMS within one week of ceremony, using
format provided by OEMS.
7. Regional EMS Instructor Network
A request to extend this item into the fourth quarter in order to allow us to incorporate
review/discussion/demo of the new state online CTS registration system was made to OEMS. Tim
Perkins approved this request. Instructor meetings are scheduled for day and evening on June 30,
and EMS stakeholders and instructors have been notified of these meeting dates.
a. Conduct a minimum of two meetings to discuss educational performance improvement, issues
surrounding educational aspect of training, instructor administrative requirements, and CTS
concerns.
b. Notify all EMT instructors, ALS Coordinators, OEMS DED Staff, OEMS Program Reps, and
Emergency Operations Instructors of the meetings. Meeting notice distribution 20 days prior
with agenda.
c. Meeting should be set up for face to face networking, but shall be conducted in a format
allowing for feedback.
d. Agenda, roster and minutes to OEMS
E. BLS-CTS Administration
This item was reported in the second quarter report. The Council has established six
consolidated testing facilities within our serve delivery area which have been approved by
OEMS. The CTS consolidated testing schedule was submitted to OEMS on January 27 and was
approved by OEMS Program Representative Ron Kendrick. The Schedule was published on our
website in February 2010. A copy of the testing schedule was distributed to all EMT-Instructors
the beginning of March 2010. CTS registration is conducted by staff as needed.
1. Establish at least one OEMS approved CTS facility within its service delivery area.
2. CTS schedule for FY 11.
3. Publish CTS schedule on web.
4. Provide CTS schedule to EMT-Instructors.
5. Register testing candidates.
6. Ensure CTS Evaluator compliance with P&P Manual
7. Maintain list of current approved CTS Evaluators, and submit to OEMS
8. Fee for initial testing.
9. Fee for retest.
10. No fees for written examination
11. Adherence to guidelines of CTS P&P Manual
F. Regional Category One CE Program
The council promotes BLS and ALS Continuing Education opportunities on our website and
through email distribution. The Council coordinates multiple ALS and BLS training programs
each year to satisfy category 1 CE requirements. A current schedule of CE programs was posted
to our website on July 1, 2009.
1. Promote ALS and BLS CE that satisfies Category 1 requirements in each planning district.
2. Submit the website address of the CE program schedule within region.
Section 6: Patient Care Protocols
Section 7: Diversion Plan
Southwest Virginia EMS Council
Ambulance Diversion Plan FY2010
Southwest Virginia EMS Council
1000 West Main Street
Abingdon, Virginia 24210
(276) 628-4151
www.southwest.vaems.org
REVISED JUNE 2010
A. PURPOSE:
This policy is intended to provide guidance for EMS agencies in
the Southwest region resulting from hospital diversions. A goal of this policy is to insure
the prompt and efficient delivery of emergency medical care to the citizens of this region
in a manner that prevents unnecessary delays and/or overburdening of portions of the
system when EMS services and/or hospitals are temporarily overwhelmed with patient
volume. Patient care, safety, and outcome will be the central consideration in all
diversion decisions.
B. SCOPE:
This policy pertains to all acute care hospitals and all licensed
EMS agencies as defined in Virginia Department of Health regulations. The policy will
have the highest impact on the hospitals and agencies of planning district 1, planning
district 2, and planning district 3; however, it is recognized that diversion status of the
hospitals within these areas can have a significant impact on neighboring hospitals in
surrounding areas and states.
C. POLICY ELEMENTS:
1. INDICATIONS: Acute care hospitals (those with emergency departments)
occasionally become overwhelmed by excessive patient volume, which exceeds
the capacity for medical staff to adequately treat and monitor patients. This may
be due to a lack of hospital resources, inability to provide patient specific
services, or a shortage of qualified healthcare providers. To alleviate this
temporary situation and insure optimal care for all patients, a receiving hospital—
after completing a process established by the medical facility—may declare a
diversion of acute patients, whereby ambulances are diverted to other area
hospitals.
a) Diversion criteria should be based on the defined capacities or
services of the hospital.
b) When the entire healthcare system is overloaded, all hospitals should
open. When all area trauma centers are on total/ED divert, all
trauma centers should be re-opened.
c) Divert status should be declared only after the hospital has exhausted
all internal resources to meet the current patient load, including any
necessary call-backs of staff, step-downs, expedited discharges,
opening of "virtual" beds, and similar mechanisms to address the
patient load.
d) Hospital diversions should not be based on financial decisions.
Hospitals should not go on divert status to hold available bed space
for anticipated elective admissions or withhold call-backs or delay
opening additional resources due to cost considerations. While on
diversion, hospitals must make every attempt to maximize bed space,
screen and defer elective admissions or procedure, and use all
SVEMS Hospital Diversion Plan Page 2—Revised June 2010
available personnel and facility resources to minimize the length of
divert status. Hospital medical staff will cooperate in promptly
assessing all current admissions for appropriate early discharge.
e) Diversion is temporary and the hospital must return to open status as
quickly as possible
2. CONTRAINDICATIONS:
a) Final determination of the patient’s destination must rest with the
provider actually caring for the patient. Emergency Medical
Technicians may by-pass the hospital on diversion and transport to
the next closest facility that is staffed and equipped to receive the
patient if, in the judgment of the EMT, the patient is stable to the
extent that extra transport time will not negatively impact or cause
harm to the patient. If uncertain as to the stability of the patient, an
EMT may seek advice from the on-line medical control physician.
b) Unstable patients and/or patients with airway obstruction,
uncontrollable airway, uncontrollable bleeding, shock, who are in
extremis, or with CPR in progress should be taken immediately to
the closest appropriate hospital without regard to the hospital’s
diversion status. Under no circumstances should an ambulance with
a cardiac arrest patient be diverted from the closest facility.
c) An EMS provider who believes acute decompensation is likely to
occur if the patient is diverted to a more distant hospital ALWAYS
has the option to take the patient to the closest Emergency
Department regardless of the diversion status. The Attendant-inCharge also has the option to ask via radio or phone to speak directly
to an Emergency Department Physician and request online medical
direction in determining the most appropriate receiving facility.
Good clinical sense and optimal patient care are the ultimate
considerations.
d) Prehospital EMS providers may disregard diversion if there are
significant weather/traffic delays or if experiencing a mechanical
problem.
e) Certain hospitals and EMS agencies may have internal
policies/agreements that supersede diversion status. These policies
should be in writing and provided to all affected EMS agencies. The
EMS agency should contact their primary transport hospital(s) to
determine what internal policies concerning diversion exist.
SVEMS Hospital Diversion Plan Page 3—Revised June 2010
f) An agency may also disregard diversion in order to insure that a
locality does not have a lapse in public safety availability.
g) When a mass casualty incident has occurred and overwhelms the
entire EMS system, possibly resulting in multiple diversions of local
healthcare facilities, EMS agencies should disregard diversion status
and transport to the closest appropriate facility.
Decisions to disregard a hospital’s diversion status may be referred for
review by the Regional Medical Direction committee and the provider’s
agency by the receiving hospital.
3. LEGAL RESTRICTIONS: When following these guidelines for the direction
of patients during periods of diversion, it is recognized that hospitals within the
region are regulated by state and federal laws and regulations regarding care and
transport of patients including the federal EMTALA law that may not be modified
by this policy. Specifically, this policy does not modify the obligation of
hospitals to comply with one or more of the following EMTALA requirements:
a) Hospital-owned ambulances/air medical services are required to
transport from the scene of an accident, injury or illness to the
hospital which owns the ambulance unless operating under a central
community plan for ambulance destinations that determine the
destination hospital for the patient in the field or unless the patient or
person acting on behalf of the patient formally requests transport to
another destination.
b) Hospital-owned ambulances/air medical services may not be
diverted by their home hospital.
c) Once a patient presents on the campus (as defined by EMTALA) the
hospital may not divert the ambulance or refuse the patient
regardless of diversion status.
d) Hospitals are required to accept transfers of patients under EMTALA
when they possess greater capabilities than the hospital seeking to
transfer the patient and the requested destination has available space
and personnel or the capability of providing care, even if that
exceeds licensed beds. Beds may not be held open for anticipated
elective admissions or contingent in-house use. All unassigned beds
are deemed available.
e) Once a patient presents to a hospital via EMS or other means seeking
emergency evaluation and care, the hospital is required to provide
care and appropriate documentation within its capabilities, including
SVEMS Hospital Diversion Plan Page 4—Revised June 2010
medical screening, additional care, stabilizing care and/or transfer in
compliance with EMTALA standards.
f) In-bound EMS units/air medical units may not be re-directed to
another facility if the hospital is not formally on divert status
consistent with these guidelines.
4. CATEGORIES/CRITERIA OF HOSPITAL DIVERSION
a) Open: Available to receive all in-bound ambulance traffic
b) ED Divert: The Emergency Department of the hospital is unable to
safely accept any in-bound EMS ambulance traffic
c) Critical care/Specialty Divert: If a facility has utilized all house
monitor beds, it may be necessary to declare Critical Care Diversion,
thereby ceasing to accept inter-facility transfers. In-bound EMS
units with probable critical patients may be diverted to other
facilities. Hospitals should not hold Critical Care or Specialty beds
for elective procedure patients. Also, due to unusual circumstances,
the hospital may be unable to care for patients requiring specialty
care (i.e., neuro, OR, or trauma, etc.) that would normally be within
the hospital's capability; therefore, declaring Specialty Divert (i.e.,
CICU Divert, PICU Divert, NICU, TRAUMA Divert, OR,
Neurosurgery). Ambulances are cautioned to consider this in dealing
with patients who may be better served by another location.
Patient/Department specific inter-facility transfers should not be
accepted while on Critical Care/Specialty divert.
d) Disaster Status/Closed to Ambulance The facility is currently
involved in a mass casualty incident (MCI), and the hospital has
instituted its internal/external disaster plan. All in-bound EMS units
not involved in the current MCI are to be diverted to other locations.
5. PROCEDURE
a) Diversion should only be declared after the hospital has exhausted
all internal resources to meet the current patient load, including any
necessary call-backs of staff, step-downs, expedited discharges,
opening of “virtual” beds, and similar mechanisms to address the
patient load.
b) The emergency room physician, department supervision, and
hospital administration should make the decision for diversion
jointly. Appropriate hospital representatives should be notified as
soon as possible of the diversion status. All personnel with diversion
SVEMS Hospital Diversion Plan Page 5—Revised June 2010
decision power must be identified and titles prospectively
documented for reference. Diversion policies and protocols are
established by the individual medical facility.
c) Once a decision to go on diversion has been made, the hospital
should contact the dispatch centers in the areas likely affected by the
diversion and ask that a general alert be issued to notify affected
EMS agencies.
d) Hospitals should notify surrounding area hospitals that will be
impacted due to the diversion.
e) Hospitals shall notify EMS agencies, including commercial
ambulance services and agencies located outside the immediate area
that routinely transport to the facility, that will be impacted due to
the diversion.
f) Immediately upon cancellation of diversion status, surrounding
hospitals and EMS agencies should be notified. Dispatch centers
should also be contacted and asked to issue a general announcement
that the hospital is no longer on diversion.
g) The Council has established a calling service that may be utilized by
area hospitals to announce changes in diversion status. Access to the
system will be granted by the Southwest Virginia EMS Council
Executive Director upon written request of the medical facility.
Hospitals wishing to use the calling system will be required to
supply information necessary to create a user account.
h) Diversion status throughout the region can be monitored on VHAAS
(the Virginia Hospital Advanced Alerting System), a web-based
hospital communication and diversion status board system owned
and operated by the Virginia Hospital and Healthcare Association
and the Virginia Department of Health as part of the Hospital
Preparedness Program (HPP). Hospitals in the region should
participate and can view the diversion status of all other hospitals in
the region. VHAAS is also available to all public safety dispatch
centers in the region to assist in directing each ambulance patient to
the appropriate hospital able to accept that patient.
D. QUALITY MONITORING
1. All hospitals shall keep a diversion record on each instance. The record should
include the administrative clearance process followed for declaring a diversion,
the type of diversion, and facts supporting the decision to declare the diversion.
SVEMS Hospital Diversion Plan Page 6—Revised June 2010
2. This policy will be reviewed annually. Efforts will be made to involve
representatives of hospitals, EMS agencies, and Council staff.
E. PLAN UPDATE AND REVIEW
The Regional Hospital Diversion Plan is reviewed annually and updated annually
to address any identified regional needs. The plan is annually distributed to all
licensed EMS agencies and hospitals serving the region. Comments and
suggestions are collected, and the plan is approved by the Southwest Virginia
EMS Council Board of Directors at their regularly-scheduled meeting.
Comments and suggestions concerning this plan or regional hospital diversion
policies are accepted on a continuous basis and should be submitted in writing to
the Southwest Virginia EMS Council.
SVEMS Hospital Diversion Plan Page 7—Revised June 2010