Part 1-000 - Policies & Guidelines

CMH EMS & MIH Protocols

Definitions

• Policy: Document that contains mandatory actions for staff of Citizens Memorial Hospital. Policy contents are typically required by law, regulation, or standard. Employees are held accountable to these documents and progressive discipline is used to enforce them. Policies are found here: https://citizensmemorial.policystat.com/. The list of CMH PHS policies with quick links can also be found below the Guidelines on this page.


• Guideline: Document that contains requests and suggestions and act as a guide to operations that only applies to signatory agencies to this protocol document. Guideline contents are typically explanations of expected performance and are operational in nature and suggested practice by medical direction and agency leadership. Guidelines are found below.


• Protocol: Document to guide patient care that only applies to signatory agencies to this protocol document. EMDs, EMRs, EMTs, AEMTs, RNs, and Paramedics that are members of the signatory agencies and utilizing these protocols will be held accountable for adhering to these protocols by the signing medical director and agency leadership. Protocols are found here: https://emsprotocols.online/cmhems/2-000.php.

Guidelines

• 1-100 - Air Transport of Patients
• 1-100-50 - Helicopter Landing Zone
• 1-200 - EMS Dispatch
• 1-200-24 - Call Natures
• 1-200-48 - Mutual Aid
• 1-200-72 - Transfer Priority Calculator
• 1-400 - EMS Communications
• 1-400-12 - Staff Communication Paths
• 1-400-48 - Medical Control
• 1-400-72 - Patient Handoff Report
• 1-450 - EMS Leadership
• 1-450-33 - Documentation Reviews
• 1-450-66 - Rounding Form
• 1-500 - EMS Education and Competency
• 1-600 - Responder Safety
• 1-600-50 - Retired
• 1-700 - EMS Operations
• 1-700-33 - Patient Care Documentation
• 1-700-60 - Hazardous Atmosphere Standby
• 1-700-88 - Retired
• 1-800 - Quality Improvement
• 1-800-33 - Clinical Reviews
• 1-800-50 - Just Culture Investigation
• 1-800-66 - Employee Remediation
• 1-850 - Rescue Task Force
• 1-850-25 - Mass Casualty

Policies

Links to policies below are those found to effect Pre-Hospital employees or Ambulance operations. This list may not be exhaustive or include recently created policies. The documents are only available after logging in by CMH employees or on CMH network-connected devices.

• Accounting Policies:
• ACC03-01 Ambulance Meal Expenses During Long Distance Transfers
• ACC03-02 Ambulance Fuel
• ACC04-01 Payroll
• ACC04-04 Travel Policy
• Administration Policies:
• ADM02-02 Committees
• ADM02-11 Vehicle Usage
• Clinics Policies:
• CLN21-01 Transferring Patients to the Emergency Department from a Clinic
• Compliance Policies:
• COM03-04 HIPAA Compliance Monitoring and Auditing
• COM04-01 Fraud, Waste, and Abuse
• Educational Services Policies:
• EDU01-07 Education Documentation
• EDU01-01 Education Services Department
• Emergency Management Policies:
• EM01-01 Emergency Management Plan
• EM01-01 Attachment 1 General Emergency Instructions
• EM01-01 Attachment 3 Department Specific Emergency Instructions
• EM01-04 Disaster Press Release
• EM01-05 Emergency Management Policy
• EM01-07 Activation and Healthcare Command Center Operations
• EM01-12 Crisis Communication Plan
• EM01-14 Evacuation, Emergency Sheltering, and Relocation Plan
• Emergency Services Policies:
• EMS01-05 Staffing Emergency Department
• EMS01-06 Integration with Other Hospital Departments
• EMS01-08 Trauma Quality Improvement Process
• EMS01-10 Ambulance Diversion and EMResource
• EMS13-02 Medical Screening Exam
• Employee Health Policies:
• EH01-08 Meningitis Employee Exposure Protocol
• Health Information Management Policies:
• HIM03-02 Release of Information
• HIM11-01 Ammending Protected Health Information
• HIM11-01 Attachment 1 Ammendments to Helath Information Precords
• Human Resources Policies:
• HR01-04 Health Coverage
• HR01-13 Conflict Management
• HR02-03 Job Classification
• HR02-04 Hospital Pride Pay
• HR02-05 Overtime Compensation
• HR02-06 Shift Differential
• HR02-08 On-Call Personnel
• HR03-01 Name Badges
• HR03-02 Sexual or Other Harassment
• HR03-03 Disciplinary Action
• HR03-04 Drug Free Workplace
• HR03-05 Dress Code
• HR03-05 Attachment 6 Prehospital
• HR03-06 Patient and Employee Information Confidentiality
• HR04-01 Employee Manual
• HR05-01 Equal Employment Opportunity Policy and Affirmative Action Plan
• HR06-06 Job Posting
• HR06-07 Selection of Employee
• HR06-08 Probationary Period
• HR06-09 Employee Transfers and Promotions
• HR06-10 General Orientation
• HR06-12 Physical Capacity Profile Testing of Employees
• HR06-14 Nepotism
• HR07-01 Grievance Procedure
• HR07-02 Staff Rights
• HR08-02 Jury Duty
• HR08-03 Leave of Absence
• HR08-04 Sick Leave - Non-Exempt (Hourly) Employees
• HR08-05 Sick Leave - Exempt Employees
• HR08-06 Telephone Etiquette / Personal Cellular Phone Usage
• HR08-09 Breaks and Meals
• HR08-10 Holiday Pay
• HR08-14 Clocking Procedures
• HR08-15 Paid Time Off
• HR09-01 Students Orientation
• HR10-01 Performance Evaluations
• HR10-02 Job Descriptions
• HR10-03 Competency Assessment
• HR11-01 Personnel Records
• HR11-02 Professional Licensure
• HR11-03 Access Records
• HR12-01 Termination
• HR13-01 Social Media Networking and Internet-Based Communications
• Infection Prevention Policies:
• IP01-10 Bed Bug Management
• IP06-01 Service Animals
• IP07-01 Cleaning and Disinfecting Patient Care Equipment
• IP08-03 Influx of Infectious Patients
• Information Services Policies:
• IS01-01 Organizational Responsibities
• IS02-01 Use of Information Technology Resources
• IS02-03 Computer Security
• IS03-01 Change Management
• IS04-01 Integrity Controls
• IS05-01 Computer Operations
• IS06-01 Support
• IS07-01 Employee Terminations Procedures
• IS08-01 Project Managment
• IS09-01 Documentation
• IS12-01 Participation in External Research or Databases
• IS13-01 Disaster Recovery and Business Continuity
• IS14-01 Mobile Device Security and Use
• IS14-02 Medical Device Security
• IS15-01 Remote Access
• IS18-01 Computer/Hardware Installation
• IS19-01 Security Management Process
• IS19-02 Maintenance Record
• IS20-01 Risk Analysis
• IS21-01 Risk Management
• IS22-01 Assigned Security Responsibility
• IS23-01 Workforce Security
• IS24-01 Workforce Clearance
• IS25-01 Security Awareness and Training
• IS26-01 Security Reminders
• IS27-01 Log-In Monitoring
• IS28-01 Password Management
• IS29-01 Evaluation
• IS30-01 Access Establishment and Modification
• IS31-01 Unique User Indentification
• IS31-02 User Mnemonic Guidelines
• IS33-01 Automatic Logoff
• IS34-01 Audit Controls
• IS35-01 Person or Entity Authentication
• IS36-01 Policies and Procedures for Security
• IS38-01 Authorizations and/or Supervision
• IS40-01 Access Authorization
• IS41-01 Employee Sanction for Violations of HIPAA Privacy and Security Policies
• IS41-03 Emergency Access Procedure
• IS41-04 Preventing, Detecting, Investigating, Containing, Correcting, Documenting, and Reporting Security Violoations
• IS43-01 Information System Activity Review
• IS43-02 Encrypting and Decrypting ePHI
• IS50-02 Network Security Policy
• IS50-03 Patch Management
• Laboratory Policies:
• LAB01-02 Laboratory Standards
• LAB03-15 Accuchek Inform II
• LAB04-01 Critical Values
• LAB05-01 Quality Control / Quality Management System
• LAB11-42 Emergency Release of Blood
• Maintenance Policies:
• MNT01-01 New Equipment Safety
• MNT02-07 Preventative Maintenance - Mechanical Equipment
• MNT02-11 Vehicle Maintenance
• MNT03-03 Electricity and Auxilliary Power
• MNT07-04 Medical Equipment Cleaning
• Marketing Policies:
• MKT01-03 Ambulance Media Inquiries
• Materials Management Policies:
• MM01-03 Receiving Supplies and Equipment
• MM02-01 Inventory Management
• Nursing Policies:
• NUR01-12 Transfer of Patients/Residents
• NUR06-17 Clinical Services Narrative Plan
• NUR08-01 Code Blue
• NUR08-07 Endotracheal Intubation
• Patient Accounts Policies:
• PA02-03 Collection Policy - Patient Accounts
• PA02-04 Collection of Self Pay Accounts
• PA02-05 Prompt Pay Discount
• PA08-02 Motor Vehicle Accident
• PA20-01 Coding Guidelines
• PA20-02 Self-Pay Discount
• Performance Improvement Policies:
• PI01-01 Performance Improvement
• PI01-05 Medical Device Reporting Program
• PI01-06 Service Alert Notification Management
• PI01-07 Cellular Phones and Radio Transmitting Devices
• PI01-08 Equipment Failure
• PI02-01 Surveying for Satisfaction
• PI02-02 Grievance Procedure, Patient/Resident
• PI02-04 Transport Safety of Patient/Resident
• PI02-05 Reporting Adverse Medical Device Incidents
• PI02-06 Just Fix It Process
• PI03-01 Event Reporting
• Pharmacy Policies:
• PHA02-03 Procurement, Receiving, and Inventory of Medications
• PHA02-15 340B Program
• PHA04-05 Medication Storage
• PHA04-10 Pharmaceutical Waste
• Pre-Hospital Policies:
• PHS01-01 Ambulance Driving and Operations
• PHS01-02 Ambulance Response Outside of the Primary Service Area
• PHS01-03 Ambulance Medical Control
• PHS01-04 Ambulance Documentation Requirements
• PHS01-05 Ambulance Staff Mental Health and Peer Counseling
• PHS01-06 Passengers in the Ambulance
• PHS01-09 Ambulance Inventory
• PHS01-11 Ambulance Station Maintenance
• PHS01-12 Ambulance Storage
• PHS01-13 Ambulance Refueling
• PHS01-15 Ambulance Clinical Quality
• PHS01-17 Ambulance Keys Security
• PHS01-18 Ambulance Robbery
• PHS01-19 Ambulance Staffing
• PHS01-20 Ambulance Employee Orientation
• PHS01-22 Ambulance Oxygen Cylinders
• PHS01-21 Ambulance Accidents
• PHS01-23 Ambulances Passing School Buses
• PHS01-24 Ambulance Medications
• PHS01-26 Rescue Squad Supplies
• PHS01-27 Ambulance Coverage for Special Events
• PHS01-28 Ambulance Equipment
• PHS01-31 Ambulance Operations
• PHS01-33 Ambulance Transfers
• PHS01-37 Ambulance Education and Competency
• PHS01-38 Ambulance Patient Non-Discrimination
• PHS02-02 Institution of Ambulance Protocols
• PHS02-04 Ambulance Patients Determined to be Dead on Arrival
• PHS02-05 Scope of Services - Prehospital Services
• PHS02-06 Ambulance Staff Response to Request for Blood Sample by Law Enforcement
• PHS02-08 Pre-Hospital Service Driving Program
• PHS02-09 Ambulance Bonus Pay
• PHS02-10 Non-Emergency Medical Transport
• PHS02-11 Ambulance Staff Criminal Reporting
• PHS03-01 Ambulance On-Call Crew
• PHS03-06 Ambulance Maintenance
• PHS03-07 Ambulance Cot Operations and Lifting of Patients
• PHS03-08 Ambulance Operations and Safety while in the Roadway
• Registration Policies:
• RG04-02 Ambulance Only
• Respiratory Care Policies:
• RC01-05 Transfers Involving Respiratory Care
• Safety Policies:
• SAF01-02 Violence Prevention
• SAF01-04 Patient/Resident Handling
• SAF01-05 Safety Surveillance
• SAF01-12 Recalls and Safety Notifications
• SAF01-15 Storeroom Safety
• SAF01-17 Eyewash Stations and Drench Showers
• SAF01-18 Personal Protective Equipment
• SAF01-21 Respiratory Protection Program
• SAF01-24 Electricity and Electrical Equipment Safety
• SAF04-01 Employee Incidents, Injuries, and Illnesses, Job Related
• SAF06-01 Hazard Communication Program - Material Safety Data Sheets
• SAF07-04 Hazardous Compressed Gases
• SAF10-02 Safety Management Plans
• Security Policies:
• PS02-12 Safe Approach Work Place Violence Program
• PS03-07 Helicopter Security
• PS03-11 M26/X26 Taser
• Social Services Policies:
• SS04-01 Patient Rights and Responsibilities
• SS04-04 Communication with Persons with Limited English Proficiency
• SS05-05 Domestic Abuse
• Surgical Services Policies:
• SUR08-10 Cleaning, Sterilization, High-Level Disinfection and Storage of Patient Care Devices
• Time Critical Diagnosis Policies:
• CV30-06 STEMI Multidisciplinary Committee Policy
• TCD01-03 Scope of Service - Stroke Program

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Change Log:

Date	Link to previous version	Description of change
10/07/20		Renamed all policies to guidelines.
10/26/20	pdf	Working on updating all policies, guidelines, memos, etc. into one place - organizedcoordinated - eliminating redundanciesconflicts.
02/25/21	pdf	Small organization step as we continue to tackle the project of organizing and improving guidelines. Removed completed changes from needed lists. Fundamental change in definitions of policies vs guidelines.
02/26/21	pdf	Various changes highlighted in individual guidelines.
04/06/21	pdf	Further working on planning for updates to guidelines and protocols. Still in the planning phases but updating the plan based on definitions provided by PHS director and CMH legal.
04/07/21		More work on flushing out the plan to make policy updates.
04/09/21	pdf	Completed the planning for changes to Guidelines vs Policies. Sent plan to Ops Chief for review.
06/05/21	pdf	Moved to emsprotocols.online
06/05/21		Changed from bullet layout to table layout to more easily find links.
06/09/21	pdf	Submitted changes for approval for PHS01-23 and PHS01-27.
06/09/21		Submitted changes for PHS02-02 for approval.
06/09/21		Made updates to PHS03-08 Ambulance Roadway Operations.
06/10/21	pdf	Added PDF files for all policies for offline viewing. Policies PHS01-23, PHS01-27, and PHS03-08 updates have been approved.
06/29/21	pdf	Updated policy PHS01-19.
09/14/21	pdf	Made policy updates to PHS01-06 (no changes), PHS01-11 (minor changes), PHS01-14 (removed), 1-400-72 (created).
09/29/21	pdf	Various changes to include: Policy PHS01-06 approved, PHS01-11 approved, PHS01-24 drafted and sent for approval, PHS01-32 retired, PHS01-34 retired, guideline 1-700-88 retired, 1-850-25 updated.
11/05/21		Added link to new policy PHS03-01.
02/08/22	pdf	Updated policies due in Jan 2022.
02/18/22	pdf	Several policy updates officially approved: PHS01-03 (Ambulance Medical Control), PHS01-08 (Ambulance Cleaning), PHS01-18 (Ambulance Robbery), PHS01-20 (Orientation), PHS01-28 (Equipment), PHS01-31 (Operations), PHS01-37 (Education), PHS01-38 (Non-Discrimination), removed PHS02-03 (Air Transport), removed PHS03-03 (Lost Equipment)
03/07/22	pdf	Added new policy for Ambulance Peer Counselors - but the policy number is incorrect.
04/11/22	pdf	Adjustments to policies and guidelines.
09/12/22	pdf	Finally cleaned up all the notes for required updates. Most of the updates have been made. The rest of the notes have been transferred to master document for future revisions.
12/09/22	pdf	Removed Policy PHS02-01.
12/29/22	pdf	Adding links to all policies that affect PHS. Several more links to add.
12/30/22	pdf	Finished adding all policies that could be found that affect pre-hospital services.
04/27/23	pdf	Renamed ambulance guidelines to EMS guidelines

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CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.