Developing EMS Agencies Policies and Procedures

Bureau of EMS Policy Statement
Policy Statement #95-09
SubjectDeveloping EMS Agency Policies and Procedures

Certain requirements of the State EMS Code (Part 800) and good business practices require that standard and specific policies and procedures be developed and maintained to define how an organization conducts business. This is particularly true in the practice of emergency medical services and the organization and management of first response and ambulance services.

The objective of this policy is to provide guidance to all New York EMS services in the development of the policies and procedures that are needed to operate an EMS service. These policies set operational parameters and minimum expectations for all members or employees of the service. The policies listed within this document are not an all-inclusive list. Other policies in addition to these and the ones listed in 800.21 may be needed by your service or required by other authorities.

Since each organization is unique, the Department has not developed a standardized "model" policy. In the following document we have provided suggestions for items which we believe EMS services need to consider when developing service specific policies and procedures. In some instances, your service will need to interact with or obtain guidance from other agencies and organizations in order to be able to develop the necessary policies.

Assistance, information and/or guidance should be sought from your Service Medical Director, County EMS Coordinator, Hospital EMS Liaison, REMSCO, REMAC, service attorney, service insurance company, etc.

General Guidelines for Developing Policies and Procedures

Each policy should be individual and identified by subject/topic. This enables anyone to quickly search all service policies for specific items. The purpose of the policy and the name of the specific policy should also be indicated. Many times policies are put in place, never to be reviewed or revised. By dating the policies everyone will know when it was implemented. This allows the organization to set up a review process to ensure all policies are meeting the current needs of the organization. It may be beneficial to assign the annual review of the organizations policies to a committee or officer.

The individual policies should be a detailed enough to cover everything that is expected of the employee/member and allow each to understand their responsibilities and actions.

Typical individual policy contents:

* Subject / Topic

* Purpose of the policy

* Specific Policy (with enough detail to allow members/ employees to understand scope and required actions).

* Dates implemented/approved/updated

* Applicable references (Part 800, NYS-EMS Policies, OSHA, DMV, FCC, etc.)

* Reviewed cycle and date

* Designate responsible individual/group for maintenance and updating of the policy

Mutual Aid:

When developing policies for mutual aid, many factors need to be considered. How will your employees/members access another agency or dispatch center? Does someone within your organization need to authorize contact with another agency? Who should be called for mutual aid? What are the specific scene requirements? Which mutual aid agency is available, closest, and most appropriate? Should your organization have policies for automatic mutual aid for ALS, extrication, multiple patients, hazardous materials, etc.? Where is the scene vs. the available mutual aid agency? Decide which tasks will be handled by the dispatcher, and those that will be handled by the scene personnel. If your primary mutual aid agencies aren't available, who else is? How long should your employees/members wait before implementing your mutual aid plan? How long should you wait for the requested agency to respond? When should your members/employees implement alternative choices?

* Access

* Authorization for Access*

* Order of priority for mutual aid

* Circumstances for automated mutual aid

* Level of care needed vs. equipment and personnel

* Look at geography and plan accordingly

* Capabilities of dispatch center and surrounding communities

* Alternate choices in the event primary mutual aid is unavailable

* Time limits before implementation of mutual aid and/or selecting an alternate agency


What is an acceptable time limit from the time a call is received until the organization responds to the incident? What actions should your employees/members or dispatch center initiate if that limit is exceeded? Does your dispatch center currently have any plans in place? How do you interact with those plans?

* Define call receipt interval and actions to be taken by crew and/or dispatch center

* Reference plans for dispatch

JOB DESCRIPTIONS: (Identify all types Administration, Care providers, Dispatchers)

Job descriptions are important to ensure that personnel hired meet the minimum qualifications. Job descriptions also provide a standard performance expectation, which make evaluating employees/member more objective. You should ensure that you see the original documents for anything you may need to copy. Sometimes individuals alter the copies. Consideration should be given to the Americans with Disabilities Act. What duties are your employees/members expected to perform? Are there any potential hazards for the job title? What will the organization provide vs. what will the employee/member be expected to provide? What are the job prerequisites? What will be required of an employee/member to maintain their position? What is the impact of Federal/State/local regulations on the position?

* Ask to see original certifications - not photocopies, then make copy of any certifications/licenses for file.

* Minimum qualifications, job duties, including potential hazards

* Certifications (including levels) needed to maintain position

* Drivers licenses

* Years of service/ experience

* Consider Americans with Disabilities Act

* Any system requirements (CME, etc.)

* Consider Federal (OSHA), State (PESH), NFPA regulations

* Consider sensitivity and responsibility of position

* When selecting individual for specific task review membership for individual with background in task (employed as safety officer at industrial plant for agency OSHA compliance officer)

Preventive Maintenance:

Maintaining vehicles as well as equipment is essential to an agency's performance. Equipment failures can lead to liability claims, injuries and even death. What is the manufacture's recommendation for maintenance? How should the equipment be cleaned? Are there any special considerations for maintenance?

* Manufacturer recommendation; including chassis and ambulance conversion

* Maintain records for purchase, maintenance, etc.

* Reference OSHA, PESH re: Bloodborne pathogens and air pathogens

Equipment Inspection:

Conducting periodic equipment inspections helps prevent problems and equipment failures. It is important to develop schedules to ensure that each piece of equipment is routinely inspected. What needs to be inspected? How frequently should it be inspected? What documentation is needed to track the inspections? What does the manufacturer recommend for preventative maintenance and/or inspections? What other regulations that impact equipment inspection (OSHA, DMV, etc.)?

* Frequency of inspections (to ensure the equipment is ready to roll)

* Consider, DMV, DOH, and local regulations

* Manufacturer specifications

* Develop inspection sheets

Reporting Of: Crimes, Child Abuse, Patient Abuse And/Or Domestic Violence

It is important for employees/member to have guidance when dealing with difficult situations. Incidents that involve violence pose a great personal risk to the responder. How should your employees/members respond to these incidents? Who should they contact regarding violent situations? How can additional resources be contacted?

* Policies for personnel to follow

* Consider police involvement and contact

* Consider phone numbers and information forms available by various agencies

* NY Social Services Law, Section 419 states:

"Any person (mandated by law or not), official or institution participating in good faith in the making of a report, taking photographs, placing a child in protective custody or providing a service pursuant to the duties of the child protective service according to the law has immunity from any liability, civil or criminal, that might otherwise result from such actions.

For the purpose of any proceeding, civil or criminal, the good faith of persons, officials or institutions required to report cases of child abuse or maltreatment is presumed as long as they were acting in the discharge of their duties and within the scope of their employment. This protection does not apply to acts of willful misconduct or gross negligence."

Responsibilities of Care Providers:

Many times patient care providers are presented with situations that require additional action to ensure patient and provider safety. What do you want your employees to do in each of the following situations? What should an employee/member do when they can't find the patient? What if a patient is behind a locked door? What action should be taken if a patient needs care but refuses treatment or transport? How should your employees respond to a request for transportation outside of your usual area? What happens if a hospital requests that the patient be transported to another facility, instead of the one originally selected? What action should your employees/members take when providing care to a minor? How should your employees/members be expected to respond when treating a psychiatric patient? What should be done for an unattended death?

1. Patient can't be located

* Bystander questioning

* Reasonable searches

* Call backs for additional information or access

2. Entry can't be gained

* Forcible entry policy re: police/fire

3. Patient in need of refuses medical care

* Medical control and physician contacts

* Informed refusal

* Police involvement

* Suggest criteria to determine with assistance of Medical Director

4. Patient seeks transport outside of ordinary area

* Designation of services receiving facility

* Emergency vs non-emergency

* Consider availability of ambulance service for community

* Consider patient stability/condition

* Environmental factors (rain, snow, sleet, etc.)

5. Hospital requests patient be transported to another facility

* Request hospital diversion policies

* Work with facilities to develop policies

* Develop with assistance from Medical Director

* Review alternatives

6. Treating minors

* Consider RMA policy if refusal

* Mechanism for locating parents

* Consider law enforcement involvement/medical control

7. Treating/transporting patients with psychiatric problems

* Crew safety/patient safety

* Underlying medical problems/ patient safety

* Consult medical control for restraint policy

* Law enforcement involvement

* Consider possible violence developing

8. Unattended death

* Who is determining death (medical personnel/ vs law enforcement/bystander)

* Consider crime scene

* Consider contacting medical control

* Consider police, coroner, and medical examiners

* Body removal

Infection Control

What are your organization's policies for infection control? Who is the Designated Officer as required by the Ryan White Act? How do your employees/members access your infection control system in the event of an exposure?

* Refer OSHA, PESH, Ryan White Act


Are there any local or regional plans already in place? If so, how does your organization interact with them? What other agencies should be involved in a hazardous materials incident? What plans do your hospitals have? How do you interact with their plans?

* Consider local/regional plans

* Consider contact with local Fire Department, "HazMat Response"

* Refer to OSHA 1910.310 (?)

* Consideration of hospital capabilities and decontamination facilities


What resources will be needed in the event of an MCI? What agencies can be and should be called upon for assistance? How will your employees/members active the MCI plan? Are there any sites within your community that pose a greater than normal risk? Do these sites have plans? Does an MCI plan already exist for your community?

* Consider local/regional plans

* Know local resources

* Be aware of potential problem sites

* Refer to and/or incorporate mutual aid plan.

Other Policies and Procedures:

EMS services may have the need to develop other polices and procedures to assist in the way operations and other business is conducted. Confidentiality of records, limiting access to records, responsibilities while driving emergency vehicles, training requirements, membership requirements, and qualifications and reporting for employees are examples of policies, that while not required are needed to have a framework to run an emergency response agency.

Issued by: John J. Clair, Associate Director - Operations

Authorized by: Edward G. Wronski, Deputy Director

of Emergency Medical Services