Loyola Emergency Medical Services System
Policies and Procedures
, TABLE OF CONTENTS
Code of Ethics Page
Ethical Standards and Behavioral Expectations 5
Section 100: General Policies Policy Number Page
Definition of Prehospital Healthcare 100.1 6
Requirements of Community Commitment 100.2 7
Backup Ambulance Coverage 100.3 9
Resource Hospital Override 100.4 10
Ambulance Inspections 100.5 11
Staffing of ALS Vehicles 100.6 13
Staffing of ALS Vehicles – One-to-One Waiver Request 100.6a 14
Staffing of Critical Care Transport Vehicles 100.6b 16
Staffing of BLS Vehicles 100.7 20
Staffing of BLS Vehicles - One-to-One Waiver Request 100.7a 21
EMS Quality Control Communication Report 100.8 22
Just Culture 100.8a 24
Implementation of Standing Medical Orders (SMOs) 100.9 26
Initiation of ALS Care 100.10 27
Advanced EMTs (AEMTs)/EMT-Intermediates (EMT-Is) 100.11 29
Section 200: Medical-Legal Policy Number Page
Falsification of Prehospital Care Reports 200.1 30
Confidentiality of Medical Records 200.2 31
Confidentiality of Medical Records: Prehospital Care Reports (PCRs) 200.2a 33
Confidentiality of Medical Records: Prehospital Communications 200.2b 34
Continuity of Care/Abandonment 200.3 36
Continuity of Care/Abandonment – Transport Destinations 200.3a 38
Personal Immunity from Liability 200.4 40
Reportable Incidents 200.5 41
Crime Scene Response 200.6 42
Care for Survivors of Rape or Sexual Assault 200.6a 44
Behavioral Emergencies: Care of Uncooperative or Impaired Patients 200.7 46
Uncooperative Patient without Law Enforcement Assistance 200.7a 48
Use of Restraints 200.8 50
Treatment of Minors 200.9 53
Consent/Refusal of Treatment 200.10 55
Release of Uninjured Students from School Bus Crash Scenes 200.10a 57
Non-Impaired Refusal of Care with Admitted Alcohol Consumption 200.10b 61
Physician/Nurse on the Scene/Use of Medications 200.11 63
Transport to Other than the Closest, Most Appropriate Hospital 200.12 64
Hospital Emergency Department Bypass 200.13 65
Do Not Resuscitate/ Withholding/ Withdrawing of Resuscitative Efforts 200.14 70
Pronouncement of Death in the Pre-hospital Setting 200.15 75
Medical Examiner Cases 200.16 76
Abuse of Mind-Altering Substances by System Participants 200.17 78
Victims of Abuse 200.18 79
Prehospital Care Reports 200.19 82
System-Wide Crisis Response 200.20 84
Illinois Abandoned Newborn Infant Protection Act 200.21 90
Email, internet and Other Social Media Service usage 200.22 92
Concealed Carry and Open Carry/Patients with Weapons 200.23 96
Interaction with Law Enforcement Personnel 200.24 98
Treatment/Transport of Police Service Dogs 200.29 101
Guidelines for Use of Service Animals 200.30 103
1
Loyola EMS System
, TABLE OF CONTENTS (continued)
Section 300: Medication and Equipment Policy Number Page
System Accountability of Controlled Substances 300.1 105
Storage and Security of Medications 300.1a 106
Documentation of Controlled Substance Usage 300.2 107
Medication Exchange 300.3 109
Prehospital Provider Disposable Supplies Exchange 300.4 111
Non-Disposable Equipment Hospital Storage/Replacement 300.5 112
Medications for New Ambulances 300.6 113
Latex-Containing Supplies 300.7 114
Section 400: Education Policy Number Page
Paramedic Academy Admission Requirements 400.1 115
Paramedic Academy Education Standards 400.2 116
Clinical Preceptor 400.3 118
EMT Program Admission Requirements 400.4 120
EMT Program Education Standards 400.5 121
Prehospital Provider Relicensure Requirements 400.7 123
Out of System Continuing Medical Education 400.8 124
Prehospital Provider Continuing Education Requirements 400.10 125
Program Tuition and Course Payment 400.11 127
EMS Lead Instructor Initial Licensure 400.12 128
EMS Lead Instructor Relicensure 400.13 129
Site Code Application 400.13a 131
EMS Assistance Fund 400.14 132
First Responder/First Responder – AED 400.15 133
National Registry Recertification 400.16 135
Section 500: Loyola Emergency Medical Services System Personnel Policy Number Page
System Entry for Prehospital Provider 500.1 137
Reinstatement of Expired Provider License 500.1a 139
Provisional Licensure 500.2 140
Personnel File Information Update 500.3 141
Prehospital Provider Licensure/Certification and Continuing Education Requirements 500.4 142
Secondary Status 500.4a 147
Personnel Record Request 500.5 148
System Department Coordinator 500.6 149
Inactive Status 500.7 151
Voluntary Status Reduction 500.7a 152
Reactivation from Inactive Status 500.8 153
Emergency Communications Registered Nurse (ECRN) 500.9 154
Entry of a Licensed ECRN 500.9a 157
ECRN Approval for Relicensure 500.10 158
Transport RN 500.11 160
Assistance from Non-EMS Personnel During Transports 500.11a 161
MERCI Radio 500.12 163
Pre-Hospital RN, Advance Practice RN, Physician Assistant/(PHRN/PHAPN/PHPA) 500.13 164
Emergency Medical Dispatcher (EMD) 500.14 165
EMD Recertification 500.15 169
EMD Agency Application 500.16 170
EMD Agency Recertification 500.17 171
Continuing Education Facilitators 500.18 172
2
Loyola EMS System
, TABLE OF CONTENTS (continued)
Section 600: Resource/Associate Hospital Policy Number Page
Emergency Medical Services System Coordinator 600.1 173
Emergency Medical Services System Administration 600.1a 175
Associate Hospital Emergency Medical Services Coordinator 600.2 176
Associate Hospital Emergency Medical Services Director 600.3 179
Online Medical Direction 600.4 180
Section 700: Infection Control Policy Number Page
**Exposure Control Plan for Prehospital Providers 700.1 181
**Exposure Notification Plan 700.2 190
Emerging Infectious Diseases (EIDs) 700.3 199
Section 800: Quality Improvement Policy Number Page
Quality Improvement Responsibilities 800.1 201
Section 900: System Participation Suspension Policy Number Page
System Participation Suspension 900.1 203
System Participation Suspension - Notification of Other EMS Systems 900.1a 206
Workplace Violence/Harassment 900.2 207
Section 1000: Transportation/Communication Policy Number Page
Aeromedical Transport 1000.1 210
Hospital Medical Control: Telephone/MERCI/Starcom Communications 1000.2 212
Invalid Assistance/Service Calls 1000.3 216
Special Procedures – Mass Casualty Incident/Disaster (MCI) 1000.4 217
Special Procedures – Multiple Victim Incident (MVI) 1000.5 223
Special Procedures – EMAC and NAC Response 1000.6 226
Section 1100: Provider Well-being/Critical Incidents Policy Number Page
Critical Incident Stress Management (CISM) 1100.1 228
Patient Follow-Ups 1100.2 231
Death/Serious Injury of a First Responder/Line of Duty Death (LODD) 1100.3 232
Section 1200: Electronic Patient Care Reporting Policy Number Page
Definitions Relating to Electronic Patient Care Report (e-PCR) 1200.1 234
EMS Agency Acquisition of ePCR Software/Program 1200.2 235
ePCR Equipment and ePCR Software/Program Access 1200.3 236
Use of ePCR Charting Software/Program and Equipment 1200.4 238
ePCR Training 1200.5 239
Security and Confidentiality 1200.6 240
Completion of ePCR Forms 1200.7 241
ePCR Addenda 1200.8 243
Submission of the ePCR 1200.9 244
Storage of ePCRs 1200.10 245
ePCR Program/Software System Downtime/Failure 1200.11 246
Personnel Changes 1200.12 247
Allowable ePCR Modifications 1200.13 248
Email/Network Requirements for ePCR Usage and Official Correspondence 1200.14 249
3
Loyola EMS System
Policies and Procedures
, TABLE OF CONTENTS
Code of Ethics Page
Ethical Standards and Behavioral Expectations 5
Section 100: General Policies Policy Number Page
Definition of Prehospital Healthcare 100.1 6
Requirements of Community Commitment 100.2 7
Backup Ambulance Coverage 100.3 9
Resource Hospital Override 100.4 10
Ambulance Inspections 100.5 11
Staffing of ALS Vehicles 100.6 13
Staffing of ALS Vehicles – One-to-One Waiver Request 100.6a 14
Staffing of Critical Care Transport Vehicles 100.6b 16
Staffing of BLS Vehicles 100.7 20
Staffing of BLS Vehicles - One-to-One Waiver Request 100.7a 21
EMS Quality Control Communication Report 100.8 22
Just Culture 100.8a 24
Implementation of Standing Medical Orders (SMOs) 100.9 26
Initiation of ALS Care 100.10 27
Advanced EMTs (AEMTs)/EMT-Intermediates (EMT-Is) 100.11 29
Section 200: Medical-Legal Policy Number Page
Falsification of Prehospital Care Reports 200.1 30
Confidentiality of Medical Records 200.2 31
Confidentiality of Medical Records: Prehospital Care Reports (PCRs) 200.2a 33
Confidentiality of Medical Records: Prehospital Communications 200.2b 34
Continuity of Care/Abandonment 200.3 36
Continuity of Care/Abandonment – Transport Destinations 200.3a 38
Personal Immunity from Liability 200.4 40
Reportable Incidents 200.5 41
Crime Scene Response 200.6 42
Care for Survivors of Rape or Sexual Assault 200.6a 44
Behavioral Emergencies: Care of Uncooperative or Impaired Patients 200.7 46
Uncooperative Patient without Law Enforcement Assistance 200.7a 48
Use of Restraints 200.8 50
Treatment of Minors 200.9 53
Consent/Refusal of Treatment 200.10 55
Release of Uninjured Students from School Bus Crash Scenes 200.10a 57
Non-Impaired Refusal of Care with Admitted Alcohol Consumption 200.10b 61
Physician/Nurse on the Scene/Use of Medications 200.11 63
Transport to Other than the Closest, Most Appropriate Hospital 200.12 64
Hospital Emergency Department Bypass 200.13 65
Do Not Resuscitate/ Withholding/ Withdrawing of Resuscitative Efforts 200.14 70
Pronouncement of Death in the Pre-hospital Setting 200.15 75
Medical Examiner Cases 200.16 76
Abuse of Mind-Altering Substances by System Participants 200.17 78
Victims of Abuse 200.18 79
Prehospital Care Reports 200.19 82
System-Wide Crisis Response 200.20 84
Illinois Abandoned Newborn Infant Protection Act 200.21 90
Email, internet and Other Social Media Service usage 200.22 92
Concealed Carry and Open Carry/Patients with Weapons 200.23 96
Interaction with Law Enforcement Personnel 200.24 98
Treatment/Transport of Police Service Dogs 200.29 101
Guidelines for Use of Service Animals 200.30 103
1
Loyola EMS System
, TABLE OF CONTENTS (continued)
Section 300: Medication and Equipment Policy Number Page
System Accountability of Controlled Substances 300.1 105
Storage and Security of Medications 300.1a 106
Documentation of Controlled Substance Usage 300.2 107
Medication Exchange 300.3 109
Prehospital Provider Disposable Supplies Exchange 300.4 111
Non-Disposable Equipment Hospital Storage/Replacement 300.5 112
Medications for New Ambulances 300.6 113
Latex-Containing Supplies 300.7 114
Section 400: Education Policy Number Page
Paramedic Academy Admission Requirements 400.1 115
Paramedic Academy Education Standards 400.2 116
Clinical Preceptor 400.3 118
EMT Program Admission Requirements 400.4 120
EMT Program Education Standards 400.5 121
Prehospital Provider Relicensure Requirements 400.7 123
Out of System Continuing Medical Education 400.8 124
Prehospital Provider Continuing Education Requirements 400.10 125
Program Tuition and Course Payment 400.11 127
EMS Lead Instructor Initial Licensure 400.12 128
EMS Lead Instructor Relicensure 400.13 129
Site Code Application 400.13a 131
EMS Assistance Fund 400.14 132
First Responder/First Responder – AED 400.15 133
National Registry Recertification 400.16 135
Section 500: Loyola Emergency Medical Services System Personnel Policy Number Page
System Entry for Prehospital Provider 500.1 137
Reinstatement of Expired Provider License 500.1a 139
Provisional Licensure 500.2 140
Personnel File Information Update 500.3 141
Prehospital Provider Licensure/Certification and Continuing Education Requirements 500.4 142
Secondary Status 500.4a 147
Personnel Record Request 500.5 148
System Department Coordinator 500.6 149
Inactive Status 500.7 151
Voluntary Status Reduction 500.7a 152
Reactivation from Inactive Status 500.8 153
Emergency Communications Registered Nurse (ECRN) 500.9 154
Entry of a Licensed ECRN 500.9a 157
ECRN Approval for Relicensure 500.10 158
Transport RN 500.11 160
Assistance from Non-EMS Personnel During Transports 500.11a 161
MERCI Radio 500.12 163
Pre-Hospital RN, Advance Practice RN, Physician Assistant/(PHRN/PHAPN/PHPA) 500.13 164
Emergency Medical Dispatcher (EMD) 500.14 165
EMD Recertification 500.15 169
EMD Agency Application 500.16 170
EMD Agency Recertification 500.17 171
Continuing Education Facilitators 500.18 172
2
Loyola EMS System
, TABLE OF CONTENTS (continued)
Section 600: Resource/Associate Hospital Policy Number Page
Emergency Medical Services System Coordinator 600.1 173
Emergency Medical Services System Administration 600.1a 175
Associate Hospital Emergency Medical Services Coordinator 600.2 176
Associate Hospital Emergency Medical Services Director 600.3 179
Online Medical Direction 600.4 180
Section 700: Infection Control Policy Number Page
**Exposure Control Plan for Prehospital Providers 700.1 181
**Exposure Notification Plan 700.2 190
Emerging Infectious Diseases (EIDs) 700.3 199
Section 800: Quality Improvement Policy Number Page
Quality Improvement Responsibilities 800.1 201
Section 900: System Participation Suspension Policy Number Page
System Participation Suspension 900.1 203
System Participation Suspension - Notification of Other EMS Systems 900.1a 206
Workplace Violence/Harassment 900.2 207
Section 1000: Transportation/Communication Policy Number Page
Aeromedical Transport 1000.1 210
Hospital Medical Control: Telephone/MERCI/Starcom Communications 1000.2 212
Invalid Assistance/Service Calls 1000.3 216
Special Procedures – Mass Casualty Incident/Disaster (MCI) 1000.4 217
Special Procedures – Multiple Victim Incident (MVI) 1000.5 223
Special Procedures – EMAC and NAC Response 1000.6 226
Section 1100: Provider Well-being/Critical Incidents Policy Number Page
Critical Incident Stress Management (CISM) 1100.1 228
Patient Follow-Ups 1100.2 231
Death/Serious Injury of a First Responder/Line of Duty Death (LODD) 1100.3 232
Section 1200: Electronic Patient Care Reporting Policy Number Page
Definitions Relating to Electronic Patient Care Report (e-PCR) 1200.1 234
EMS Agency Acquisition of ePCR Software/Program 1200.2 235
ePCR Equipment and ePCR Software/Program Access 1200.3 236
Use of ePCR Charting Software/Program and Equipment 1200.4 238
ePCR Training 1200.5 239
Security and Confidentiality 1200.6 240
Completion of ePCR Forms 1200.7 241
ePCR Addenda 1200.8 243
Submission of the ePCR 1200.9 244
Storage of ePCRs 1200.10 245
ePCR Program/Software System Downtime/Failure 1200.11 246
Personnel Changes 1200.12 247
Allowable ePCR Modifications 1200.13 248
Email/Network Requirements for ePCR Usage and Official Correspondence 1200.14 249
3
Loyola EMS System
