Del. Admin. Code tit. 16, Department of Health and Social Services, Division of Public Health, Emergency Medical Services (EMS), 4302, app C

Current through Register Vol. 28, No. 7, January 1, 2025

Appendix C - QUALITY MANAGEMENT

1. The service or organization shall have a written QA/CQI plan which includes the following components:

a) Responsibilityssignment of accountability

b) Scope of care

c) Important aspects of care

d) Indicators

e) Thresholds for evaluation which are appropriate to the individual service

f) Methodology

2. The service or organization shall regularly hold QA/CQI meetings.

3. The service or organization's monitoring and evaluation process shall have the following characteristics:

a) Driven by important aspects of care identified by the air medical service's QA/CQI plan

b) Indicators and control thresholds are used to objectively monitor the important aspects of care

c) Evidence of QA/CQI studies and evaluation in compliance with written QA/CQI plan

d) Evidence of reporting QA/CQI activities through established QA/CQI organizational structure

e) Evidence of on-going re-evaluation of action plans until problem resolution occurs

4. Quarterly review shall monitor, at a minimum, the following:

a) Reason for transport

b) Mechanism of injury or illness

c) Medical interventions performed or maintained

(1) Time of intervention consistently documented

(2) Patient's response to intervention documented

(3) Appropriateness of interventions performed or omission of needed interventions

d) Patient's outcome (morbidity and mortality) at the time of arrival at destination (including any change in condition during flight)

e) Timeliness of the transport

f) Safety practices

(1) Safety issues may be handled through the Safety Committee when a problem is identified.

(2) QA/CQI personnel may collect data and refer to the Safety Committee for action and resolution.

g) Operational criteria to include at a minimum the following indicators:

(1) Number of aborted and canceled flights due to weather

(2) Number of aborted and canceled flights due to maintenance

(3) Number of aborted and canceled flights resulting in the use of alternative modes of transport due to patient condition.

5. Utilization appropriateness - the following indicators may trigger a review of the EDIN record by the Office of Emergency Medical Services, or their designate, to determine the medical appropriateness of the transport, based upon patients who are:

a) Discharged home directly from the Emergency Department, or discharged within 24 hours of admission

b) Transported without an IV line or oxygen

c) In cardiopulmonary arrest where CPR is in progress at the referring location

d) Not transferred from a critical care unit, emergency department, or other specialty care unit.

e) "Scheduled transports"

f) Air transported more than once for the same illness or injury within 24 hours

g) Transported from the scene of an injury and fails to meet the criteria outlined in the "Prehospital Trauma Triage Scheme" in Section VI of the State Trauma System Regulations.

h) Transported interfacility, and the receiving facility is not a higher level of care than the referring facility

6. For both QA/CQI and utilization review programs, there shall be evidence of actions taken in problem areas and the evaluation of the effectiveness of that action.

Del. Admin. Code tit. 16, Department of Health and Social Services, Division of Public Health, Emergency Medical Services (EMS), 4302, app C

4 DE Reg. 1827 (5/1/01)