1 TO: FROM: RE: ALS and BLS Ambulance Providers Base and Receiving Hospitals Continuing Education Providers Fire Departments Training Centers Other Interested parties Karen Petrilla, EMS Specialist Protocol, Policy and Procedure Manual Update DATE: September, 2009 Attached are the new and updated EMS policies that will go into effect on October, These polices have been reviewed and approved by Humberto Ochoa, MD, the EMS Agency Medical Director, and Bruce Barton, EMS Agency Director. Please distribute to your personnel and schedule training as necessary/required within the next 30 days. Existing copies of these policies should be discarded and replaced with the enclosed policies in your Riverside County Emergency Medical Services Protocol, Policy and Procedures Manual. Included with the policies are a synopsis of all the changes and an updated Table of Contents for your policy manual. This update packet will be available on-line at our website within a few days. You will find it under the Important News column. It will be integrated into the Policy and Procedure Manual pull-down prior to its effective date. Should you have any questions on these policies, please contact me at the EMS Agency office - - (95) Attachments
2 Fall 2009 Policy and Procedure Update All policies effective October, 2009 unless otherwise noted Service Providers two new STEMI centers added, both in San Bernardino Co -- LLUMC and San Antonio Community Hospital RCRMC listed as an adult (only) trauma center REACH added as a new air provider Policy Review total restructuring of this policy (approved by PMAC -08) EMT-I Training as approved by the training agencies -- minor wording changes, and new #7 added CE Provider minor grammar and wording changes to more closely align with T EMT-P Training new policy -- as approved by the training agencies 50 - Initial Responder Policy restoration of omitted verbiage no date change EMS Aircraft Ops, Equipment, and Personnel deletion of and D & E List for ALS Emergency Apparatus 3.n. - size 5 Fr. pharyngeal suction catheter removed 7.e. add meconium aspirator(s) to the optional equipment list D & E List for ALS Ambulances 3.n. - size 5 Fr. pharyngeal suction catheter removed 7.e. add meconium aspirator(s) to the optional equipment list PPE for Ambulances addition of the federally-required hi visibility safety vests BLS Transport after ALS Assessment new policy Consent and Refusal of Medical Treatment.2 - verbiage changes to coincide with policy 500 (PMAC -08) Intro to ALS Policies Two lines added for clarification of BH contact and transportation
3 Fall 2009 Policy Update Page 2 of Cardiac Chest Discomfort change of BP minimum for NTG and MS administration wording changes to clarify the need for 2L: and completion of the STEMI assessment Asystole clarification of IO access PEA Burns clarification of IO access change of BP minimum for MS administration Non-Traumatic Shock clarification of IO access Altered Level of Consciousness typographical corrections --- no date change Beta Blockers - Ca++ Channel Blockers clarification of IO access Narcotics - Sedatives clarification of IO drug use clarification of ET use Acute Pulmonary Edema change of BP minimum for NTG and MS administration 25 - King Airway new policy -- This skill is to be implemented only after adoption by the provider agency and approval/confirmation by the EMS Agency
5 RIVERSIDE COUNTY EMS AGENCY POLICY, PROTOCOL, and PROCEDURE MANUAL TABLE of CONTENTS POLICY NO. TITLE EFF. DATE Section 000 ADMINISTRATION: The Organization 000 Riverside County EMS Agency: Mission and Values Statement 4//97 00 Overview of Riverside County EMS 4// State Emergency Medical Services Framework 4// Pertinent EMS Legislation 2// EMS Agency Organizational Structure 4// EMS Agency Roles and Responsibilities //08 50 Emergency Medical Services Director //03 55 Emergency Medical Services Assistant Director // Emergency Medical Services Medical Director // Emergency Medical Services Specialist / Senior Specialist // Trauma Coordinator // Disaster Preparedness Planner 8// Office Assistant I / II / III 4// Emergency Medical Care Committee (EMCC) 2// Prehospital Medical Advisory Committee (PMAC) 5// Service Providers 0// Policy Review Procedure 0//09 Section 2000 ADMINISTRATION: Quality Assessment / Improvement 2000 Quality Assessment / Improvement Responsibilities 8// EMS Agency 4//97 20 Emergency Medical Dispatch (EMD) Provider Agencies 2// EMT-I and First Responder Provider Agencies 2// Defibrillation Medical Oversight // ALS Provider Agencies 4// Base Hospitals 4// Confidential Incident Review Process 4// Certificate Review Process 7// Trauma Audit Committee 2// Trauma Program Managers Committee // Receiving Hospital Trauma Patient Registry 7//06 Section 3000 ADMINISTRATION: Certification 3000 Fee Schedule 2// Continuing Education (CE) For EMS Personnel // EMT-I Certification 6// EMT-I Recertification 6// EMT-I Certification by Challenge 6//08 - -
6 POLICY NO. TITLE EFF. DATE 3400 EMT-Paramedic Accreditation 8// EMT-Paramedic Continuing Accreditation (Reverification) 2// Mobile Intensive Care Nurse (MICN) // Mobile Intensive Care Nurse (MICN) Reauthorization // Mobile Intensive Care Nurse (MICN) Authorization by Challenge 2//05 Section 4000 ADMINISTRATION: Program Approval 4000 Emergency Medical Technician-I (EMT-I) Training 0//09 40 EMT AED Service Provider 2// First Responder Defibrillation Provider Agency 2// EMT-I Skills Competency Verification // Emergency Medical Dispatch (EMD) Training 2// Emergency Medical Dispatch (EMD) Provider Agency 2// Continuing Education Provider 0// Emergency Medical Technician-Paramedic (EMT-P) Training 0//09 Section 5000 OPERATIONS: General Policy (BLS/ALS) 500 Authority for Medical Emergency Scene Management 9//06 50 Initial Responder Policy 7// ALS Responder 4// Emergency Medical Services Aircraft Operations, Equipment, and Personnel 0// Equipment and Supplies for First Responder / EMT-I Emergency Apparatus 2// Equipment and Supplies for Basic Life Support Ambulances 6// Equipment and Supplies for Advanced Life Support Emergency Apparatus 0// Equipment and Supplies for Advanced Life Support Ambulances 0// Personal Protective Equipment (PPE) for Ambulances 6// Radio Communication Standard 6// ReddiNet Operations // Ambulance Diversion // Cancellation / Reduction of Ambulance Equipment At Scene 4// Utilization of BLS Ambulance When Primary ALS Ambulance is Delayed 7// EMT-P Non-Acceptance of Patient Care Responsibility // BLS Transport After ALS Assessment for Rural Transport Providers 0// Crime Scene Management 4// Consent and Refusal of Medical Treatment 0// Transport 7// Restraints 7// Withholding Resuscitation Efforts // Withdrawal of Resuscitation Efforts // Do Not Resuscitate (DNR) // Prehospital Medical Destination 6// Trauma Triage Indicators and Destination // Burn Patient Destination 6// STEMI Receiving Centers // Multiple Casualty Incident (MCI) Scene Management 6// Utilization of Mobile Basic & Advanced Life Support Caches // Self-Treatment with Mark-I Kits // Self-Application (Protection) with an Emergency Escape Hood 6//05-2 -
7 POLICY NO. TITLE EFF. DATE Section 6000 OPERATIONS: Patient Care Policy (BLS) 6000 Introduction to BLS Protocols 6// Preprescribed Medical Devices 6// EMT-I Medical Adjuncts Monitoring 6// EMT-I Interfacility Transport of Patients With IV Lines 6// BLS Defibrillation Protocol 6// Axial Spinal Immobilization 6//08 Behavioral Emergencies 600 Assault Victim //07 60 Crisis //07 Cardiac Emergencies 6200 Chest Pain // Cardiac Arrest Severe Bradycardia //07 Environmental Emergencies 6300 Burns // Drowning / Near Drowning // Heat Illness / Hyperthermia // Hypothermia / Frostbite //07 Medical Emergencies 6400 Abdominal Pain // Anaphylaxis // Hypertensive Emergencies // Shock (Non-Traumatic) //07 Neurologic Emergencies 6500 Altered Level of Consciousness / Coma (Non-Diabetic) // Altered Level of Consciousness / Coma (Complications of Diabetes) // Acute Cerebrovascular Accident / Transient Ischemic Attack (CVA, TIA) // Seizures // Syncope / Near Syncope //07 OB / Gyn Emergencies 6600 Severe Pre-Eclampsia / Eclampsia // Imminent Delivery (Normal) // Imminent Delivery (With Complications) // Vaginal Hemorrhage without Shock // Vaginal Hemorrhage with Shock // Neonatal Resuscitation //07 Poisonings 6700 Poisons / Drugs //07 Respiratory Emergencies 6800 Respiratory Arrest // Acute Respiratory Distress // Airway Obstruction // Croup / Epiglottitis //07-3 -
8 POLICY NO. TITLE EFF. DATE Traumatic Emergencies 6900 Traumatic Arrest // Traumatic Shock // Extremity Trauma // Head-Neck-Facial Trauma //07 Section 7000 OPERATIONS: Adult Treatment Protocols (ALS) 7000 Introduction to ALS Protocols 0// Management of Controlled Substances 2// Physician on Scene 4// ALS Interfacility Transfers 2// EMT-P Interfacility Transport of Patient with IV Lines // Intravenous Infusions of Heparin and Nitroglycerin 6// ALS Unit Reporting Format 6// Advanced Life Support Guidelines 7//06 Cardiac Emergencies 7200 Cardiac Chest Discomfort 0// STEMI Assessment 2// Bradycardia // Paroxysmal Supraventricular Tachycardia (PSVT) 6// Wide Complex Tachycardia or Ventricular Tachycardia with Pulses // Ventricular Fibrillation Pulseless Ventricular Tachycardia 6// Asystole 0// Pulseless Electrical Activity (PEA) 0//09 Environmental Emergencies 7300 Burns 0// Heat Illness 2// Hypothermia Frostbite 4//97 Medical Emergencies 740 Allergic Reaction 4// Hypoglycemia Diabetic Ketoacidosis 4// Non-Traumatic Shock 0//09 Neurologic Emergencies 7500 Altered Level of Consciousness 2// Acute Cerebrovascular Accident // Status Seizure 2//05 OB / Gyn Emergencies 7600 Eclamptic Seizures // Childbirth 7//99 Poisonings 770 Beta Blockers Calcium Channel Blockers 0// Caustics Corrosives 4// Cyclic Antidepressants 2// Narcotics Sedatives 0//09-4 -
11 Page of 3 ADMINISTRATION: The Organization Policy: 700 BASE HOSPITALS: SERVICE PROVIDERS Desert Regional Medical Center Eisenhower Medical Center Inland Valley Medical Center JF Kennedy Memorial Hospital Palo Verde Hospital Riverside Community Hospital Riverside County Regional Medical Center RECEIVING HOSPITALS (not listed above): Arrowhead Regional Medical Center (SBCo) Corona Regional Medical Center Hemet Valley Medical Center Kaiser Permanente-Riverside Loma Linda University Medical Center (SBCo) Menifee Valley Medical Center Moreno Valley Community Hospital Parkview Community Hospital Rancho Springs Medical Center Redlands Community Hospital (SBCo) San Gorgonio Memorial Hospital TRAUMA CENTERS: Arrowhead Regional Medical Center (Level 2) Desert Regional Medical Center (Level 2) Inland Valley Medical Center (Level 3) Loma Linda University Medical Center (ACS Level, Adult with Pediatric Emphasis TC) Riverside Community Hospital (Level 2) Riverside County Regional Medical Center (Level 2, County-designated Pediatric TC) STEMI CENTERS Desert Regional Medical Center Eisenhower Medical Center Loma Linda University Medical Center (SBCo) Riverside Community Hospital San Antonio Community Hospital (SBCo)
12 Page 2 of 3 ADMINISTRATION: The Organization Policy: 700 BURN CENTERS: Arrowhead Regional Medical Center SERVICE PROVIDERS OBSTETRICAL/NURSERIES: Corona Regional Medical Center (Level Nursery) Desert Regional Medical Center (Level 2 Nursery) Hemet Valley Medical Center (Level Nursery) Inland Valley Medical Center (Level Nursery) JF Kennedy Memorial Hospital (Level Nursery) Kaiser Permanente Hospital (Level 2 Nursery) Loma Linda University Medical Center (Level 3 Nursery) Moreno Valley Community Hospital (Level Nursery) Parkview Community Hospital (Level 3 Nursery) Redlands Community Hospital (Level 2 Nursery) Riverside Community Hospital (Level 2 Nursery) Riverside County Regional Medical Center (Level 3 Nursery) San Gorgonio Memorial Hospital (Level Nursery) Rancho Springs Medical Center (Level Nursery) Level = Basic Nursery Level 2 = Intermediate Nursery Level 3 = Intensive Care Nursery ADVANCED LIFE SUPPORT (ALS) AMBULANCE PROVIDERS: American Medical Response (Riverside, Hemet, and Desert Cities divisions) Blythe Ambulance Service Cathedral City Fire Department Idyllwild Fire Protection District Riverside County Fire Department (including Cove Communities, Indio)
13 Page 3 of 3 ADMINISTRATION: The Organization Policy: 700 SERVICE PROVIDERS ADVANCED LIFE SUPPORT (ALS) SERVICE PROVIDERS: Corona Fire Department Murrieta Fire Department Norco Fire Department Palm Springs Fire Department Riverside City Fire Department Riverside County Fire Department AIR AMBULANCE PROVIDERS: Mercy Air REACH CHP Air Operations (air rescue) DESIGNATED 550 RECEIVING FACILITIES CESU - - Children s Evaluation Services Unit ETS - - Emergency Treatment Services OCS - - Oasis Crisis Services Moreno Valley Community Hospital
14 Page of 2 ADMINISTRATION: Policy Review Procedure Policy: 800 POLICY REVIEW PROCEDURE. The policy review process is an advisory process to the EMS Agency for the formulation of prehospital care policies. Policy suggestions and/or draft policies are accepted from committees, system participants, individuals and/or interested parties. 2. The EMS Agency tracks all policies in the review process. The status of each policy under consideration will be available during the review process. 3. New Policies and/or Major Revisions to Existing Policies 3. Public Testimony - Proposed new policies and major revisions to existing polices will be subject to public comment on a broad scale 3.. The EMS Agency will make copies of the proposed changes/new policy available to the appropriate system participants and/or interested parties for comments Proposals that affect the EMS system as a whole will be sent out and/or posted on the Riverside County EMS Agency s website at for review by all system participants Proposals that apply to a limited group will only be sent to those who would be directly affected Time will be allotted at the appropriate committee(s) meeting for public testimony and discussion by the committee(s) members. Specific recommendations may be made by the committee(s) regarding the policy All comments will be reviewed by the EMS Agency Director and staff. Suggestions for additions or deletions will be taken into consideration. From these comments, a second draft proposal will be formulated. 3.2 Written Public Comment - The second draft of the proposal will be subject to written comment The second draft will be included on the agenda as an attachment for the next most appropriate Prehospital Medical Advisory Committee (PMAC) meeting nd drafts that affect the EMS system as a whole will be sent out and/or posted on the Riverside County EMS Agency s website at for review by all system participants nd drafts that apply to a limited group will only be sent to those who would be directly affected The period allowed for the return of comments will be no less than 30 days Comments should identify specific recommendations for change Comments may be mailed, ed, or faxed to the EMS Agency, but must be received no later than 5pm on the deadline date Responses from EMS Agency regarding the committee(s) recommendations will be distributed with the agenda for the subsequent appropriate committee(s) meeting. ADMINISTRATION: Policy Review Procedure Policy: 800
15 Page 2 of 2 POLICY REVIEW PROCEDURE 3.3 Policy Finalization 3.3. All policies will be prepared in final form by the EMS Agency. Public testimony, written comments, and committee recommendations will be taken into consideration by the EMS Agency during the finalization of the policy Finalized policies will either be held until the next EMS Policy Manual update, or, if necessary, distributed immediately. 4. Minor Policy Changes Policy changes of a minor nature will be subject to the Public Testimony portion of review. Minor changes include but are not limited to: changes in wording to clarify the objective changes in the listed order for clarity or better flow changes because the new/changed policy failed to comply with other current policies overlooked steps in a process changes to deal with unforeseen consequences 5. Automatic Policy Changes Some policy changes will occur without any input form the public or specific committees. Automatic changes include: changes required in order to comply with state and local law and/or regulation correction of typographical or formatting errors 6. After implementation of a new policy, it may be determined that changes are needed that were not initially foreseen in its development. Such necessary changes occurring within the first year of implementation will be subject to Public Testimony (only) prior to implementation.
16 Page of 2 ADMINISTRATION: Program Approval Policy: 4000 EMERGENCY MEDICAL TECHNICIAN-I (EMT-I) TRAINING. An agency or institution may request approval from the Riverside County EMS Agency as an EMT-I training provider. 2. Any institution/agency requesting approval as an EMT-I training/refresher provider must meet the qualifications for training providers as outlined in Title 22 Regulations (Section 00065). 3. Provider approval shall be for four (4) years, ending on the final day of the final month of the approval period. 4. Any training/refresher course offered by an approved provider must be executed within the approved periods. Courses beginning or ending outside of an approval period will not be considered approved courses and certification will not be granted to the participants. 5. Approved training courses will abide by state laws, regulations, and Riverside County EMS Agency policies and procedures. 6. Minimum competency requirements for program participants to successfully complete and pass approved training/refresher programs or a challenge examination will not be less than 80% on written final examinations and 80% on skills examinations, with 00% of the skills critical factors attained. 7. Each course offered by an approved training program shall have a designated Principal Instructor (PI) who shall be responsible for covering the approved content as specified by the program, personally instruct a minimum of 5% of the course content, be available for student conferences, and, in conjunction with the Program Director, oversee and approve all student grades. 8. Notification of each course offered by the approved provider shall be given to the EMS Agency using the Notification of Proposed EMS Course form, which shall be submitted as early as 60 days but not less than 30 days prior to the beginning of each course. 9. Challenge testing - test only option 9. Approved training programs are required to offer an EMT-I challenge exam no less than once each time a course is offered. 9.2 Challenge examinations shall be equivalent to the final written examination of a comprehensive EMT-I training program, with skills testing, to include, but not be limited to, patient assessment (medical and trauma), diagnostics and vital signs, all phases of airway management, spinal immobilization techniques, treatment of hemorrhage and shock, treatment of soft tissue injuries, splinting (to include traction splinting), AED, and childbirth. 0. Refresher classes must be offered no less than once per year.
17 Page 2 of 2 ADMINISTRATION: Program Approval Policy: 4000 EMERGENCY MEDICAL TECHNICIAN-I (EMT-I) TRAINING. All qualified institutions/agencies shall submit the following:. A completed Application for EMS Training/Refresher Program Approval (form EMS/TR-APP)..2 The completed application packet a minimum of 90 days prior to the beginning of the first proposed course offering or 90 days prior to their current program expiration if applying for reapproval..3 The names and qualifications of their Program Director, Clinical Coordinator and Principal Instructor(s) using the appropriate forms. 2. The EMS Agency will notify the submitting institution/agency within ten (0) working days of the receipt of the application packet that: 2. It has been received; and 2.2 It is complete or, if not, what information is missing. 3. The EMS Agency will notify the submitting institution/agency in writing of the approval/disapproval decision within 90 days of the receipt of the completed application packet. If approval is not granted, the reasons will be specified in writing.
18 Page of 5 ADMINISTRATION: Program Approval Policy: 4300 CONTINUING EDUCATION PROVIDER. The purpose of this policy is to establish procedures that allow for the approval of prehospital continuing education (CE) program providers in Riverside County and to assist providers in meeting the standards and requirement for CE providers in Riverside County. 2. Riverside County Emergency Medical Services (EMS) Agency recognizes the importance of uniformity on a statewide level for the process of continuing education and will abide by the most recent versions of the Title 22 (California Code of Regulations, CCR) regulations and State EMS Authority documents related to this issue. Riverside County EMS policy is intended to delineate and clarify the regulations, and in all cases supersedes them. 3. Any individual, agency or company within Riverside County may apply for approval by Riverside County EMS Agency as a recognized provider of prehospital continuing education. Riverside County EMS will approve course providers, not individual courses. 3. Approved EMS training centers will be granted CE provider status upon identification and appropriate documentation of CE staff, CE provider-specific documents (course completion certificates, rosters, advertisements), and the signing of the CE provider agreement. 4. The approved provider agrees to follow all policies, guidelines and procedures as established by the Riverside County EMS Agency, the State EMS Authority, and state laws and regulations. Providers will be notified, in writing, a minimum of 30 days in advance of the implementation of any revisions. 5. The approved provider will notify the Riverside County EMS Agency a minimum of one calendar month in advance of all CE course offerings by sending this information to the EMS Agency. 5. A Riverside County approved provider offering CE courses in another county must additionally notify THAT county s EMS agency of courses being offered in their jurisdiction. 6. Provider approval shall be for up to four (4) years. 6. Provisional approval of up to one () year may be granted to an agency whose Program Director is qualified by experience only. Full approval may be granted pending completion of specified educational requirements (reference #6 below). 6.2 Approval expires the final day of the final month of the approval period. 7. Provider approval is non-transferable. 8. Approved providers failing to comply with applicable policies and/or procedures may have their approval suspended or revoked by the EMS Agency.
19 Page 2 of 5 ADMINISTRATION: Program Approval Policy: 4300 CONTINUING EDUCATION PROVIDER 9. Providers must structure educational activities in accordance with the needs of their participants. ALS level classes will be expected to have both ALS objectives and BLS objectives if the course will be open/advertised to both levels of personnel. 0. Courses jointly sponsored by two or more providers will have only one of those providers responsible for issuing CE and maintaining records. The responsible provider will be the provider whose approval number is on the advertisements, roster and course completion certificates.. Providers must maintain CE records in a secure environment and are responsible for the security and integrity of the records they maintain.. Records shall be maintained a minimum of four (4) years..2 The name, address, and license/certification number of each person receiving a course completion (CE) certificate shall be kept on file and be made available at the request of the EMS Agency or the State EMS Authority..3 Copies of each of the following shall be maintained with each class file:.3. Course advertisement(s)..3.2 Instructor resume(s)..3.3 Course roster -- one for each day, if a multi-day course..3.4 Course overview, learning objectives, and detailed/comprehensive outline (teaching outline &/or lecturer s notes)..3.5 Copies of any student handouts (controlled notes, articles, etc)..3.6 Copy (blank) of the learning evaluation tool(s)..3.7 Copies of the completed learning evaluations from the participants, OR a summary/analysis of their scores..3.8 Copies of the completed course evaluations from the participants, OR a summary of their findings..3.9 A copy of the course completion certificate. 2. Determination of CE credit 2. Credit may only be issued to a participant upon successful passing of a written and/or skills competency based evaluation specific to the material covered by the course, class, or activity objectives. 2.2 Credit for structured clinical or ride-out, teaching, precepting and field care audit (FCA) will be issued on a : (hours:credit) basis Structured clinical and ride-out credits can only be issued by the agency which provides and reviews the structure (outline) that the individual must complete as part of his clinical/ride-out time. (In most cases this will be a hospital.) Teaching credits may only be issued by the provider employing the individual Credit may be issued only once during an individual s certification/licensure/authorization cycle for instructing a particular class or topic.
20 Page 3 of 5 ADMINISTRATION: Program Approval Policy: 4300 CONTINUING EDUCATION PROVIDER Precepting credit may only be issued by the approved training program contracted with the preceptor or his employer. 2.3 Partial credit may be issued to a course participant at the provider's discretion provided that: 2.3. The credit given is not less than one () CE hour, nor issued in less than one-half ( ½ ) hour increments The participant has completed all course evaluations Partial credit is recorded on the course completion certificate, and a record of the partial credit is maintained by the provider. 2.4 CE credit shall be issued only for actual class time attended. 3. All CE course advertisements must include, at minimum: 3. The provider s name and CE approval number (33-XXXX). 3.2 A clear, concise description of the course contents and objectives. 3.3 The target audience (ALS, BLS or both levels). 3.4 The number and type of EMS CE to be granted. (ex. 3 hours of CE, the blank to be filled in with one of the following phrases: instructor-based or non-instructor-based ) 3.5 Cost of course and information on refund policy. 4. Course evaluations are required for all CE offerings and must include, at minimum: 4. The extent to which the course met its stated objectives. 4.2 The adequacy of the instructor's knowledge of the subject matter. 4.3 Appropriateness of the teaching techniques/tools used. 4.4 Applicability/usability of the information to the participants' practice. 4.5 The extent to which the information was presented at a level that the participant could understand and assimilate. 5. Course completion certificates must be issued to all CE participants successfully passing the course. 5. Certificates must be issued to participants within 30 calendar days of course completion. 5.2 Certificates shall be tamper resistant. 5.3 Certificates shall include, at minimum: 5.3. Provider s name, address and EMS CE approval number (33-XXXX) Name of course Date of course completion Number and type of CE granted Participant s name and license/certification/authorization number Signature of course instructor or program director The following statement: "This course has been approved for (number) hours of continuing education by approved California EMS CE Provider 33-XXXX and was: (check one) instructor based, non-instructor based. OR... and was (non-)instructor based.
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