THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.

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1 Regional Emergency Medical Advisory Committee Minutes November 10, 2015 The Regional Emergency Medical Advisory Committee (REMAC) of New York City met on Tuesday, November 10, 2015 at the Offices of the Regional EMS Council of NYC, 475 Riverside Drive, Lounge, New York City. This meeting can be viewed via webcast at Members Present Absent Excused EMS Community Emergency Department Nikolaos Alexandrou, MD Medical Directors (3) Allen Cherson, DO Nurses (2) Administrators (2) FDNY EMS Christopher Graziano, MD Eric Cohen, RN Mimi Langsam, RN Vacant Kevin Munjal, MD Commissioner or Non- Physician Designee Medical Director (3) Vacant Dario Gonzalez, MD Glenn Asaeda, MD Bradley Kaufman, MD Online Medical Control Physicians (2) Nathan Reisman, MD Doug Isaacs, MD Evan Suchecki, EMTP

2 Emergency Medical Technicians (Basic/Paramedic) (2) Christopher Swanson, EMTP GNYHA President or Non- Physician Designee (1) Alison Burke Vacant, alt Emergency Physician (1) Jeffrey Rabrich, MD Michael Redlener, MD, alt Ambulance Service Medical Director (1) Heidi Cordi, MD, Second Vice Chair On Line Medical Control Physicians (2) Lewis Marshall, JD, MD Chair Josef Schenker, MD Emergency Department Administrator (2) Michael Guttenberg, DO Vacant Emergency Medical Technicians (Basic/Paramedic) (2) R. Shawn Bowe, EMTP/Anthony Conrardy, EMTP, alt Dominick Battinelli, EMTP Medical Standards Committee ALS Physician (1) Paul Barbara, MD BLS Physician (1) David Ben-Eli, MD Medical Society of New York Physician (1) New York City Department of Health & Mental Hygiene-Emergency Preparedness Program Physician (1) Peter Wyer, MD Celia Quinn, MD, MPH

3 Members Present Absent Excused New York City Health & Hospitals Corporation Physician (1) New York City Police Department Physician (1) Vacant Charles Martinez, MD Victor Politi, MD, alt NYS Volunteer Ambulance & Rescue Association/District 4 & 18 Ambulance Service Medical Director (1) Joseph Bove, MD, First Vice Chair Emergency Medical Technicians (Basic/Paramedic) (2) Ralph Cefalo, EMT Martin Grillo, EMTP Burn Surgeon (1) Robert J. Winchell, MD Pediatric Emergency Medicine Physician (1) George Foltin, MD Stephen Blumberg, MD, alternate Psychiatric Emergency Medicine Physician (1) William Fisher, MD Regional EMS Council NYC Physician (1) Robert Crupi, MD Trauma Surgeon (1) Arthur Cooper, MD Gary Marshall, MD, alternate Training & Education Committee Physician (1) Jessica van Voorhees, MD

4 Members Present Absent Excused United New York Ambulance Network (UNYAN) Ambulance Service Medical Director (1) Victor Politi, MD Emergency Medical Technicians (Basic/Paramedic) (2) Non-Voting X Michael Vatch, EMTP Robert Ackerman, Alt Maryanne Sawyer, EMT vacant, alt At Large Yedidyah Langsam, PhD, EMTP At Large Vacant Public Christopher Sorrentino, RN STAFF Nancy A. Benedetto, Executive Director Administration Marie Diglio, EMTP, Executive Director Operations Joseph Raneri, Disaster Preparedness Coordinator GUESTS: Carolina Pereira, FDNY EMS Fellow Dr. Lewis Marshall, Chair, called the meeting to order. For the purposes of web casting, a roll call was performed. A quorum was present. The Minutes of the October 20, 2015 REMAC Meeting were approved.. Voting Requirements. A quorum is based on the number of voting seats whether they are filled or vacant. Currently, REMAC has 28 voting seats, so when voting, a majority of members must vote in the affirmative to pass any motion. That means, 15 votes in the affirmative are needed to pass any motion.

5 CORRESPONDENCE REPORT The Offices of the Council received the following correspondence: Membership: The following members requested to be excused: Robert Crupi, Michael Vatch, Robert Ackerman. FDNY nominates Nathan Reisman to replace Dr. Zimmerman. - This appointment was discussed and approved. From NYS DOH: None Public Notice from New York State Department of Health, Bureau of EMS, Operations Unit, to be read into the REMAC Minutes of the following enforcement actions: Provider / Agency Name none EMT / Agency # Penalty Violation of County of Residence FDNY EMS: Deficit Reduction Act notice PCR inventory and non-compliance reports. Epi-Pen Auto Injector Applications received from: None

6 Spine Injury Updates: - Many are currently in the process of completing the online program, but have been delayed due to difficulty accessing the NYS DOH online program. This appears to be a system wide issue. Complete Maimonides Chevra Hatzalah VAC East Midwood VAC Forest Hills VAC NYRA Montefiore Rockaway Point Vol Fire and Rescue Ambulance PAPD Ambulance Jamaica Hospital Flushing Hospital Medical Center MediSys Ambulance Services In Process FDNY, January 31, 2016 t anticipated completion date TransCare, December 31 anticipated completion St. Luke s Roosevelt EMS has 80% completion as of 11/2/15 Flatlands, anticipate 11/30/15 completion Hunter Ambulance/Hunter EMS SIUH Northshore Ambulance (11/1/2015) New-York Presbyterian Hospital NYU Lutheran (80% complete, done within the next week) Little Neck - Douglaston Community Ambulance Corps NYS DOH has been advised that NYC REMAC has granted extensions to these requesting services. The Office of the Council sent the following correspondence: Agendas, Minutes and associated attachments for the meeting. REMAC and Medical Standards Bylaws SUBCOMMITTEE REPORTS Medical Standards Committee (Bradley Kaufman, MD, Chair) In the absence of Dr. Bradley Kaufman, Dr. Jessica van Voorhees reported the following actionable motions. 1. Delete Hyperventilation from BLS Protocol 421 Head and Spine Injuries by adding a new #7: Add: New # 7: Hyperventilation should not be performed. This motion was voted upon via a roll-call vote, as follows: 19 in favor, 0 opposed, 0 abstain. The motion carried. 2. Delete the age limit of over 33 for administration of epinephrine in BLS Protocol 407 Wheezing and 410 Anaphylactic Reaction: If the patient is having severe respiratory distress or shock and is under 33 years of age, administer Epinephrine (one dose only) via an auto-injector. NOTE: Patients 9 years of age and older or weighing more than 30 kg (66 lbs) use adult Epinephrine auto-injector (0.3 mg); patients younger than 9 years of

7 age or weighing less than 30 kg (66 lbs) use pediatric Epinephrine autoinjector (0.15 mg). Administration of epinephrine via auto-injector must be reported to your agency s medical director as soon as possible Contact On-Line Medical Control for authorization to administer a second dose of Epinephrine, via an auto-injector, if needed and if available, or for initial administration of Epinephrine via auto-injector to a patient who is 33 years of age or older. This motion was voted upon via a roll-call vote, as follows: 16 in favor, 4 opposed, 0 abstain. The motion carried. The next meeting of the Medical Standards Committee will be held on Tuesday, January 12, 2016 REGIONAL COUNCIL UPDATE The Regional Emergency Medical Services Council of New York City did not have a quorum. The next meeting of the Regional EMS Council will be held on Tuesday, January 26, JOINT REMSCO/REMAC QA COMMITTEE UPDATE (JOSEPH SCHENKER, MD, CHAIR) Dr. Schenker reported that the Joint Regional Emergency Medical Services Council/Regional Emergency Medical Advisory Committee (REMAC) Quality Improvement Committee met on July 10 and November 3, The following is a summary of both meetings: Course Sponsor applications: NEW Application: Recommended for approval Davis Training Programs, Inc. This will be forwarded to REMSCO for consideration. ALS Agency Medical Director Requirements: Originally allowed grand-fathering. This was changed to allow for a two-year implementation sunset date. Most existing medical directors already meet new requirements. Intention is to promote system involvement of medical directors. Evidence of meeting new requirements would only require a simple check list sent to QA Committee. Medical directors not meeting new requirements would lose OLMCP status. Ambulance and ALS First Response Services cannot operate without a REMAC approved OLMCP. REMAC received copy of this draft document and discussed it. It was stated that this policy was originally created for ALS agency medical directors. Once implemented it may be expanded to include BLS agency medical directors. REMAC referred the document back to QA for final revision. The draft document is attached.

8 Community Paramedicine Program Report Dr. Kevin Munjal gave a report on the status of this program as of October 30, 2015: Nine (9) physicians have been trained and credentialed as Tele-Medicine Physicians, another 12 are in process. 20 paramedics have been trained. Cases have been treated with success, showing an increase in avoidance of transport to hospital. Overall, a very positive outcome. Additional information will be provided. Members were impressed, and expressed hope that this program could be expanded in the region. QA Study in Process: Notification Times Trauma (and other specialty) notifications must be studied. Dr. Schenker will develop questions for a survey to identify baseline for notifications A survey to EMS agencies will be developed. Trauma criteria that can be understood and utilized by filed providers must be developed. FDNY has provided a copy of its notification policy The next QA Meeting is scheduled for January 5, STATE EMS COUNCIL/SEMAC UPDATE (Yedidyah Langsam, PhD) No new report. The next SEMSCO/SEMAC meeting will be held on December 8 & 9, UNFINISHED BUSINESS The Medical Standards and REMAC Bylaws have been distributed to members for review. They have aged at the October and November meetings, and will be voted upon at January 2016 meeting. NEW BUSINESS No new business was discussed. Members were wished a happy holiday and new year. The meeting adjourned at 7:30pm. The next meeting of the REMAC Committee will be held on January 12, 2016.

9 REGIONAL EMERGENCY MEDICAL ADVISORY COMMITTEE BYLAWS JANUARY 2010 WORKING DRAFT The Regional Emergency Medical Advisory Committee (REMAC) of New York City is a subcommittee of the Regional Emergency Medical Services Council (REMSCO) of New York City established pursuant to Chapter 804 of the Laws of 1992, Amended Article 30 of the New York State Public Health Law. It is comprised of representatives of organizations within the emergency medical services system of the City of New York. It is established to provide medical guidance and advice on the prehospital care, and inter-facility transport and other outof-hospital care identified in Article 30, to the emergency medical care providers that operate in the City of New York. PURPOSE The specific functions of this group are: 1. Coordinate the development of a regional medical control system; 2. To develop regional standards of pre-hospital care, interfacility transport, other out-ofhospital care identified in Article 30 and medical direction thereof; 3. To develop and approve treatment, triage, and transportation protocols; 4. Participate in quality improvement activities addressing system-wide concerns, including the review of protocol compliance, medical care rendered and medical supervision provided throughout the system; and 5. To approve training sites, course curricula, and certification standards and processes for prehospital personnel and medical control physicians. MEMBERSHIP to be discussed with full REMAC There shall be 42 members of REMAC. Membership shall include representatives from the following organizations: 1. Fire Department, City of New York a. One (1) Commissioner or Non-Physician Designee b. Three (3) Medical Directors c. Two (2) On Line Medical Control Physicians d. Two (2) Emergency Medical Technicians (Basic/Paramedic) 2. Greater New York Hospital Association a. One (1) President or Non-Physician Designee b. One (1) Emergency Department Physician c. One (1) Ambulance Service Medical Director d. Two (2) On Line Medical Control Physicians e. Two (2) Emergency Department Administrators f. Two (2) Emergency Medical Technicians (Basic/Paramedic) 3. New York State Ambulance Association a. One (1) Ambulance Service Medical Director b. Two (2) Emergency Medical Technicians (Basic/Paramedic) WORKING DRAFT Page 1

10 Regional Emergency Medical Advisory Committee of New York City Bylaws 5. New York State Volunteer Ambulance & Rescue Association a. Ambulance Service Medical Director 3 b. Two (2) Emergency Medical Technicians (Basic/Paramedic) 6. Three (3) Emergency Department Medical Directors 7. Two (2) Emergency Department Nurses 7 8. Two (2) Emergency Department Administrators 9. One (1) Trauma Surgeon from a regional Trauma Center One (1) Burn Surgeon from a regional Burn Center Psychiatric Emergency Medicine Physician Pediatric Emergency Medicine Physician New York City Police Department Physician New York City Health & Hospitals Corporation Physician Regional EMS Council of New York City Physician Training & Education Committee Physician Medical Standards Committee a. BLS Physician 1 b. ALS Physician NYC Department of Health & Mental Hygiene Healthcare Emergency 1 Preparedness Program Physician 19. Medical Society of the State of New York Physician Non-Voting Seats 3 a. Two (2) At Large b. Public (consumer) TOTAL 42 Among these organizations providing representatives, those that provide physician representatives shall provide physicians who are active in emergency medical services. Others nominated by their constituent organizations are members of this group either ex-officio or are appointed due to their professional affiliations. TERMS OF APPOINTMENT With the exception of those who hold their positions ex-officio (by virtue of holding another office, i.e., Medical Director FDNY EMS), each appointment shall be for a period of two years. Members may succeed themselves. Nominations are due in September, official vote shall take place in October, followed by appointments in the following January. Terms will begin on January 1 st, and end on December 31 st. APPOINTMENT PROCESS Nominations from the constituent organizations of REMAC shall be made to REMAC which shall forward the nominations to the Regional EMS Council for approval. It is the responsibility of each constituent organization to define the process by which a member will be nominated to REMAC. Where constituent organizations do not normally meet for the purpose of this kind, or where there is more than one constituent organization that falls under the organizational Approved March 200 Page 2 Revised/Approved January 2008 WORKING DRAFT

11 Regional Emergency Medical Advisory Committee of New York City Bylaws category permitted to nominate to REMAC, the involved constituent organizations shall choose a mutually acceptable, rotating nomination process. On Line Medical Control Physicians are those physicians who are credentialed by REMAC, are in compliance with Part 80 of the New York State Public Health Code, and are actively providing on line medical control through a facility approved by REMAC. For purposes of nominating On Line Medical Control Physicians from the municipal sector, REMAC shall seek a nomination from the Office of Medical Affairs of the Fire Department City of New York. For the purposes of nominating Emergency Department Physicians, Nurses, and Administrators (not appointed by other organizations) REMAC shall seek nominations from the emergency medical community and various emergency medical organizations. For the purposes of nominating a Trauma Surgeon, REMAC shall seek nominations from the Regional Trauma Center Advisory Committee. For the purposes of nominating a Burn Surgeon, REMAC shall seek nominations from regional Burn Centers. For the purposes of nominating a Psychiatric Emergency Physician, REMAC shall seek a nomination from the Commissioner of Health and Mental Hygiene of the City of New York or a regional academic psychiatric training program. For the purposes of nominating a representative from the Pediatric Emergency Medicine Physician community, REMAC shall seek a nomination from the Committee on the Emergency Medical Services for Children of District II of the American Academy of Pediatrics. For the purposes of nominating a representative from the NYC Department of Health & Mental Hygiene Healthcare Emergency Preparedness Program Physician, REMAC shall seek a nomination from the Commissioner of Health and Mental Hygiene of the City of New York or designee. REMOVAL FROM MEMBERSHIP Once seated, a representative may be removed by the nominating constituent organization or a two-thirds written vote of the entire membership of REMAC. Members with more than three unexcused absences from regular meetings each REMAC year shall be considered to have voluntarily resigned and will be notified in writing thereof. Absences for which members are represented by their designated alternates shall not be counted as unexcused absences. Vacancies shall be filled as soon as possible after they arise, in accordance with the process described above, to complete the un-expired portion of the terms. DESIGNATED ALTERNATES Designated alternates for each member are permissible provided that they are duly nominated by the constituent organization involved. Designated physician alternates may vote when their principal member is not present. MEETING TIME REMAC shall meet not fewer than six times per year. A calendar of meetings shall be distributed at the beginning of each REMAC year. Approved March 200 Revised/Approved January 2008 WORKING DRAFT Page 3

12 Regional Emergency Medical Advisory Committee of New York City Bylaws CONDUCT OF BUSINESS Only physicians are eligible to vote. Designated physician alternates shall be counted as voting members for the purposes of quorum when their principal is not present. All issues shall be decided by a simple majority of those present and voting, provided that a quorum is present. A quorum shall consist of 50% of the seated, voting members, but shall never be less than ten (10). All votes shall be voice votes, unless a written vote is requested by a member of REMAC. The Chair shall be empowered to allow for a written and or electronic ballot in the event that a quorum cannot be achieved for two (2) successive meetings, when so directed by the membership of REMAC. OFFICERS REMAC shall have as officers a Chair, 1st Vice Chair, and 2nd Vice Chair. The Chair and Vice Chairs shall be physicians. All officers shall serve for a period of two years. The Chair may participate fully in all debates and shall have the right to cast a vote in the event of a tie. The Chair shall preside at all meetings and shall have the right to convene emergency meetings as necessary. The Vice Chair shall assume the responsibilities of the Chair in the absence of the Chair. REMAC shall nominate to the Commissioner of Health of the State of New York two (2) physicians to serve on the State Emergency Medical Advisory Committee. COMMITTEES REMAC shall establish an Executive Committee, consisting of its three elected officers. The Executive Committee shall have general supervision of the affairs of REMAC between its regular meetings, and shall have the power to approve the credentials of medical control physicians, subject to review by REMAC. REMAC shall establish standing Advisory Committees that focus on medical control issues related to Advanced and Basic Life Support (Medical Standards Committee), including first responders, and a standing Joint Quality Assurance/Quality Improvement (QA/QI) Committee in conjunction with the Regional EMS Council. The standing Committees shall develop their own Bylaws and submit the Bylaws to REMAC for approval. The Chair, with the approval of REMAC, shall establish a Nominating Committee for officers biennially. The Chair, with the approval of REMAC, shall establish ad hoc Committees as needed. The Chair, with the approval of REMAC, shall prospectively define the scope of activity and duration of service of all ad hoc committees. Representation on REMAC Committees shall be inclusive of all prehospital care sectors, as appropriate. AMENDMENTS These Bylaws may be amended only after proposed amendment has aged between, at a minimum, two (2) consecutive REMAC meetings and then by a two-thirds vote of the seated, voting members of REMAC. Approved March 200 Revised/Approved January 2008 WORKING DRAFT Page 4

13 Regional Emergency Medical Advisory Committee of New York City Bylaws PROCESS/REPORTING RELATIONSHIP OF REMAC Regional Emergency Medical Services Council of New York City (REMSCO) Decisions on medical matters made by REMAC will be sent to the Regional Emergency Medical Services Council of New York City for advice and comment and to the Regional Emergency Medical Services Council of New York City, Inc. for information purposes only. State Emergency Medical Advisory Committee (SEMAC) REMAC shall report to the State Emergency Medical Advisory Committee as required by Statute. CONSTRUCTION If any part of these Bylaws is in conflict with Statute, the Statute shall prevail. SEVERABILITY If any part of these Bylaws is judged invalid by a Court of competent jurisdiction, the judgment shall not invalidate the remainder thereof. Approved March 200 Revised/Approved January 2008 WORKING DRAFT Page 5

14 Revised REMAC DRAFT DRAFT REMAC Requirements for ALS EMS Agency Medical Director The Regional Emergency Medical Advisory Committee (REMAC) of New York City has statutory authority to oversee the provision of medical care by Emergency Medical Services operating in New York City. The Regional Emergency Medical Advisory Committee (REMAC) of New York City operates under the auspices of Article Thirty of the New York State Public Health Law All Advanced Life Support (Paramedic Level) Agencies are required, as a condition of initial and/or continued REMAC NYC approval, to provide medical direction and oversight with a REMAC credentialed Agency Medical Director. To ensure adequate physician involvement and to maintain quality, agencies must maintain a ratio of one (1) REMAC credentialed EMS Medical Director for every 100 paramedics employed by or affiliated with that agency. 2. In addition to being licensed to practice medicine in New York State, a REMAC credentialed EMS Agency Medical Director must fulfill at least one of the following categories: a. Category A Board Certified or Board Eligible in EMS Medicine by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM). b. Category B i. Successfully completed an acceptable, unaccredited fellowship in EMS AND 1 Article 30, Section 3004-A. Regional Emergency Medical Advisory Committees. 1. Regional emergency medical advisory committees shall develop policies, procedures, and triage, treatment, and transportation protocols which are consistent with the standards of the state emergency medical advisory committee and which address specific local conditions. Regional emergency medical advisory committees may also approve physicians to provide on line medical control, coordinate the development of regional medical control systems, and participate in quality improvement activities addressing system-wide concerns. Hospitals and prehospital medical care services shall be authorized to release patient outcome information to regional emergency medical advisory committees for purposes of assessing prehospital care concerns. Regional quality improvement programs shall be presumed to be an extension of the quality improvement program set forth in section three thousand six of this article, and the provisions of subdivisions two and three of such section three thousand six shall apply to such programs. DRAFT

15 Revised REMAC DRAFT ii. Have completed a minimum of 24 months of EMS practice of at least 400 hours per year. c. Category C i. Board certification in Emergency Medicine, Internal Medicine, General Surgery, or Pediatrics by an American Board of Medical Specialties (ABMS) member Board. AND ii. Have completed a minimum of 48 months of EMS practice of at least 400 hours per year. d. Category D i. Have completed a minimum of 60 months of EMS practice of at least 400 hours per year. NOTES Definition of EMS Practice as used in above categories: Physicians can have practiced EMS as Assistant Medical Director, Associate Medical Director, Medical Director, or within another leadership role of one or more EMS agencies with patient care responsibility; or as a direct provider of prehospital emergency care; or any combination of these roles. REMAC credentialing of a physician as an EMS Agency Medical Director must be renewed every 5 years. Maintenance of REMAC Certification as an Agency Medical Director requires that the physician: 1. Must be approved by REMAC of New York City as having met its credentialing requirements as an On-Line Medical Control Physician (see Section II: REMAC On-Line Medical Control Physician); 2. Attends four (4) REMAC committee or subcommittee meeting each year, 3. perform, and submit documentation to support the performance of one CME didactic event per year, 4. submit to the REMAC a summary of your agency s quality improvement program and provide updates every 2 years, 5. perform a medical case review (MCR) and provide or arrange for remediation for all prehospital providers who are under his/her authority at the time in which a patient care concern is identified, 6. Must submit evidence, if requested, of involvement in at least three (3) of the following areas within the past two (2) years, prior to appointment as Service Medical Director: a. 50 Continuing Medical Education hours in emergency medicine or EMSrelated activities in appropriate specialties; b. 20 hours of prehospital teaching activities (e.g., CME, QA/QI, etc.); DRAFT

16 Revised REMAC DRAFT c. Active provision of emergency medical care (Emergency Department, Trauma Team, etc.); d. Provision of On-Line Medical Control (minimum of one 8-hour shift per year quarter); e. ALS ambulance observation (minimum of one 8-hour shift per year quarter). 7. Attendance at protocol updates, as required. DRAFT