Maryland EMS Base Station Application

Facility Information Section

Facility Name*

Facility Mailing Address*

Application Point of Contact Name*

Application Point of Contact Mailing Address*

Application Point of Contact Phone Number*

Application Point of Contact Email Address*

Base Station Director (Medical Director) Name*

Maryland Physician License Number*

Base Station Director Mailing Address*

Base Station Director Phone Number*

Base Station Director Email Address*

In which specialties is the Base Station Director Board Certified or Board Prepared?*

Completion Date of Latest Base Station Course (MD)*

Base Station Coordinator Name*

Maryland Nursing License Number*

Base Station Coordinator Mailing Address*

Base Station Coordinator Phone Number*

Base Station Coordinator Email Address*

Completion Date of Latest Base Station Course (RN)*

Has this facility previously operated an EMS Base Station in the State of Maryland?*

Select

What clinical training sites does your facility provide to EMS clinicians?*

Select

Does your facility agree to maintain EMS consultation records using standardized MIEMSS radio report forms as patient record and quality assurance?*

Select

Will your facility notify the State EMS Medical Director of changes in the Base Station Director and/or Base Station Coordinator within two weeks of any changes?*

Select

Base Station in General (COMAR 30.03.06.02)

Is the EMS Base Station part of a licensed hospital?*

Yes

No

What licensed hospital is your facility's base station affiliated with?*

What are/would be the hours of operation of your EMS Base Station?*

Which of the following communication equipment does your facility maintain?*

Select

Is your staff familiar with communications equipment operations?*

Yes

No

Describe the process your facility uses in the maintenance and testing of communications equipment.*

Describe the process your facility uses to monitor and respond to MEMRAD alerts. Also describe information security practices your facility takes with regards to MEMRAD.*

Are consults audited using MIEMSS approved tools?*

Yes

No

Does your facility maintain consult audit records for five years?*

Yes

No

Describe your facility's process for EMS to provide feedback to your facility.*

Describe designated EMS space and what equipment is provided for EMS clinicians.*

What EMS agencies does your facility have agreements with for clinical training and in what units are EMS clinicians authorized to participate in clinical training?*

***Copies of agreements must be attached in the attachments section***

What documentation is maintained showing allowed skills and scheduling processes for EMS clinician clinical training?*

***Copies of policies or other documentation must be attached in the attachments section***

Describe the process your facility uses to obtain and track eMEDS or MIEMSS short forms at patient transfer.*

Describe the process used to ensure eMEDS records are attached to a hospital medical record.*

***Site survey will include random assessment of medical records to ensure compliance***

Does your facility currently use the MIEMSS approved consult form?*

Yes

No

How is the consult form linked to a patient's hospital record?*

***Site survey will include random assessment of medical records to ensure compliance***

Personnel (COMAR 30.03.06.03)

Is there a written job description for the EMS Base Station Medical Director?*

***Must attach job description in the attachments section***

Yes

No

Is there a written job description for the EMS Base Station Coordinator?*

***Must attach job description in the attachments section***

Yes

No

How many full-time/part-time Maryland licensed physicians provide online medical direction?*

***Must attach a list of physician names, license numbers, and current board certification/eligibility status in the attachments section***

Are all physicians performing on-line medical direction either board certified or board eligible?*

Yes

No

Have all physicians that are providing on-line medical direction completed a MIEMSS approved base station course?*

***All physician base station course certificates must be attached in the attachment section of this document***

Yes

No

Do all physicians participating in on-line medical direction complete annual protocol updates by July 1st of each year?*

***Attach documentation of protocol update completion in the attachments section***

Select

Do RN, PA, and/or NP answer the EMRC Radio?*

***If yes, base station course completion certificates and annual protocol update documentation must be attached in the attachments section***

Yes

No

Do physician residents or fellows answer the EMRC radio?*

***If yes, base station course completion certificates and annual protocol update documentation must be attached in the attachments section***

Select

On-Line Medical Direction (COMAR 30.03.06.04)

Describe the process for on-line medical direction at your facility (ie. who answers the radio, how are physicians notified, etc.)*

Do the Base Station Medical Director and/or the Base Station Coordinator attend a combined minimum of 50% of the Regional EMS Advisory Council Meetings?*

Yes

No

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