# COMAR Title 30 — Maryland Institute for Emergency Medical Services Systems (MIEMSS)

## Subtitle 03 — Ems Operational Programs

### Chapter 06 — Base Stations

#### Regulation .05 Quality Improvement.

*COMAR 30.03.06.05*

A. The hospital of which the base station is a unit, or the free standing emergency center if the base station is within a free standing emergency center, shall:

  (1) Monitor and participate in MEMRAD;

  (2) Monitor their utilization of CHATS alerts; and

  (3) Participate in mitigation strategies to improve systems efficiencies and patient safety.

B. The base station director and base station coordinator shall:

  (1) Assure that online medical direction and consultation provided by the base station is:

    (a) Timely;

    (b) Appropriate; and

    (c) Otherwise consistent with Maryland Medical Protocols for Emergency Medical Services Providers;

  (2) Assure the MIEMSS approved Prehospital Consultation/Interventions Radio Report Forms are complete, signed and linked to the patient record through a patient identifier;

  (3) Develop and implement a process which facilitates monthly quality assurance/quality improvement review of EMS consults which:

    (a) Reviews all priority one/critical patient consults and select lower priority consults for a minimum of 30 consults per month;

    (b) Allows for ongoing documentation of tracking, trending, loop closure and retention of Quality Assurance/Quality Improvement review findings for 5 years;

    (c) Notifies EMS operational programs upon discovery of patient care, quality or protocol variance issues involving EMS providers or the EMS system;

    (d) Notifies EMS operational programs and MIEMSS Office of the State Medical Director upon discovery of conduct that is specifically prohibited under the requirements of COMAR 30.02.04.01;

    (e) Monitors hospital’s response rates to MEMRAD notifications and alerts;

    (f) Participates in local, regional, and State EMS quality improvement activities;

    (g) Provides patient follow-up data as required by MIEMSS for public health oversight purposes to determine the appropriateness and outcome of EMS care for:

      (i) Inpatients; and

      (ii) Outpatients; and

      (iii) Reports as required by MIEMSS for quality assurance and performance improvement purposes.

C. The State EMS Medical Director through the MIEMSS regional medical directors shall:

  (1) Coordinate online medical direction functions; and

  (2) Regularly review the quality improvement activities of approved base stations.