SECOND REGULAR SESSION
[TRULY AGREED TO AND FINALLY PASSED]
SENATE SUBSTITUTE FOR
HOUSE COMMITTEE SUBSTITUTE FOR
HOUSE BILL NO. 1790
94TH GENERAL ASSEMBLY
To repeal sections 96.160, 190.100, 190.176, 190.200, 190.241, 190.243, and 190.245, RSMo, and to enact in lieu thereof seven new sections relating to the time critical diagnosis system.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 96.160, 190.100, 190.176, 190.200, 190.241, 190.243, and 190.245, RSMo, are repealed and seven new sections enacted in lieu thereof, to be known as sections 96.160, 190.100, 190.176, 190.200, 190.241, 190.243, and 190.245, to read as follows:
96.160. 1. Each facility established or operated and maintained under the provisions of sections 96.150 to 96.228 shall be governed by a board of trustees who shall serve without compensation. Each such board of trustees shall consist of five trustees, who shall be citizens of the city, unless the council shall provide by ordinance for a larger board of not more than fifteen trustees. Trustees shall be appointed by the mayor with the approval of the council and shall be chosen with reference to their fitness for such position; provided no member of the city council and no member of the immediate family of a member of the city council shall be a member of the board.
2. An ordinance providing for a larger board of trustees [shall require that three-fifths of such trustees shall be citizens of the city and] may provide that some or all of the [remaining] trustees need not be citizens of the city, but shall be citizens of the state of Missouri.
3. Any city establishing or maintaining and operating more than one health care facility may provide by ordinance that one board of trustees shall manage and operate two or more health care facilities.
190.100. As used in sections 190.001 to 190.245, the following words and terms mean:
(1) "Advanced life support (ALS)", an advanced level of care as provided to the adult and pediatric patient such as defined by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.001 to 190.245;
(2) "Ambulance", any privately or publicly owned vehicle or craft that is specially designed, constructed or modified, staffed or equipped for, and is intended or used, maintained or operated for the transportation of persons who are sick, injured, wounded or otherwise incapacitated or helpless, or who require the presence of medical equipment being used on such individuals, but the term does not include any motor vehicle specially designed, constructed or converted for the regular transportation of persons who are disabled, handicapped, normally using a wheelchair, or otherwise not acutely ill, or emergency vehicles used within airports;
(3) "Ambulance service", a person or entity that provides emergency or nonemergency ambulance transportation and services, or both, in compliance with sections 190.001 to 190.245, and the rules promulgated by the department pursuant to sections 190.001 to 190.245;
(4) "Ambulance service area", a specific geographic area in which an ambulance service has been authorized to operate;
(5) "Basic life support (BLS)", a basic level of care, as provided to the adult and pediatric patient as defined by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.001 to 190.245;
(6) "Council", the state advisory council on emergency medical services;
(7) "Department", the department of health and senior services, state of Missouri;
(8) "Director", the director of the department of health and senior services or the director's duly authorized representative;
(9) "Dispatch agency", any person or organization that receives requests for emergency medical services from the public, by telephone or other means, and is responsible for dispatching emergency medical services;
(10) "Emergency", the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity that would lead a prudent layperson, possessing an average knowledge of health and medicine, to believe that the absence of immediate medical care could result in:
(a) Placing the person's health, or with respect to a pregnant woman, the health of the woman or her unborn child, in significant jeopardy;
(b) Serious impairment to a bodily function;
(c) Serious dysfunction of any bodily organ or part;
(d) Inadequately controlled pain;
(11) "Emergency medical dispatcher", a person who receives emergency calls from the public and has successfully completed an emergency medical dispatcher course, meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.245;
(12) "Emergency medical response agency", any person that regularly provides a level of care that includes first response, basic life support or advanced life support, exclusive of patient transportation;
(13) "Emergency medical services for children (EMS-C) system", the arrangement of personnel, facilities and equipment for effective and coordinated delivery of pediatric emergency medical services required in prevention and management of incidents which occur as a result of a medical emergency or of an injury event, natural disaster or similar situation;
(14) "Emergency medical services (EMS) system", the arrangement of personnel, facilities and equipment for the effective and coordinated delivery of emergency medical services required in prevention and management of incidents occurring as a result of an illness, injury, natural disaster or similar situation;
(15) "Emergency medical technician", a person licensed in emergency medical care in accordance with standards prescribed by sections 190.001 to 190.245, and by rules adopted by the department pursuant to sections 190.001 to 190.245;
(16) "Emergency medical technician-basic" or "EMT-B", a person who has successfully completed a course of instruction in basic life support as prescribed by the department and is licensed by the department in accordance with standards prescribed by sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245;
(17) "Emergency medical technician-intermediate" or "EMT-I", a person who has successfully completed a course of instruction in certain aspects of advanced life support care as prescribed by the department and is licensed by the department in accordance with sections 190.001 to 190.245 and rules and regulations adopted by the department pursuant to sections 190.001 to 190.245;
(18) "Emergency medical technician-paramedic" or "EMT-P", a person who has successfully completed a course of instruction in advanced life support care as prescribed by the department and is licensed by the department in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245;
(19) "Emergency services", health care items and services furnished or required to screen and stabilize an emergency which may include, but shall not be limited to, health care services that are provided in a licensed hospital's emergency facility by an appropriate provider or by an ambulance service or emergency medical response agency;
(20) "First responder", a person who has successfully completed an emergency first response course meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.245 and who provides emergency medical care through employment by or in association with an emergency medical response agency;
(21) "Health care facility", a hospital, nursing home, physician's office or other fixed location at which medical and health care services are performed;
(22) "Hospital", an establishment as defined in the hospital licensing law, subsection 2 of section 197.020, RSMo, or a hospital operated by the state;
(23) "Medical control", supervision provided by or under the direction of physicians to providers by written or verbal communications;
(24) "Medical direction", medical guidance and supervision provided by a physician to an emergency services provider or emergency medical services system;
(25) "Medical director", a physician licensed pursuant to chapter 334, RSMo, designated by the ambulance service or emergency medical response agency and who meets criteria specified by the department by rules pursuant to sections 190.001 to 190.245;
(26) "Memorandum of understanding", an agreement between an emergency medical response agency or dispatch agency and an ambulance service or services within whose territory the agency operates, in order to coordinate emergency medical services;
(27) "Patient", an individual who is sick, injured, wounded, diseased, or otherwise incapacitated or helpless, or dead, excluding deceased individuals being transported from or between private or public institutions, homes or cemeteries, and individuals declared dead prior to the time an ambulance is called for assistance;
(28) "Person", as used in these definitions and elsewhere in sections 190.001 to 190.245, any individual, firm, partnership, copartnership, joint venture, association, cooperative organization, corporation, municipal or private, and whether organized for profit or not, state, county, political subdivision, state department, commission, board, bureau or fraternal organization, estate, public trust, business or common law trust, receiver, assignee for the benefit of creditors, trustee or trustee in bankruptcy, or any other service user or provider;
(29) "Physician", a person licensed as a physician pursuant to chapter 334, RSMo;
(30) "Political subdivision", any municipality, city, county, city not within a county, ambulance district or fire protection district located in this state which provides or has authority to provide ambulance service;
(31) "Professional organization", any organized group or association with an ongoing interest regarding emergency medical services. Such groups and associations could include those representing volunteers, labor, management, firefighters, EMT-B's, nurses, EMT-P's, physicians, communications specialists and instructors. Organizations could also represent the interests of ground ambulance services, air ambulance services, fire service organizations, law enforcement, hospitals, trauma centers, communication centers, pediatric services, labor unions and poison control services;
(32) "Proof of financial responsibility", proof of ability to respond to damages for liability, on account of accidents occurring subsequent to the effective date of such proof, arising out of the ownership, maintenance or use of a motor vehicle in the financial amount set in rules promulgated by the department, but in no event less than the statutory minimum required for motor vehicles. Proof of financial responsibility shall be used as proof of self-insurance;
(33) "Protocol", a predetermined, written medical care guideline, which may include standing orders;
(34) "Regional EMS advisory committee", a committee formed within an emergency medical services (EMS) region to advise ambulance services, the state advisory council on EMS and the department;
(35) "Specialty care transportation", the transportation of a patient requiring the services of an emergency medical technician-paramedic who has received additional training beyond the training prescribed by the department. Specialty care transportation services shall be defined in writing in the appropriate local protocols for ground and air ambulance services and approved by the local physician medical director. The protocols shall be maintained by the local ambulance service and shall define the additional training required of the emergency medical technician-paramedic;
(36) "Stabilize", with respect to an emergency, the provision of such medical treatment as may be necessary to attempt to assure within reasonable medical probability that no material deterioration of an individual's medical condition is likely to result from or occur during ambulance transportation unless the likely benefits of such transportation outweigh the risks;
(37) "State advisory council on emergency medical services", a committee formed to advise the department on policy affecting emergency medical service throughout the state;
(38) "State EMS medical directors advisory committee", a subcommittee of the state advisory council on emergency medical services formed to advise the state advisory council on emergency medical services and the department on medical issues;
(39) "STEMI" or "ST-elevation myocardial infarction", a type of heart attack in which impaired blood flow to the patient's heart muscle is evidenced by ST-segment elevation in electrocardiogram analysis, and as further defined in rules promulgated by the department under sections 190.001 to 190.250;
(40) "STEMI center", a hospital that is currently designated as such by the department to care for patients with ST-segment elevation myocardial infarctions;
(41) "STEMI care", includes education and prevention, emergency transport, triage, and acute care and rehabilitative services for STEMI that requires immediate medical or surgical intervention or treatment;
(42) "Stroke", a condition of impaired blood flow to a patient's brain as defined by the department;
(43) "Stroke care", includes emergency transport, triage, and acute intervention and other acute care services for stroke that potentially require immediate medical or surgical intervention or treatment, and may include education, primary prevention, acute intervention, acute and subacute management, prevention of complications, secondary stroke prevention, and rehabilitative services;
(44) "Stroke center", a hospital that is currently designated as such by the department;
[(39)] (45) "Trauma", an injury to human tissues and organs resulting from the transfer of energy from the environment;
[(40)] (46) "Trauma care" includes injury prevention, triage, acute care and rehabilitative services for major single system or multisystem injuries that potentially require immediate medical or surgical intervention or treatment;
[(41)] (47) "Trauma center", a hospital that is currently designated as such by the department.
190.176. 1. The department shall develop and administer a uniform data collection system on all ambulance runs and injured patients, pursuant to rules promulgated by the department for the purpose of injury etiology, patient care outcome, injury and disease prevention and research purposes. The department shall not require disclosure by hospitals of data elements pursuant to this section unless those data elements are required by a federal agency or were submitted to the department as of January 1, 1998, pursuant to:
(1) Departmental regulation of trauma centers; or
(2) The Missouri head and spinal cord injury registry established by sections 192.735 to 192.745, RSMo; or
(3) Abstracts of inpatient hospital data; or
(4) If such data elements are requested by a lawful subpoena or subpoena duces tecum.
2. All information and documents in any civil action, otherwise discoverable, may be obtained from any person or entity providing information pursuant to the provisions of sections 190.001 to 190.245.
190.200. 1. The department of health and senior services in cooperation with local and regional EMS systems and agencies may provide public and professional information and education programs related to emergency medical services systems including trauma, STEMI, and stroke systems and emergency medical care and treatment. The department of health and senior services may also provide public information and education programs for informing residents of and visitors to the state of the availability and proper use of emergency medical services, of the value and nature of programs to involve citizens in the administering of prehospital emergency care, including cardiopulmonary resuscitation, and of the availability of training programs in emergency care for members of the general public.
2. The department shall, for STEMI care and stroke care respectively:
(1) Compile and assess peer-reviewed and evidence-based clinical research and guidelines that provide or support recommended treatment standards;
(2) Assess the capacity of the emergency medical services system and hospitals to deliver recommended treatments in a timely fashion;
(3) Use the research, guidelines, and assessment to promulgate rules establishing protocols for transporting STEMI patients to a STEMI center or stroke patients to a stroke center. Such transport protocols shall direct patients to STEMI centers and stroke centers under section 190.243 based on the centers' capacities to deliver recommended acute care treatments within time limits suggested by clinical research;
(4) Define regions within the state for purposes of coordinating the delivery of STEMI care and stroke care, respectively;
(5) Promote the development of regional or community-based plans for transporting STEMI or stroke patients via ground or air ambulance to STEMI centers or stroke centers, respectively, in accordance with section 190.243; and
(6) Establish procedures for the submission of community-based or regional plans for department approval.
3. A community-based or regional plan shall be submitted to the department for approval. Such plan shall be based on the clinical research and guidelines and assessment of capacity described in subsection 1 of this section and shall include a mechanism for evaluating its effect on medical outcomes. Upon approval of a plan, the department shall waive the requirements of rules promulgated under sections 190.100 to 190.245 that are inconsistent with the community-based or regional plan. A community-based or regional plan shall be developed by or in consultation with the representatives of hospitals, physicians, and emergency medical services providers in the community or region.
190.241. 1. The department shall designate a hospital as an adult, pediatric or adult and pediatric trauma center when a hospital, upon proper application submitted by the hospital and site review, has been found by the department to meet the applicable level of trauma center criteria for designation in accordance with rules adopted by the department as prescribed by section 190.185.
2. The department shall designate a hospital as a STEMI or stroke center when such hospital, upon proper application and site review, has been found by the department to meet the applicable level of STEMI or stroke center criteria for designation in accordance with rules adopted by the department as prescribed by section 190.185. In developing STEMI center and stroke center designation criteria, the department shall use, as it deems practicable, appropriate peer-reviewed or evidence-based research on such topics including, but not limited to, the most recent guidelines of the American College of Cardiology and American Heart Association for STEMI centers, or the Joint Commission's Primary Stroke Center Certification program criteria for stroke centers, or Primary and Comprehensive Stroke Center Recommendations as published by the American Stroke Association.
3. The department of health and senior services shall, not less than once every five years, conduct an on-site review of every trauma, STEMI, and stroke center through appropriate department personnel or a qualified contractor. On-site reviews shall be coordinated for the different types of centers to the extent practicable with hospital licensure inspections conducted under chapter 197, RSMo. No person shall be a qualified contractor for purposes of this subsection who has a substantial conflict of interest in the operation of any trauma, STEMI, or stroke center under review. The department may deny, place on probation, suspend or revoke [a trauma center] such designation in any case in which it has reasonable cause to believe that there has been a substantial failure to comply with the provisions of this chapter or any rules or regulations promulgated pursuant to this chapter. If the department of health and senior services has reasonable cause to believe that a hospital is not in compliance with such provisions or regulations, it may conduct additional announced or unannounced site reviews of the hospital to verify compliance. If a trauma, STEMI, or stroke center fails two consecutive on-site reviews because of substantial noncompliance with standards prescribed by sections 190.001 to 190.245 or rules adopted by the department pursuant to sections 190.001 to 190.245, its [trauma] center designation shall be revoked.
[3.] 4. The department of health and senior services may establish appropriate fees to offset the costs of trauma, STEMI, and stroke center reviews.
[4.] 5. No hospital shall hold itself out to the public as [an adult, pediatric or adult and pediatric trauma center] a STEMI center, stroke center, adult trauma center, pediatric trauma center, or an adult and pediatric trauma center unless it is designated as such by the department of health and senior services.
[5.] 6. Any person aggrieved by an action of the department of health and senior services affecting the trauma, STEMI, or stroke center designation pursuant to this chapter, including the revocation, the suspension, or the granting of, refusal to grant, or failure to renew a designation, may seek a determination thereon by the administrative hearing commission [pursuant to the provisions of chapter 536] under chapter 621, RSMo. It shall not be a condition to such determination that the person aggrieved seek a reconsideration, a rehearing, or exhaust any other procedure within the department.
190.243. 1. Severely injured patients shall be transported to a trauma center. Patients who suffer a STEMI, as defined in section 190.100, shall be transported to a STEMI center. Patients who suffer a stroke, as defined in section 190.100, shall be transported to a stroke center.
2. A physician or registered nurse authorized by a physician who has established verbal communication with ambulance personnel shall instruct the ambulance personnel to transport a severely ill or injured patient to the closest hospital or designated trauma, STEMI, or stroke center, as determined according to estimated transport time whether by ground ambulance or air ambulance, in accordance with transport protocol approved by the medical director and the department of health and senior services, even when the hospital is located outside of the ambulance service's primary service area. When initial transport from the scene of illness or injury to a trauma, STEMI, or stroke center would be prolonged, the STEMI, stroke, or severely injured patient may be transported to the nearest appropriate facility for stabilization prior to transport to a trauma, STEMI, or stroke center.
[2.] 3. Transport of the STEMI, stroke, or severely injured patient shall be governed by principles of timely and medically appropriate care; consideration of reimbursement mechanisms shall not supersede those principles.
[3.] 4. Patients who [are not severely injured] do not meet the criteria for direct transport to a trauma, STEMI, or stroke center shall be transported to and cared for at the hospital of their choice so long as such ambulance service is not in violation of local protocols.
190.245. The department shall require hospitals, as defined by chapter 197, RSMo, designated as trauma, STEMI, or stroke centers to provide for a peer review system, approved by the department, for trauma, STEMI, and stroke cases [pursuant to the provisions of] , respective to their designations, under section 537.035, RSMo. For purposes of sections 190.241 to 190.245, the department of health and senior services shall have the same powers and authority of a health care licensing board pursuant to subsection 6 of section 537.035, RSMo. Failure of a hospital to provide all medical records necessary for the department to implement provisions of sections 190.241 to 190.245 shall result in the revocation of the hospital's designation as a trauma, STEMI, or stroke center. Any medical records obtained by the department or peer review committees shall be used only for purposes of implementing the provisions of sections 190.241 to 190.245 and the names of hospitals, physicians and patients shall not be released by the department or members of review committees.