Agreement to Provide Medical Direction Allowing The

Agreement to Provide Medical Direction Allowing the

______Department

to Provide Emergency Care in Cases of Anaphylaxis

This agreement has been developed between: Dr.______located at ______, New York and the ______Department located at ______, New York. It outlines the procedures for acquisition, storage, accounting, use and disposal of epinephrine autoinjectors (EAI). This agreement is entered into for the sole purpose of providing immediate, lifesaving emergency care to individuals requesting medical assistance from the ______Department suffering anaphylaxis as a result of severe allergic reaction to insects or certain food substances. It in no way permits any member of the ______Department to engage in the practice of medicine outside the parameters set forth by this agreement.

Care Providers

Members of the ______Department who possess current New York State Department of Health certification as Certified First Responder (CFR) or Emergency Medical Technician (EMT)any level, are emergency medical service providers (hereinafter referred to as "designated personnel") and may use the epinephrine autoinjector as outlined in this agreement. These designated personnel will have successfully completed specialized training as outlined in this agreement. They may be responsible for storage, accounting, use and disposal of the auto injector.

Training

Designated personnel will have successfully completed a special training course approved by the New York State Department of Health. The curriculum that will be used at the ______Department will be the current New York State Department of Health Office of Emergency Medical Services protocol for Anaphylactic Reaction with Respiratory Distress or Shock and the appropriate chapter of an approved current edition of an EMT textbook. A New York State Department of Health Office of Emergency Medical Services Certified Instructor Coordinator (C.I.C.) will teach the course. This course will teach proper identification of anaphylaxis and treatment using the epinephrine autoinjector. Designated personnel will complete refresher training in this subject at least every year, or as recommended by Dr. ______. The ____ department will maintain a list of members appropriately trained (attached). This list will be maintained at ______Department headquarters.

Acquisition of AutoInjectors

The ______Department will acquire the epinephrine autoinjectors from a licensed supplier or pharmacy and place them on emergency response vehicles and may distribute them to designated personnel. The maximum count of autoinjectors on site at the ______Department will be no more than ____(__) and will not fall below a minimum count of ____ (_) of each adult and pediatric dosage.

Storage of AutoInjectors

Portions of the stock of epinephrine autoinjectors will be stored in a sealed compartment on emergency response vehicles or medical kits as well as a locked cabinet at ____ department headquarters. The drug will be stored in an environment as outlined by the manufacturer's guidelines.

Accounting of AutoInjectors On site

The on site stock of autoinjectors will be counted at least once each week at the, time of EMS equipment inspection. The designated personnel assigned to inspect each vehicle will do the count. The count will be recorded on the weekly EMS inspection sheet, which will be maintained at ______Department headquarters. The inspection will include the location of the supply, date, name and signature of the designated personnel performing the count. A separate log will be maintained in the locked supply cabinet at ______headquarters for the reserve stock. This log will include the location of the supply, the date, and the name and signature of the designated personnel performing the count. Removal of reserve stock for placement on emergency response vehicles shall be recorded on the log identifying the emergency response vehicle receiving the stock, the date and name of the designated personnel withdrawing the stock. Use of an autoinjector during a medical emergency, including lot number and time of use, will be recorded in the epinephrine autoinjector administration log as well as on the New York State Health Department Prehospital Care Report form. These logs will be maintained at ______Department headquarters for no less than seven years. A signature list of approved and trained designated personnel will be maintained at ______Department headquarters and a copy provided to Dr. _____. A new signature list will be completed and filed with each change of personnel authorized to use the epinephrine autoinjector.

Use of an Epinephrine Autoinjector

Use of an epinephrine autoinjector will be documented and recorded in accordance with New York State Department of Health Office of Emergency Medical Services established protocols.

Disposal of Used Epinephrine AutoInjectors

Immediately after use, an epinephrine autoinjector will be placed in an approved biohazard rigid container designed to hold contaminated sharp instruments. Full sharps containers will be taken to ______for disposal. Used epinephrine autoinjectors are regulated waste and cannot be disposed of in the regular garbage.

Administration of an Epinephrine AutoInjector

Use and documentation of an epinephrine autoinjector will be in accordance with existing New York State Department of Health Office of Emergency Medical Services protocols. In addition Dr. _____ will be notified each time an EAl is used.

Protocol for Use of an Epinephrine AutoInjector

See attached New York State Office of Emergency Medical Services protocol for Anaphylactic Reaction with Respiratory Distress or Shock

We, the undersigned, have read and agree to the provisions stated in this document.

______

NameSign & Date

Advanced Life Support Coordinator

______

NameSign & Date

CEO

______

Physician’s NameSign & Date

Medical Director

NYS License #