HomeMy WebLinkAbout106.071 - EMS-18, Notification of Suspected Aerosol Transmissibel Disease or Pathogen Patient
Fresno City Fire Department
100 Administrative Manual
SECTION 106.071 (EMS-18, NOTIFICATION OF SUSPECTED AEROSOL
TRANSMISSIBLE DISEASE OR PATHOGEN PATIENT )
PURPOSE
The Emergency Medical Services (EMS) form EMS-18 is used by the Designated
Infection Control Officer (DICO) to inform a facility in writing of a patient who has been
transported with suspected aerosol transmissible disease or pathogen.
APPLICATION
The EMS-18 form is to be completed by the DICO on an as-needed basis.
OPERATIONAL POLICY
The EMS-18 form will be completed by the DICO and faxed to the appropriate facility
to meet the Department’s legal obligation to inform a facility of a possible source
patient with an aerosol transmissible disease. When this form is returned to the DICO,
it will be reviewed and a hard copy will be filed in a locked f ile cabinet, as well as
electronically filed in a secured “DICO Only” folder on the Training Division T drive.
OPERATIONAL GUIDELINE
This section intentionally left blank.
PROCESS
1. Complete the form.
2. FAX the completed form to the Infection Prevention Office at the
receiving hospital.
3. Call the Infection Prevention Office at the receiving hospital to verify
receipt.
Effective Date: June 2013 Kevin Reynolds, Captain Current Revision Date: 09/13/2022 Section 106.071
Next Revision (2) Date: 09/13/2027 Page 1 of 3
4. When this form is returned to the DICO, review it and file a hard copy in
a locked file cabinet.
5. File the form electronically a secured “DICO Only” folder on the Training
Unit T drive.
INFORMATION
This form follows Cal OSHA Title 8 regulations. For more information, access the
following link: Cal Osha Title 8 Regulations.
DEFINITIONS
This section intentionally left blank.
CROSS-REFERENCES
Administrative Manual
Section 203.10, Infection Control
Effective Date: June 2013 Kevin Reynolds, Captain
Current Revision Date: 09/13/2022 Section 106.071
Next Revision (2) Date: 09/13/2027 Page 2 of 3
I I I I
IB
I I I
□
□
□
I I
EMS-18
NOTIFICATION of SUSPECTED AEROSOL TRANSMISSIBLE DISEASE
OR PATHOGEN PATIENT
Source Patient Information DICO Log #
Source Patient Name: Date of Exposure: Time:
Location
Transferred: Children’s Hospital
Clovis Community CRMC Kaiser Madera
St.
Agnes VA
Date of Exposure: Time:
Location:
Fresno Fire Department
Incident No:
Source Patient Hospital
Encounter Number:
Type of Exposure (Check
those that apply)
Additional Comments or Information
Mouth to Mouth
Aerosolized Respiratory
Aerosolized Droplet
Detailed description of exposure event
Detailed description of patient/suspect symptoms
Exposed Employee Information
Name: Job
Title:
Department:
Agency Information: EMS LeadershipAcademy from California Fire Chief's Association
EMS Section (EMS Specialist Track). The suspected individual having an ATD was
brought to your facility. Refer questions to Designated Infection Control Officer (559) 621-4155.
Instructions: Designated Officer/Contact Person will FAX this form to the appropriate
Infection Prevention Office. Call appropriate Infection Prevention Office to verify receipt.
Notification made by (name):______________________________________________________
Section 106.071
Page 3 of 3