§ 5-4. Ambulances.

(a)

Purpose and intent. It is the purpose of this Uniform Emergency Medical Service (EMS) Ordinance to:

(1)

Establish a regulated ambulance service system which can provide clinical quality of care, with reasonable, reliable response time standards, and with the goal of furnishing the best possible chance of survival, without disability or preventable complication, to each ambulance patient.

(2)

Establish a sole-provider ambulance system, because it is unreasonable to have unnecessarily high rates and/or public subsidy to make needed improvements to ambulance service in the service area, when a more efficiently designed system can achieve the same results at lower cost. The most efficient design to achieve the goals of high-quality service, at the lowest cost, consistent with the quality of care required, is the implementation of the system described herein.

(3)

Provide a method to develop specific performance standards, adequate review, and either continuation of service or an appropriate procedure to obtain alternate proposals from other providers.

(4)

To provide more effective medical oversight by recognizing a multi-jurisdictional medical control board of licensed physicians expert in emergency medicine and related specialties as the entity empowered hereunder to oversee and regulate all clinical aspects of the emergency medical system which affect patient care within this jurisdiction.

(b)

Definitions. The following words and phrases as used in this section, shall have the following meanings:

Administrator. The City of Terrell City Manager, who has been assigned responsibility for providing administrative and clerical services necessary to the orderly issuance, renewal, suspension, revocation, or restriction of licenses, certifications and permits pursuant to authorization by the medical control board, which licenses, certifications, and permits shall be accepted as valid throughout the regulated service area, including this jurisdiction.

Advanced life support ambulance. Any vehicle which is equipped to provide treatment of life-threatening emergencies through the use of advanced airway management, intravenous therapy, and other advanced prehospital care procedures, and which is equipped to transport sick or injured persons to or from health care facilities.

Ambulance. Any privately or publicly owned motor vehicle or helicopter that is specifically designed or constructed and equipped and is intended to be used for and is maintained or operated for the transportation of patients.

Ambulance patient or patient. Any person being transported in a reclining position within the regulated service area to or from a health care facility except when the transportation originates outside the regulated service area.

Ambulance service contractor. That entity which is then currently under contract to provide all ambulance and ambulance patient services within this jurisdiction and throughout the regulated service area, except those services specifically exempted by subsection (c) of this section.

Approved emergency room/department. A health care facility which possess a Level 4 or higher trauma categorization as defined by the Texas Department of Health.

Approved user fee. Those membership fees, mileage charges, subsidy payments, if any, and total average bill (exclusive of membership fees and mileage charges) approved for this jurisdiction by the city council from the uniform schedule of price/subsidy options.

Base station physician. A physician licensed to practice medicine in the State of Texas, and certified by the medical control board as knowledgeable of the prehospital emergency medical protocols, EMS radio procedures and the general operating policies of the ambulance service contractor, and from whom ambulance personnel may take medical direction by radio or other remote communications device.

City council. That group of officials elected to govern the affairs of this city.

Contract service area. The geographic area encompassing the regulated service area of the City of Terrell.

Emergency medical technician (EMT). An individual who is a "specially skilled emergency medical technician" under V.T.C.A., Health and Safety Code ch. 773, or its successor.

EMS board. That agency established by the master ambulance service contract for purposes of supervising financial aspects of the master ambulance service contract, and to perform various administrative services and functions as defined in the master ambulance service contract.

EMS system. That network of individuals, organizations, facilities and equipment whose participation is required to generate a clinically-appropriate, preplanned system-wide response for prehospital care and transport or interfacility transport, so as to provide each patient the best possible chance of survival without disability, given available financial resources and EMS technology.

Extraordinary adjustment. A change of the uniform schedule of subsidy/price options which is not a scheduled cost-of-living adjustment, but is instead an adjustment justified on the basis of either an increase in the system standard of care, or on the basis of an unusual increase in the cost of a factor of production when such increase in cost is industry wide and the result of causes beyond the ambulance service contractor's reasonable control.

Helicopter rescue unit. Any rotary wing aircraft providing basic or advanced life support services and patient transportation originating from the scene of emergency incidents which occur within the contract service area.

Master ambulance service contract. That ambulance service contract between the City of Terrell and the ambulance service contractor.

Medical audit. An official inquiry into the circumstances involving an ambulance run or request for ambulance service, conducted by the medical director or a licensed physician designated by the medical director, or by the medical control board.

Medical control. That direction given ambulance personnel by a base station physician through direct voice contact, with or without vital sign telemetry, as required by applicable medical protocols promulgated by the medical control board, and by V.T.C.A., Health and Safety Code ch.r 773, or its successors.

Medical control board or MCB. That board of physicians as exists primarily by virtue of section 31-14 of the ordinance of the City of Tyler, Texas, passed on May 26, 1992, regulating ambulance service within that city. These provisions shall control the MCB unless such section 31-14 is changed and amended in any regard. At that time such change shall only be binding under this section if the change is approved by the city council.

Medical director. An emergency physician, expert in the prehospital practice of emergency medicine, appointed by the ambulance service contractor.

Medical protocol. Any diagnosis-specific or problem-oriented written statement of standard procedures, or algorithm, promulgated by the medical control board as the proper standard of prehospital care for a given clinical condition.

Mutual aid agreement. A written agreement between one or more providers of ambulance service whereby the signing parties agree to provide backup ambulance service to one another under conditions and pursuant to terms specified in the agreement.

Paramedic. A person qualified as a certified "paramedic emergency medical technician" as defined by V.T.C.A., Health and Safety Code ch. 773, or its successor.

Person. Any individual, firm, partnership, association, corporation, governmental entity, or other group or combination acting as a unit.

Senior paramedic in charge. That person among the certified personnel assigned to an ambulance, not the driver, who is a certified paramedic designated by the ambulance service contractor as the individual in command of the ambulance.

Special event. Any public event located within the regulated service area, for which standby ambulance service is arranged in advance, and for which an ambulance (or ambulances) are hired by the sponsor of the event or other interested party.

Specialized mobile intensive care unit. A vehicle which is specifically constructed, equipped, staffed, and employed in the interfacility transport of patients whose requirements for enroute medical support are likely to exceed the clinical capabilities of a paramedic level ambulance.

System standard of care. The combined compilation of all priority dispatching protocols, prearrival instruction protocols, medical protocols (i.e., for first responders and ambulance personnel), protocols for selecting destination hospital, standards for certification of prehospital care personnel (i.e., telephone calltakers, first responders, ambulance personnel and on-line medical control physicians), developed and adopted by the medical control board as well as standards governing requirements for on-board medical equipment and supplies, and licensure of ambulance services and first responder agencies. The system standard of care shall simultaneously serve as both a regulatory and contractual standard.

(c)

Patient and at-scene management.

(1)

General rule. Authority for patient management in a medical emergency shall be vested in the senior paramedic in charge. Authority for the management of the scene of a medical emergency shall be vested in the appropriate public safety officials. The scene of a medical emergency shall be managed in a manner calculated to minimize the risk of death or health impairment to the patient and to other persons who may be exposed to the risk as a result of the emergency condition and priorities shall be placed in the interests of those persons exposed to the more serious risks of life and health. Public safety officials shall ordinarily consult with the senior paramedic in charge at the scene in the determination of the relevant risk factors. In the event a licensed physician is present at the scene and desires to assume direction and control of patient care, the licensed physician may do so but shall be required to sign a form approved by the medical director releasing the senior paramedic in charge from responsibility for directing patient care and declaring that such responsibility has been assumed by the signer.

(2)

Exception—Police or fire emergency. In the event that the senior officer of the fire department or the police department present at the scene determines that a police or fire emergency condition exists, the officer shall inform the senior paramedic in charge that such condition exists. Upon such notification, the senior paramedic and all other ambulance personnel at the scene shall defer to the command of the officer. An example, by way of explanation only and not by way of limitation, of a fire emergency is that when an auto accident occurs and the fire department officer determines that the danger of fire to the medical personnel rendering aid is unacceptably high. An example of a policy emergency is that when an auto accident occurs and the traffic hazard presented by the vehicles involved places drivers or medical personnel in an unacceptably high risk.

(d)

Authority to operate—Exceptions.

(1)

No person shall operate or cause to be operated an ambulance nor furnish, conduct, maintain, advertise or otherwise be engaged in the business or service of the transportation of ambulance patients within the regulated service area, or provide special events standby coverage, unless such person is the ambulance service contractor. No person shall knowingly solicit ambulance services as regulated herein except the ambulance service contractor.

(2)

However, the prohibitions set forth in subsection (1), immediately above, shall not be applicable to an ambulance or ambulance service provider:

a.

Which is rendering assistance to patients in the case of a major catastrophe or emergency with which the contractor's ambulances are insufficient or unable to cope; or is

b.

Transporting a patient who is picked up from a location beyond the regulated service area and transported to a location within the regulated service area; or is

c.

Transporting a patient who is picked up from a location beyond the regulated service area and transported to a location beyond the limits of the regulated service area and only incidentally passing through the regulated service area; or is

d.

Transporting a patient who is picked up from a location within the regulated service area and transported to a location beyond the regulated service area, providing said ambulance or ambulance service initially transported that same patient into the regulated service area and is making the return trip.

(3)

Violations of this section are hereby declared to be public nuisances and shall be prohibited and abated in actions at law or in equity.

(e)

Medical control board.

(1)

System standard of care adopted. The system standard of care as defined herein is hereby adopted as the minimum requirement for compliance with this section, and the medical control board (MCB) is hereby recognized as the clinical standards-setting body for this jurisdiction.

(2)

System participation. Any hospital within this jurisdiction which operates an emergency room or emergency department meeting the requirements of an "approved emergency room/department" shall be eligible to appoint its physician director of said emergency room or department (or his/her physician designee) to membership on the medical control board, and such representative shall have full voting rights when the MCB has been notified in writing by an officer of the hospital.

(3)

Coordination of activities. The medical director appointed by the ambulance service contractor shall serve as ex-officio, nonvoting chair of the medical control board, and shall be responsible for arranging meetings, creating the agenda, keeping minutes, ensuring compliance with this section, and developing a process for monitoring compliance with the system standard of care, subject to approval by the medical control board.

(4)

Duties and responsibilities. Responsibilities of the medical control board shall be as follows:

a.

To set the system standard of care and provide periodic revisions. The system standard of care shall address minimum requirements and recommended higher standards governing the licensure of organizations, the certification of individuals, and the permitting of vehicles employed within the EMS system, and shall be developed in accordance with the following table of contents:

1.

Prevention, CPR and other public information programs

2.

Telephone access (emergency and routine)

3.

Control center operations

4.

First responder services

5.

Ambulance services

6.

On-line medical control

7.

Quality improvement and clinical research.

b.

Approve and periodically verify a process for monitoring the EMS system's actual performance to determine compliance or noncompliance.

c.

Authorize the issuance, denial, revocation, suspension or restriction of licenses, permits and certifications issued pursuant to this section.

d.

Licenses, certifications, and permits in good standing issued by any jurisdiction within the regulated service area pursuant to written authorization by the medical control board shall be recognized and accepted as valid by this jurisdiction.

(5)

Selection of patient destination. Medical protocols approved by the medical control board shall establish protocols for selection of the destination hospital, which protocols shall be strictly followed by paramedic personnel and on-line medical control physicians, except when a departure from protocol is justified on the basis of special considerations of patient care or practical barriers to implementation (e.g. blocked roads, hospital divert status, etc.). In developing such "transport protocols," the medical control board shall strictly adhere to the following priorities of consideration, and shall recognize these priorities in the sequence presented:

a.

First consideration: patient care and safety;

b.

Second consideration: patient/family choice;

c.

Third consideration: fairness in distribution of patients among hospitals. In this regard, the following rules shall apply:

1.

Nonemergencies. All "nonemergency patients" (as defined by patient-assessment protocols approved by the medical control board) shall be transported to the destination selected by the patient, the patient's family, or the patient's personal physician, without exception.

2.

Nonlife threatening emergencies. Patients experiencing a "nonlife threatening emergency" (as defined by patient-assessment protocols approved by the medical control board) shall be transported to the facility of choice designated by the patient, the patient's family, or the patient's personal physician, or if no such preference is stated, to the nearest hospital approved by the medical control board for receipt of patients experiencing nonlife threatening emergencies.

3.

Life threatening emergencies. Patients experiencing life threatening emergencies (as defined by patient-assessment protocols approved by the medical control board) shall, in accordance with transport protocols approved by the medical control board, be delivered to the "nearest appropriate facility," taking into consideration the patient's condition and location, the patient's medical requirements, and the respective capabilities of hospitals within and, for some types of patients, outside) the "contract service area." Such transport protocols shall not be inconsistent with then currently approved trauma system protocols (when available).

4.

Enforcement. Inappropriate and unjustified deviations from these patient-destination protocols by a paramedic without direct authorization by a base station physician or inappropriate and unjustified instructions regarding such deviation by a base station physician shall be subject to sanction by the medical control board provided such sanctions are applied in accordance with due process procedures approved by the city attorney. Such sanctions may include reprimand, suspension of certification, or revocation of certification, depending upon frequency and severity of error.

5.

Binding arbitration available. In the event any hospital desires to dispute a policy of the medical control board affecting patient distribution, that hospital may at its option institute procedures for binding arbitration as follows:

i.

The hospital wishing to contest the specified policy shall present its position in writing to the medical control board, including one or more proposed remedies acceptable to the hospital.

ii.

If the medical control board rejects all remedies proposed by the hospital, the hospital may appoint a physician expert in the medical specialty to which the contested policy is related to serve as a member of an arbitration team, provided that such physician shall have no affiliation, direct or indirect, with any hospital or physician group practicing within the contract service area.

iii.

The medical control board shall then appoint a physician expert in the medical specialty to which the contested policy is related to serve as a member of the arbitration team, provided that such physician shall have no affiliation, direct or indirect, with any hospital or physician group practicing within the contract service area.

iv.

The two appointed members of the arbitration team shall then jointly appoint a third physician expert in the medical specialty to which the contested policy is related to serve as the third member of the arbitration team, provided that such physician shall have no affiliation, direct or indirect, with any hospital or physician group practicing within the contract service area.

v.

The arbitration team shall then review such written documentation related to the dispute as may be available, and shall conduct such site visit inspections and onsite interviews as the team deems appropriate, and shall render a decision on the disputed matter either in favor of the medical control board or in favor of the hospital initiating the arbitration process, and such decision shall be final. The arbitration team shall not have authority to impose any resolution which was not proposed by either the medical control board or the hospital initiating the proceedings.

vi.

The actual and reasonable cost of the arbitration process, including consulting fees and travel reimbursement, shall be paid by the hospital initiating the arbitration process.

(f)

Compliance with law. All persons and entities regulated under this section shall comply with the laws of the state and reference to permits, licenses, minimum equipment and minimum qualifications of operators and attendants and all state and federal laws and regulations applicable to its ambulance operation.

(g)

Failure to pay service charges—Prohibited.

(1)

It shall be unlawful for any person, with intent to defraud, to request or accept the service of any ambulance within the city, having no intention of paying for such service.

(2)

Failure, by the person requesting or accepting the services of an ambulance, to pay to the person furnishing such service the customary charge therefor within 90 days after demand for payment is made, shall be prima facie evidence of intent to defraud and prima facie evidence that such person had no intention of paying for such services when the same were requested or accepted.

(3)

Demand for payment, as used in this section, shall be written demand, sent by registered or certified mail addressed to the person requesting or accepting such services and to the address given by or on behalf of such person at the time the services were requested or accepted. Intent to defraud or intention not to pay for such services may be shown by direct evidence.

(h)

Violations—Penalties. Any person who shall violate any provision of this section shall be deemed guilty of a misdemeanor and upon conviction thereof shall be fined. Each day such violation shall continue, or be permitted to continue, shall be deemed a separate offense. It shall not be necessary for the complaint to negate any exception contained in this section concerning any prohibited act, but any such exception made in this section may be urged as a defense by any person charged by such complaint. Since this section has a penalty for violation, it shall become effective after its publication in the newspaper.

(i)

Program fees.

(1)

Definitions. For the purpose of this article, the following words and phrases shall have meanings respectively ascribed to them by this section.

Landlord shall mean any person, company, corporation, or other entity that owns or manages single-family and/or multifamily residential living units and leases them to tenants and is responsible for payment of the utility bills for the living units.

Living unit shall mean a residential unit providing complete, independent living facilities for a family, including permanent provisions for living, sleeping, eating, cooking and sanitation.

Medical service program shall mean the services, products, expertise, equipment, and cost associated with the "EMS Membership Program", billed monthly on a utility customer's bill.

Multifamily residential utility customer shall mean a City of Terrell utility customer with two or more living units served by one city utility bill; provided multifamily residential living units will not include hotels, motels, or college dormitories.

Single-family residential utility customer shall mean a City of Terrell utility customer with one living unit receiving one city utility bill.

Tenant shall mean the person or persons that sign the lease for a living unit at a specific location within the city limits of the City of Terrell, which living unit receives City of Terrell utility services.

Tenant's household shall include all the individuals permanently residing together in the leased living unit with the tenant.

EMS membership program shall mean the program, as it currently exists or may hereafter be amended, which is sponsored by CareFlite.

Utility customer shall mean the person or persons that established a utility account with the City of Terrell for utility services for a single-family residential or multifamily residential living unit.

Utility customer's household shall include all individuals permanently residing together in a living unit at a specific location within the corporate limits of the City of Terrell, which living unit receives City of Terrell utility services.

(2)

EMS membership program and fee.

a.

Each single-family residential utility customer and multifamily residential utility customer within the corporate limits of the city shall be included in the EMS membership program, unless the utility customer affirmatively declines participation in said program in the manner set forth in section 5.4-12 of this article.

b.

Single-family residential utility customers participating in the program shall have included within their utility bills a charge of $1.00 per month.

c.

Multifamily residential utility customers participating in the program shall be billed one dollar per month per living unit.

d.

The total number of living units attributed to multifamily residential utility customers and landlords shall be based upon the number of living units on record with the City of Terrell Utilities Department. It is the responsibility of all multifamily residential utility customers and landlords to annually confirm with the utilities department whether this number of living units is in fact accurate. Adjustments may be made to the number of units on record with the utilities department based on information provided by sworn affidavit from the multifamily residential utility customer or landlord and confirmed by the city. Multifamily residential utility customers and landlords shall make staff available to meet at the subject residences with city utilities department personnel to confirm the number of living units as provided for by the utility customer in the sworn affidavit mentioned herein.

(3)

Nonparticipation election.

a.

Any utility customer who desires to not participate in the EMS membership program shall sign and file a declaration of nonparticipation, on forms prescribed and provided by the city.

b.

If a multifamily residential utility customer or landlord or his or her authorized representative elects for a property not to participate in the EMS membership program, the multifamily residential utility customer or landlord or his or her authorized representative shall obtain from each tenant a written and signed acknowledgement stating that the tenant:

1.

Understands that the tenant and the tenant's household are not included in the EMS membership program;

2.

Understands that the tenant may affirmatively elect to personally participate in the medical service program by contacting CareFlite and enrolling in the program at the same price as offered to participating single-family residential utility customers;

3.

Understands that failure to participate in the program will subject the tenant and tenant's household to the full costs associated with CareFlite's services; and

4.

Has been informed of the estimated per trip costs for an emergency ambulance transport run. The written and signed acknowledgement described herein shall be maintained in the multifamily residential utility customer's or landlord's or his/her authorized representative's records and available for inspection by the City of Terrell upon request. This acknowledgement must be obtained for all tenants and all new tenants moving into the landlord's or multifamily residential utility customer's property at any time.

c.

Failure to obtain and maintain on file the written acknowledgement for each tenant shall be a separate violation of this section. In addition, every 30-day period from the beginning of a lease until written acknowledgement is received or the multifamily residential utility customer or landlord or his/her authorized representative elects for a property to participate in the medical service program shall constitute a separate offense for each tenant affected.

(4)

Receipt of service charges. The service charges herein established for the EMS membership program shall be billed to each utility customer monthly, along with the bill for other city utility services and shall carry the same due date as now or may hereafter be established for utility service bills.

(5)

Accountability for funds received. The city is not responsible for the provision of services by CareFlite. The city's sole responsibility is to properly receive, record and transfer to CareFlite the funds paid by the participating utility customers for EMS membership program benefits under the medical service program.

(6)

Adjustment of charges, appeal. Any utility customer who considers the EMS membership program charges applicable to his/her living unit to be erroneous because said utility customer opted out of the program, may request review of the charges by the city's utilities department. Additionally, any landlord or multifamily residential utility customer who encounters special circumstances that would justify modifying the number of living units determined in accordance with the provisions of section 5.4-11 (such as fire, act of God, or renovations), may request review thereof by the city's utilities department. Any other problems experienced by the utility customer with regard to his/her EMS membership program benefits shall be referred to CareFlite.

(7)

Civil and criminal penalties. The city shall have the power to administer and enforce the provisions of this subsection as may be required by governing law. Any person violating any provision of this subsection is subject to suit for injunctive relief as well as prosecution for criminal violations. Any violation of this subsection is hereby declared to be a nuisance.

a.

Criminal prosecution. Any person violating any provision of this subsection shall, upon conviction, be fined a sum not exceeding $500.00. Each day that a provision of this subsection is violated shall constitute a separate offense. An offense under this subsection is a Class C Misdemeanor.

b.

Civil remedies. Nothing in this subsection shall be construed as a waiver of the city's right to bring action to enforce the provisions of this subsection and to seek remedies allowed by law, including, but not limited to, the following:

1.

Injunctive relief to prevent specific conduct that violates the ordinance or to require specific conduct that is necessary for compliance with the ordinance; and

2.

A civil penalty of up to $150.00 per day when it is shown that the defendant was actually notified of the provisions of the ordinance and after receiving notice committed acts in violation of the ordinance or failed to take action necessary for compliance with the ordinance; and other available relief.

(Ord. No. 1815, §§ 1—8, 4-2-96; Ord. No. 2631, arts. I—VII, 5-5-15 )

Editor's note

At the city's instruction, Ord. No. 1815, §§ 1—8, adopted Apr. 2, 1996, replaced § 4, ambulances, § 4.1, nonemergency call ambulance service, § 4.2, emergency ambulance service and enacted a new § 4 as set out herein. Formerly §§ 4, 4.1 and 4.2 pertained to the same subject matter and derived from Ord. No. 1632, §§ I—IV, adopted Dec. 4, 1990.