PROPOSED RULES
Original Notice.
Preproposal statement of inquiry was filed as WSR 02-11-077.
Title of Rule: Advanced life support (ALS)/intermediate life support (ILS) ongoing training and evaluation program (OTEP). The proposal will require amending WAC 246-976-161, 246-976-171, and 246-976-930.
Purpose: The Department of Health certifies and recertifies EMS personnel as part of the comprehensive, statewide emergency medical services and trauma system. These sections identify the standards for renewing a certification.
Statutory Authority for Adoption: RCW 18.71.205 and 18.73.081.
Statute Being Implemented: RCW 18.71.205 and 18.73.081.
Summary: The proposed changes will provide standards for an ALS/ILS OTEP, amend current CME requirements for endotracheal intubations, specifically regarding the use of human subjects, end-tidal CO2 measurement devices and intensive airway management training programs, and change the pediatric continuing education requirements to competency based learning with standardized learning objectives.
Reasons Supporting Proposal: The proposed changes will provide an additional option for ALS and ILS providers to renew their certification, it will provide for consistency in pediatric training, and it will provide standards that may be met without compromising patient care.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Dane Kessler, 310 Israel Road S.E., Tumwater, WA, (360) 236-2842.
Name of Proponent: Department of Health, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The proposed amendments will expand the method of recertification and allow ALS and ILS providers a second option; to complete an OTEP developed for these advanced levels of care. This is in addition to the CME method already established.
The proposed rules will amend the endotracheal intubation requirements for the CME method of recertification in regards to the use of human subjects versus artificial training aids, will require the use of end-tidal CO2 measurement devices, and will allow for the use of a DOH approved intensive airway management training program. These changes will ensure that the skills maintenance requirements are more easily met without compromising patient care; while at the same time making certain that proper training is being done.
The proposed changes will provide pediatric continuing education requirements for all levels of providers that are based on learning objectives rather than just specific hours, and the training will be competency based. This will provide for consistent training.
Proposal Changes the Following Existing Rules: WAC 246-976-161: (1) Establishes standards for the ALS/ILS OTEP which were not previously set in rule. Note: The standards under this new method require fewer number of required IV starts and endotracheal intubations per year than the current CME method. (2) Reduces the number of endotracheal intubations that must be performed on humans to 4 per year in the CME method (the total number of intubations that must be performed each year has not been changed). (3) Requires the verification of proper tube placement and continued placement of the endotracheal tube in the trachea through the use of end-tidal CO2 measurement device (requirement in both OTEP and CME methods). (4) Allows for the use of DOH approved intensive airway management training programs when necessary (allowed for in both OTEP and CME methods). (5) Requires pediatric training to now be competency based, and redefines "Other pediatrics topics" to include pediatric objectives that must be covered during the training.
WAC 246-976-171 and 246-976-930: Eliminates unnecessary language, and incorporates the new ALS/ILS OTEP method in the requirements for applying for recertification.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department reviewed and analyzed this proposal and has determined that no small business economic impact statement (SBEIS) is required. The Regulatory Fairness Act, under RCW 19.85.030 required agencies to conduct an SBEIS if a rule imposes more than minor costs on businesses within an industry. Since this proposal does not impose more than minor costs to businesses, the department has not completed an SBEIS on this proposal.
RCW 34.05.328 does not apply to this rule adoption. This proposal sets criteria that are necessary for an individual to comply with in order to obtain a certification.
Hearing Location: Department of Health, 310 Israel Road S.E., Tumwater, WA 98501, on January 27, 2004, at 9:00 a.m.
Assistance for Persons with Disabilities: Contact Tami Schweppe by January 20, 2004, TDD (800) 833-6388 or (360) 236-2829.
Submit Written Comments to: Tami Schweppe, P.O. Box 47853, Olympia, WA 98504-7853, fax (360) 236-2829, by January 20, 2004.
Date of Intended Adoption: January 28, 2004.
December 18, 2003
Mary C. Selecky
Secretary
OTS-6609.2
AMENDATORY SECTION(Amending WSR 00-08-102, filed 4/5/00,
effective 5/6/00)
WAC 246-976-161
((Continuing medical education (CME),
skills maintenance, and ongoing training and evaluation
(OTEP).)) Education requirements for certification.
(((1)
General requirements. See Tables A and B. You must document
your annual CME and skills maintenance requirements, as
indicated in the tables. You must complete all CME and skills
maintenance requirements for your current certification period
to be eligible for recertification.
(2)(a) You must complete the number of MPD-approved CME hours appropriate to your level of certification, as indicated in Table A.
(b) If you are a first responder or EMT, you may choose to complete an approved OTEP program instead of completing the required number of CME hours and taking the recertification exams.
(3) You must demonstrate proficiency in certain critical skills, indicated in Table B, to the satisfaction of the MPD:
(4) IV starts.
(a) During your first year of certification as an IV technician, combined IV/airway technician, ILS technician, or paramedic, you must perform a minimum of thirty-six successful IV starts. EXCEPTION: If you have completed a certification period as an IV or ILS technician, you do not need to meet this requirement during your first year of certification as a paramedic.
(b) By the end of your initial certification period, you must perform a minimum of one hundred eight successful IV starts.
(5) Intubations.
(a) During your first year of certification as an airway technician, combined IV/airway technician, combined ILS/airway technician or paramedic, you must perform a minimum of twelve successful endotracheal intubations. EXCEPTION: If you have completed a certification period as an airway technician, you do not need to meet this requirement during your first year of certification as a paramedic.
(b) By the end of your initial certification period, you must perform a minimum of thirty-six successful endotracheal intubations.
(6) Description of selected terms used in the table:
| (( CME REQUIREMENTS |
||||||||
SKILLS MAINTENANCE REQUIREMENTS |
||||||
• CPR includes the use of airway adjuncts appropriate to
the level of certification.
• Pharmacology: Pharmacology specific to the medications
approved by your MPD (NOT REQUIRED FOR FIRST RESPONDERS).
• Pediatrics: This includes patient assessment, CPR and
airway management, and spinal immobilization and packaging.
• "IV starts": Proficiency in intravenous
catheterization performed on sick, injured, or preoperative
adult and pediatric patients. With written authorization of
the MPD, IV starts may be performed on artificial training
aids.
• Endotracheal intubation: Proficiency in endotracheal
intubations, at least half of which must be performed on human
subjects. With written authorization of the MPD, up to half
of the intubations may be performed on artificial training
aids.
• Intraosseous infusion: Proficiency in intraosseous
line placement in pediatric patients.
• Proficiency: Ability to perform a skill properly,
demonstrated to the satisfaction of the MPD.
• Pediatric airway: Proficiency in pediatric airway
management.)) (1) Education is required for the
recertification of all certified EMS personnel. This
education may be obtained by completing the continuing medical
education (CME) method, or through the ongoing training and
evaluation program (OTEP) method, identified below.
(a) To complete the CME method you must:
(i) Complete and document the educational requirements, indicated in Table A of this section, appropriate to your level of certification.
(ii) Complete and document the skills maintenance requirements, indicated in Table B of this section, appropriate to your level of certification.
(A) IV starts for IV technicians, combined IV/airway technicians, ILS technicians, combined ILS/airway technicians, or paramedics:
(I) During your first certification period, you must perform a minimum of one hundred eight successful IV starts.
• During the first year, you must perform a minimum of thirty-six successful IV starts.
• During the second and third year, you must perform a minimum of thirty-six successful IV starts per year, which may be averaged over the second and third years of the certification period.
(II) If you have completed a certification period, you must demonstrate proficiency in starting IVs to the satisfaction of the MPD (see later certification periods in Table B of this section).
(B) Endotracheal intubations for airway technicians, combined IV/airway technicians, combined ILS/airway technicians or paramedics:
(I) During your first certification period, you must perform a minimum of thirty-six successful endotracheal intubations.
• During the first year, you must perform a minimum of twelve successful endotracheal intubations of which four of the endotracheal intubations must be performed on humans.
• During the second and third year, you must perform a minimum of twelve endotracheal intubations per year, which may be averaged over the second and third years of the certification period. Four of these endotracheal intubations per year must be performed on humans.
(II) If you have completed a certification period, you must perform a minimum of four successful human endotracheal intubations per year, which may be averaged over the three-year certification period (see later certification periods in Table B of this section).
(III) Upon approval of the MPD, individuals unable to complete the required endotracheal intubations during the certification period, may meet the endotracheal intubation requirements by completing a department-approved intensive airway management training program, which includes lecture, hands-on training, and proficiency evaluation.
(iii) Successfully complete the Washington state written examination and practical skills examination as identified in WAC 246-976-171.
(b) To complete the OTEP method you must:
(i) Complete a DOH- and MPD-approved OTEP that includes requirements indicated in Table A of this section, appropriate to your level of certification.
(ii) Complete and document the skills maintenance requirements, indicated in Table B of this section, appropriate to your level of certification.
(A) IV starts for IV technicians, combined IV/airway technicians, ILS technicians, combined ILS/airway technicians, or paramedics:
(I) During your first certification period, you must perform a minimum of thirty-six successful IV starts.
• During the first year, you must perform a minimum of twelve successful IV starts.
• During the second and third year, you must perform a minimum of twelve successful IV starts per year, which may be averaged over the second and third years of the certification period.
(II) If you have completed a certification period, you must demonstrate proficiency in starting IVs to the satisfaction of the MPD (see later certification periods in Table B of this section).
(B) Endotracheal intubations for airway technicians, combined IV/airway technicians, combined ILS/airway technicians or paramedics:
(I) During your first certification period, you must perform a minimum of twelve successful endotracheal intubations.
• During the first year, you must perform a minimum of four successful human endotracheal intubations.
• During the second and third year, you must perform a minimum of four human endotracheal intubations per year, which may be averaged over the second and third years of the certification period.
(II) If you have completed a certification period, you must perform a minimum of two successful human endotracheal intubations per year, which may be averaged over the three-year certification period (see later certification periods in Table B of this section).
(III) Upon approval of the MPD, individuals unable to complete the required endotracheal intubations during the certification period, may meet the endotracheal intubation requirements by completing a department-approved intensive airway management training program, which includes lecture, hands-on training, and proficiency evaluation.
(C) Skills maintenance requirements may be obtained as part of the OTEP.
(D) Individuals participating in an OTEP meet skill maintenance requirements by demonstrating proficiency in the application of those skills to the county MPD during the OTEP.
(c) Any applicant changing from the OTEP method to the CME method must meet all requirements of the CME method.
(d) Education requirements for recertification - Table A:
| TABLE A: EDUCATION REQUIREMENTS FOR RECERTIFICATION |
Basic Life Support | Intermediate Life Support (EMT-Intermediate Levels) |
Paramedic (ALS) |
|||||
| FR | EMT | IV | Air | IV/Air | ILS | ILS/Air | Paramedic | |
| Annual Requirements | ||||||||
| CPR & Airway | X | X | X | X | X | X | X | |
| Spinal Immobilization | X | X | X | X | X | X | X | |
| Patient Assessment | X | X | X | X | X | X | X | |
| Certification Period Requirements | ||||||||
| Infectious Disease | X | X | X | X | X | X | X | X |
| Trauma | X | X | X | X | X | X | X | |
| Pharmacology | X | X | X | X | X | X | ||
| Other Pediatric Topics | X | X | X | X | X | X | X | X |
| *Additional education course hours totaling: | 15 hrs | 30 hrs | 45 hrs | 45 hrs | 60 hrs | 60 hrs | 75 hrs | 150 hrs |
| "X" indicates an individual must demonstrate knowledge and competency in the topic or skill. | |
| *Individuals obtaining education through the CME method must complete the total number of educational course hours indicated above. However, due to the competency-based nature of OTEP, fewer class hours may be needed to complete these requirements than the total course hours indicated above. |
| TABLE B: SKILLS MAINTENANCE REQUIREMENTS |
Intermediate Life Support (EMT-Intermediate Levels) |
Paramedic (ALS) |
|||||
| IV | Air | IV/Air | ILS | ILS/Air | Paramedic | ||
| First Certification Period | |||||||
| • First Year of Certification | |||||||
| IV Starts | |||||||
| Continuing Education Method may not be averaged | 36 | 36 | 36 | 36 | 36 | ||
| OTEP Method | 12 | 12 | 12 | 12 | 12 | ||
| Endotracheal intubations (4 must be performed on humans for each method) |
|||||||
| Continuing Education Method may not be averaged | 12 | 12 | 12 | 12 | |||
| OTEP Method | 4 | 4 | 4 | 4 | |||
| Intraosseous infusion placement | X | X | X | X | X | ||
| • Second and Third Years of Certification | |||||||
| • Annual Requirements | |||||||
| IV Starts* | |||||||
| Continuing Education Method | 36 | 36 | 36 | 36 | 36 | ||
| OTEP Method | 12 | 12 | 12 | 12 | 12 | ||
| Endotracheal intubations* (4 per year must be performed on humans for each method) |
|||||||
| Continuing Education Method | 12 | 12 | 12 | 12 | |||
| OTEP Method | 4 | 4 | 4 | 4 | |||
| Intraosseous infusion placement | X | X | X | X | X | ||
| • During the Certification Period | |||||||
| Pediatric airway management | X | X | X | X | |||
| Multi-lumen airway placement | X | X | |||||
| Defibrillation | X | X | |||||
| Later Certification Periods | |||||||
| • Annual Requirements | |||||||
| IV Starts | X | X | X | X | X | ||
| Endotracheal intubations (2 per year must be performed on humans for each method) |
|||||||
| Continuing Education Method | 4 | 4 | 4 | 4 | |||
| OTEP Method | 2 | 2 | 2 | 2 | |||
| Intraosseous infusion placement | X | X | X | X | X | ||
| • During the Certification Period | |||||||
| Pediatric airway management | X | X | X | X | |||
| Multi-lumen airway placement | X | X | |||||
| Defibrillation | X | X | |||||
| "X" indicates an individual must demonstrate proficiency of the skill to the satisfaction of the MPD. | |
| *The second and third year requirements may be averaged over the two years. |
(i) Reciprocity candidates credentialed less than three years must meet Washington state's skill maintenance requirements for the initial certification period identified above.
(ii) Reciprocity candidates credentialed three years or more must meet Washington state's skill maintenance requirements for second and subsequent certification periods.
(iii) The county MPD may evaluate an individual's skills to determine if the individual is proficient in the application of those skills prior to recommending certification. The MPD may recommend an individual obtain specific training to become proficient in any skills deemed insufficient by the MPD or delegate.
(g) Description of selected terms used in Tables A and B:
• Class hours: Actual hours spent to become knowledgeable in a topic(s) or proficient in a skill(s).
• Course hours: The predetermined time scheduled to conduct a course or topic.
• CPR and airway management includes foreign body obstruction (FBAO) and the use of airway adjuncts appropriate to the level of certification, for adults, children and infants following national standards, assuring the following pediatric objectives are covered.
• Pediatric objectives - The EMS provider must be able to:
1. Identify and demonstrate airway management techniques for infants and children.
2. Demonstrate infant and child CPR.
3. Demonstrate FBAO technique for infants and children.
• Endotracheal intubation: Proficiency includes the verification of proper tube placement and continued placement of the endotracheal tube in the trachea through the use of an end-tidal CO2 measurement device.
• Infectious disease: Infectious disease training must meet the requirements of chapter 70.24 RCW.
• Intraosseous infusion: Proficiency in intraosseous line placement in pediatric patients.
• IV starts: Proficiency in intravenous catheterization performed on sick, injured, or preoperative adult and pediatric patients. With written authorization of the MPD, IV starts may be performed on artificial training aids.
• Multi-lumen airway placement: Proficiency includes the verification of tube placement and continued placement for proper tracheal ventilation through the use of an end-tidal CO2 measurement device.
• Other pediatric topics: This includes anatomy and physiology and medical problems including special needs patients appropriate to the level of certification, assuring the following pediatric objectives are covered.
• Anatomy and physiology - The EMS provider must be able to:
1. Identify the anatomy and physiology and define the differences in children of all ages.
2. Identify developmental differences between infants, toddlers, preschool, school age and adolescents, including special needs children.
• Medical problems including special needs patients - The EMS provider must be able to:
1. Identify the differentiation between respiratory distress and respiratory failure.
2. Identify the importance of early recognition and treatment of shock in the infant and child patient.
3. Identify causes and treatments for seizures.
4. Identify life-threatening complications of meningitis and sepsis.
5. Identify signs and symptoms of dehydration.
6. Identify signs and symptoms of hypoglycemia.
7. Identify how hypoglycemia may mimic hypoxemia.
8. Identify special needs pediatric patients that are technologically dependant (tracheotomy tube, central line, GI or feeding tubes, ventilators, community specific needs).
9. Identify the signs and symptoms of suspected child abuse.
10. Identify the signs and symptoms of anaphylaxis and treatment priorities.
11. Identify the importance of rapid transport of the sick infant and child patient.
• Patient assessment: This includes adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.
• Pediatric objectives - The EMS provider must be able to:
1. Identify and demonstrate basic assessment skills according to the child's age and development.
2. Demonstrate the initial assessment skills needed to rapidly differentiate between the critically ill or injured and the stable infant and child patient.
3. Identify and demonstrate the correct sequence of priorities to be used in managing the infant and child patient with life threatening injury or illness.
4. Identify that the priorities for a severely injured and critically ill infant and child are:
a. Airway management,
b. Oxygenation,
c. Early recognition and treatment of shock,
d. Spinal immobilization,
e. Psychological support.
5. Demonstrate a complete focused assessment of an infant and a child.
6. Demonstrate ongoing assessment of an infant and a child.
7. Identify the differences between the injury patterns of an infant and a child compared to that of an adult.
8. Identify the psychological dynamics between an infant and a child, parent or caregiver and EMS provider.
• Pharmacology: Pharmacology specific to the medications approved by the MPD (not required for first responders).
• Proficiency: Ability to demonstrate and perform all aspects of a skill properly to the satisfaction of the MPD or delegate.
• Spinal immobilization and packaging: This includes adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.
• Pediatric objectives - The EMS provider must be able to:
1. Demonstrate the correct techniques for immobilizing the infant and child patient.
2. Identify the importance of using the correct size of equipment for the infant and child patient.
3. Demonstrate techniques for adapting adult equipment to effectively immobilize the infant and child patient.
• Trauma: For adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.
• Pediatric objectives - The EMS provider must be able to:
1. Identify the importance of early recognition and treatment of shock in the infant and child patient.
2. Identify the importance of early recognition and treatment of the multiple trauma infant and child patient.
3. Identify the importance of rapid transport of the injured infant and child patient.
(2) Topic content to meet the educational requirements identified in subsection (1) of this section must:
(a) Meet annual and certification period educational requirements identified in Appendix A, utilizing:
(i) The course objectives found in curricula identified in WAC 246-976-021, Training course requirements, for the level of certification being taught.
(ii) The current national standards published for CPR, foreign body airway obstruction (FBAO), and automatic defibrillation.
(iii) County medical program director (MPD) protocols, regional patient care procedures, and county operating procedures.
(iv) Transitional training or updates in standards as identified by the department.
(b) Be approved by the MPD;
Any additions or major changes to an approved OTEP require documented approval from the county MPD and DOH.
(c) Be presented and evaluation by course personnel meeting the following qualifications:
(i) Evaluators must:
(A) Be a currently certified BLS or ALS provider who has completed at least one certification cycle. Certification must be at or above the level of certification being evaluated.
(B) Complete an evaluator's workshop, specific to the level of certification being evaluated;
(C) Complete the evaluator application, DOH Form 530-012;
(D) Be approved by the county MPD and DOH.
(ii) Instructors must:
(A) Be a currently certified BLS or ALS provider who has completed at least one certification cycle at or above the level of certification being taught.
(B) Be a currently approved evaluator at the level of certification being taught.
(C) Be approved by the county MPD to instruct and evaluate EMS topics.
(iii) Guest lecturers, when utilized, must have specific knowledge and experience in the skills of the prehospital emergency care field for the topic being presented and be approved by the county MPD to instruct EMS topics.
[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-161, filed 4/5/00, effective 5/6/00.]
(a) An ongoing training and evaluation program (OTEP) of skills as authorized in RCW 18.73.081 (3)(b) for first responders and EMTs; and
(b) Examinations for renewal of certification.
If you are a first responder or an EMT, you may choose to complete an approved OTEP program instead of completing the required number of CME hours and taking the recertification exam.
(2) To apply for renewal of certification, submit to the department on approved forms:
(a) All the information identified in WAC 246-976-141(2); EXCEPT current certification is considered proof of course completion, age, and initial infectious disease training;
(b) Proof of completion of CME and skills maintenance required for the level of certification sought, as defined in this chapter and identified on the table above. For first responders and EMTs, this includes proof of successful demonstration of skills, by:
(i) Successfully completing an approved OTEP; or
(ii) Passing an approved practical examination within the six months prior to application. An applicant changing from the ongoing training and evaluation program to the practical examination program must take the practical examination prior to the end of the certification period.)) To apply for recertification, the applicant must provide information that meets the requirements identified in WAC 246-976-141(2); EXCEPT current Washington state certification is considered proof of course completion, age, and initial infectious disease training.
(1) Proof of successful completion of education and skills maintenance, required for the level of certification, as defined in this chapter and identified in Tables A and B of WAC 246-976-161.
(2) Demonstrate knowledge and practical skills competency:
(a) For individuals participating in the OTEP method of education at the level of certification, successful completion of the OTEP fulfills the requirement of the DOH written and practical skills examinations.
(b) Individuals completing the CME method of education must provide proof of successful completion of the DOH written examination and practical skills examination for the level of certification.
(i) Basic life support (BLS) and intermediate life support (ILS) personnel must successfully complete the DOH approved practical skills examination for the level of certification.
(ii) Paramedics must successfully complete practical skills evaluations required by the MPD to determine ongoing competence.
[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-171, filed 4/5/00, effective 5/6/00.]
(1) The department shall review, recommend changes to, and approve regional plans and regional patient care procedures based on the requirements of this chapter and recommendations from the steering committee, and upon consideration of the needs of patients.
(a) The department may approve regional plans which include standards that are consistent with chapter 70.168 RCW and other state and federal laws, but which exceed the requirements of this chapter.
(b) The department will develop a process for biennial update of regional and statewide planning. The process will include provisions to amend regional plans between biennial updates.
(2) ((The department will publish standards for minimum
required knowledge and skill objectives for ongoing training
and evaluation programs (OTEP) for first responders and EMTs,
as authorized in RCW 18.73.081 (3)(b). The department will
publish procedures to approve OTEPs.
(3))) The department will publish prehospital trauma triage procedures for activation of the trauma system from the field. The procedures will include assessment of the patient's:
(a) Vital signs and level of consciousness;
(b) Anatomy of injury;
(c) Biomechanics of the injury; and
(d) Comorbid and associated risk factors.
(((4))) (3) The department may approve pilot programs and
projects which have:
(a) Stated objectives;
(b) A specified beginning and ending date;
(c) An identified way to measure the outcome;
(d) A review process;
(e) A work plan with a time line;
(f) If training of EMS((/TC)) personnel is involved,
consistency with the requirements of WAC 246-976-021(5).
(((5))) (4) The department will review at least every
four years:
(a) Rules, policies, and standards for EMS((/TC)), with
the advice of the steering committee;
(b) Rules and standards for licensure of services and
vehicles, and for certification of EMS((/TC)) personnel, with
the advice of the L&C committee((;)).
[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-930, filed 4/5/00, effective 5/6/00. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), § 246-976-930, filed 12/23/92, effective 1/23/93.]