WSR 24-15-104

PERMANENT RULES

DEPARTMENT OF HEALTH

[Filed July 22, 2024, 2:39 p.m., effective September 30, 2024]

Effective Date of Rule: September 30, 2024.

Purpose: Emergency medical services (EMS) and trauma care systems chapter updates. The department of health (department) identified updates, revisions, and housekeeping items needed for chapter 246-976 WAC. By doing so, the department will satisfy the requirements of RCW 43.70.041, enacted and codified in 2013, which directs the department and other state agencies to establish a formal review process of existing rules every five years to reduce the regulatory burden on businesses without compromising public health and safety. The department is adopting amendments to align with current national standards; make rules more clear, concise, and organized; adopt changes to address barriers to initial and renewal application processes; and respond to new legislative requirements.

The amendments to existing rules and new sections will ensure regulations and standards are clear, concise, and reflect current standards of care and best practice for the benefit and safety of the public.

Citation of Rules Affected by this Order: New WAC 246-976-026, 246-976-139 and 246-976-261; and amending WAC 246-976-010, 246-976-022, 246-976-023, 246-976-024, 246-976-031, 246-976-032, 246-976-033, 246-976-041, 246-976-141, 246-976-142, 246-976-143, 246-976-144, 246-976-161, 246-976-162, 246-976-163, 246-976-171, 246-976-182, 246-976-260, 246-976-270, 246-976-290, 246-976-300, 246-976-310, 246-976-330, 246-976-340, 246-976-390, 246-976-395, 246-976-920, 246-976-960, and 246-976-970.

Statutory Authority for Adoption: RCW 18.71.205, 18.73.081, 43.70.040, and 70.168.050; ESSB 5751 (chapter 70, Laws of 2017), SHB 1258 (chapter 295, Laws of 2017), ESHB 1551 (chapter 76, Laws of 2020), ESSB 5229 (chapter 276, Laws of 2021), SSB 5380 (chapter 314, Laws of 2019), SHB 1276 (chapter 69, Laws of 2021), and SHB 1893 (chapter 136, Laws of 2022).

Adopted under notice filed as WSR 24-03-061 on January 12, 2024.

Changes Other than Editing from Proposed to Adopted Version: A. WAC 246-976-023 Initial emergency medical services (EMS) training course requirements and course approval. In subsection (3)(f), the department made a minor edit to clarify the title of a department document from "Course Completion Record" to "EMS Course Completion Verification form," which is the correct title of this document.

B. WAC 246-976-031 EMS instructors, initial approval, and recognition. In subsection (1)(a), the department made a minor edit to change the word "student" to "clinical." This clarifies that an emergency services evaluator (ESE) may function as a clinical preceptor to a student and is not a student. The intent of this standard is to allow an ESE to be identified by a training program as a person who can provide mentorship and oversight of a student in an EMS training program who is conducting field time with an EMS service as a part of their training. The proposed rule was worded in a way that interested parties felt was confusing, so the department made this minor edit to clarify the intent.

C. WAC 246-976-139 Provisional certification. In subsection (3) the department made a minor edit to correct the word "filed" to "field." The intent of this standard is that a person holding a provisional certification would be able to apply for full certification upon successful completion of any EMS service field training. In the proposed rule the word was misspelled and said "filed." The spelling of the word was corrected.

D. WAC 246-976-141 To obtain initial EMS provider certification following the successful completion of Washington state approved EMS course. In subsection (5), the department made a minor edit to remove the word "and." The intent of this standard is that proof of competency is a current and valid certification from another state or national organization recognized by the department. In the proposed rule the word "and" implied that an applicant had to provide additional proof beyond a current and valid certification from another state or national organization recognized by the department. That was not the intent and removing the word "and" clarifies this.

E. WAC 246-976-141 To obtain initial EMS provider certification following the successful completion of Washington state approved EMS course. In subsection (6), the department restored the language which allows senior EMS instructors and training coordinators to affiliate with a department-approved training program with the approval of the county medical program director if they are unable to be affiliated with a licensed aid or ambulance service or an EMS service supervisory organization. The department inadvertently left out this option and it was corrected.

F. WAC 246-976-142 To obtain reciprocal (out of state) EMS certification based on out of state or national EMS certification approved by the department. In subsection (5), the department made a minor edit to remove the word "and." The intent of this standard is that proof of competency is a current and valid certification from another state or national organization recognized by the department. In the proposed rule, the word "and" implied that an applicant had to provide additional proof beyond a current and valid certification from another state or national organization recognized by the department. That was not the intent and removing the word "and" clarifies this.

G. WAC 246-976-142 To obtain reciprocal (out of state) EMS certification based on out of state or national EMS certification approved by the department. In subsection (6), the department restored the language which allows senior EMS instructors and training coordinators to affiliate with a department-approved training program with the approval of the county medical program director if they are unable to be affiliated with a licensed aid or ambulance service or an EMS service supervisory organization. The department inadvertently left out this option and it was corrected.

H. WAC 246-976-161 General education and skill maintenance requirements for EMS provider certification. In subsection (4), the department made a minor edit to add "to the skills and procedures identified on the Washington State Approved Skills and Procedures for Certified EMS Providers list (DOH 530-173)." This addition clarifies that the intent of this provision is related to providing opportunities for certified EMS providers to practice the skills and procedures relevant to EMS clinical practice and patient care.

I. WAC 246-976-171 Recertification, reversion, reissuance, and reinstatement of certification. In subsection (2)(c), the department restored the language which allows senior EMS instructors and training coordinators to affiliate with a department-approved training program with the approval of the county medical program director if they are unable to be affiliated with a licensed aid or ambulance service or an EMS service supervisory organization. The department inadvertently left out this option and it was corrected.

J. WAC 246-976-300 Ground ambulance and aid service—Equipment. In table (A), the department made minor edits to clarify equipment standards. We removed the asterisk from the end-tidal CO2 detector and supraglottic airways for intermediate and advanced level services. The intent of this standard is to identify the number and type of equipment that must be made available on licensed ambulances, aid vehicles, and emergency services supervisory organizations. In the proposed rule, an asterisk implied that this equipment was optional for intermediate and advanced levels of care when, in fact, the equipment is required for intermediate and advanced levels of care. This was an error and has been corrected. In table (A), the department made a minor edit to clarify the equipment standard for intubation insertion equipment and added the word "Assortment" to the ALS AID/ESSO column. This was an error and has been corrected. In subsection (2)(c), the department added a semicolon after the word "monitoring."

K. Chapter 246-976 WAC, for consistency, the department made minor edits throughout the proposal to make consistent use of the terms "continuing medical education (CME) and ongoing training." These terms were used in a variety of ways throughout the document and the department edited these terms all to say the same thing.

L. Chapter 246-976 WAC, for consistency, the department made minor edits throughout the proposal to make consistent use of the term "county medical program director." This phrase was used in a variety of ways throughout the document and the department edited this phrase to say the same thing.

A final cost-benefit analysis is available by contacting Catie Holstein, P.O. Box 47853, Olympia, WA 98504-7853, phone 360-688-3425, fax 360-236-2830, TTY 800-833-6388 or 711, email HSQA.EMS@doh.wa.gov, website https://doh.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 2, Amended 7, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 29, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 9, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 29, Repealed 0.

Date Adopted: July 22, 2024.

Kristin Peterson, JD

Chief of Policy

for Umair A. Shah, MD, MPH

Secretary

OTS-4953.3

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-010Definitions.

Definitions in RCW 18.71.200, 18.71.205, 18.73.030, and 70.168.015 and the definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Activation of the trauma system" means mobilizing resources to care for a trauma patient in accordance with regional patient care procedures.

(2) "Adolescence" means the period of physical and psychological development from the onset of puberty to maturity, approximately ((twelve to eighteen))12 to 18 years of age.

(3) "Advanced cardiac life support (ACLS)" means a training course established with national standards recognized by the department that includes the education and clinical interventions used to treat cardiac arrest and other acute cardiac related problems.

(4) "Advanced emergency medical technician (AEMT)" means a person who has been examined and certified by the secretary as an intermediate life support technician as defined in RCW 18.71.200 and 18.71.205.

(5) "Advanced first aid" means an advanced first-aid course prescribed by the American Red Cross or its equivalent.

(6) "Advanced life support (ALS)" means the level of care or service that involves invasive emergency medical ((services))procedures requiring the advanced medical treatment skills of a paramedic.

(7) (("Agency" means an aid or ambulance service licensed by the secretary to provide prehospital care or interfacility ambulance transport.

(8))) "Agency response time" means the interval from dispatch to arrival on the scene.

(((9)))(8) "Aid service" means an EMS agency licensed by the secretary to operate one or more aid vehicles, consistent with regional and state plans, and the department-approved license application. Aid services respond with aid equipment and certified emergency medical services providers to the scene of an emergency to provide initial care and treatment to ill or injured people.

(9) "Ambulance" or "aid service activation" means the dispatch or other initiation of a response by an ambulance or aid service to provide prehospital care or interfacility ambulance transport.

(10) "Ambulance service" means an EMS agency licensed by the secretary to operate one or more ground or air ambulances, consistent with regional and state plans, and the department-approved license application.

(11) "Approved" means approved by the department of health.

(12) "ATLS" means advanced trauma life support, a course developed by the American College of Surgeons.

(13) "Attending surgeon" means a physician who is board-certified or board-qualified in general surgery, and who has surgical privileges delineated by the facility's medical staff. The attending surgeon is responsible for care of the trauma patient, participates in all major therapeutic decisions, and is present during operative procedures.

(14) "Available" for designated trauma services described in WAC 246-976-485 through 246-976-890 means physically present in the facility and able to deliver care to the patient within the time specified. If no time is specified, the equipment or personnel must be available as reasonable and appropriate for the needs of the patient.

(15) "Basic life support (BLS)" means the level of care or service that involves basic emergency medical ((services))procedures requiring basic medical treatment skills as defined in chapter 18.73 RCW.

(16) "Board certified" or "board-certified" means that a physician has been certified by the appropriate specialty board recognized by the American Board of Medical Specialties. For the purposes of this chapter, references to "board certified" include physicians who are board-qualified.

(17) "Board-qualified" means physicians who have graduated less than five years previously from a residency program accredited for the appropriate specialty by the accreditation council for graduate medical education.

(18) "BP" means blood pressure.

(19) "Certification" means the secretary recognizes that an individual has proof of meeting predetermined qualifications, and authorizes the individual to perform certain procedures.

(20) "Consumer" means an individual who is not associated with the EMS/TC system, either for pay or as a volunteer, except for service on the steering committee, or regional or local EMS/TC councils.

(21) "Continuing medical education method (CME method)" ((or (CME method) means prehospital EMS recertification education required after initial EMS certification to maintain and enhance skill and knowledge))means a method of obtaining education required for the recertification of EMS providers. The CME method requires the successful completion of department-approved knowledge and practical skill certification examinations to recertify.

(22) "County operating procedures (COPs)" ((or "COPS" means the))means department-approved written operational procedures adopted by the county MPD and the local EMS council ((specific to county needs)). COPs provide county level guidance and operational direction which supports the delivery of patient care and coordination of patient transport and movement within the local emergency care system. COPs must be compatible with and work in coordination with state triage and destination procedures, regional patient care procedures, and patient care protocols.

(23) "CPR" means cardiopulmonary resuscitation.

(24) (("Critical care transport" means the interfacility transport of a patient whose condition requires care by a physician, RN or a paramedic who has received special training and approval by the MPD.

(25)))"Data user" means any individual who may access or possess data for any use, including quality improvement, administrative record keeping, research, surveillance, or evaluation.

(25) "Data use agreement" means a signed agreement with the department for transmitting, receiving, and using records containing individually identifiable or potentially identifiable health information. The agreement specifies, at a minimum what information will be exchanged, the conditions or restrictions under which the information will be used and protected, restrictions on redisclosure of data and restrictions on attempt to locate information associated with a specific individual.

(26) "Department" means the Washington state department of health.

(((26)))(27) "Dispatch" means to identify and direct an emergency response unit to an incident location.

(((27)))(28) "Diversion" means the EMS transport of a patient past the usual receiving facility to another facility due to temporary unavailability of care resources at the usual receiving facility.

(((28)))(29) "E-code" means external cause code, an etiology included in the International Classification of Diseases (ICD).

(((29)))(30) "ED" means emergency department.

(((30)))(31) "Electronic patient care report" means the record of patient care produced in an electronic data system.

(32) "EMS agency" means an EMS service such as an emergency services supervisory organization (ESSO), aid or ambulance service licensed or recognized by the secretary to provide prehospital care or interfacility transport.

(33) "Emergency medical procedures" means the skills that are performed within the scope of practice of EMS personnel certified by the secretary under chapters 18.71 and 18.73 RCW.

(((31)))(34) "Emergency medical services and trauma care (EMS/TC) system" means an organized approach to providing personnel, facilities, and equipment for effective and coordinated medical treatment of patients with a medical emergency or injury requiring immediate medical or surgical intervention to prevent death or disability. The emergency medical services and trauma care system includes prevention activities, prehospital care, hospital care, and rehabilitation.

(((32)))(35) "Emergency medical responder (EMR)" means a person who has been examined and certified by the secretary as a first responder to render prehospital EMS care as defined in RCW 18.73.081.

(((33)))(36) "Emergency medical technician (EMT)" means a person who has been examined and certified by the secretary as an EMT to render prehospital EMS care as defined in RCW 18.73.081.

(((34)))(37) "EMS" means emergency medical services.

(((35)))(38) "EMS provider" means an individual certified by the secretary or the University of Washington School of Medicine under chapters 18.71 and 18.73 RCW to provide prehospital emergency response, patient care, and transport.

(((36)))(39) "Emergency services supervisory organization (ESSO)" means an entity that is authorized by the secretary to use first responders to provide medical evaluation and initial treatment to sick or injured people, while in the course of duties with the organization for on-site medical care prior to any necessary activation of emergency medical services. ESSOs include law enforcement agencies, disaster management organizations, search and rescue operations, and diversion centers.

(40) "EMS/TC" means emergency medical services and trauma care.

(((37)))(41) "Endorsement" means a higher form of recognition that requires successful completion of a department-approved MPD specialized training course. Endorsements are added to an EMS providers primary EMS certification.

(42) "General surgeon" means a licensed physician who has completed a residency program in surgery and who has surgical privileges delineated by the facility.

(((38)))(43) "ICD" means the international classification of diseases, a coding system developed by the World Health Organization.

(((39)))(44) "Initial recognition application procedure (IRAP)" means the application and procedure that a senior EMS instructor (SEI) candidate must complete and submit to the department to apply for initial recognition as an SEI.

(45) "Injury and violence prevention" means any combination of educational, legislative, enforcement, engineering and emergency response initiatives used to reduce the number and severity of injuries.

(((40)))(46) "Interfacility transport" means medical transport of a patient between recognized medical treatment facilities requested by a licensed health care provider.

(((41)))(47) "Intermediate life support (ILS)" means the level of care or service that may involve invasive emergency medical ((services))procedures requiring the ((advanced)) medical treatment skills of an advanced ((EMT))emergency medical technician (AEMT).

(((42) "IV"))(48) "Venous access" means a fluid or medication administered directly into the venous system.

(((43)))(49) "Local council" means a local EMS/TC council authorized by RCW 70.168.120(1).

(((44)))(50) "Medical control" means oral or written direction ((of))provided by the MPD or MPD physician delegate to EMS providers who provide medical care ((that certified prehospital EMS personnel provide)) to patients of all age groups. ((The oral or written direction is provided by the MPD or MPD delegate.

(45)))(51) "Medical control agreement" means a department-approved written agreement between two or more MPDs, ((using similar protocols that are consistent with regional plans, to assure))that provides guidance regarding aspects of medical oversight to support continuity of patient care between counties((, and to facilitate assistance)). MPD agreements must be compatible and work in coordination with state triage and destination procedures, county operating procedures, patient care procedures, and patient care protocols.

(((46)))(52) "Medical program director (MPD)" means a person who meets the requirements of chapters 18.71 and 18.73 RCW and is certified by the secretary as the county MPD. The MPD is responsible for both the supervision of training and medical control of EMS providers.

(((47) "MPD))(53) "Medical program director delegate (MPD delegate)" means a physician appointed by the MPD and recognized and approved by the department. An MPD delegate may be:

(a) A prehospital training physician who supervises specified aspects of training EMS personnel; or

(b) A prehospital supervising physician who provides online medical control of EMS personnel.

(((48)))(54) "Medical program director policy" means a department-approved written policy adopted by the county MPD that establishes expectations, procedures, and guidance related to the administrative activities of providing oversight to EMS providers and are within the roles and responsibilities of the MPD.

(55) "National Emergency Medical Services Information System (NEMSIS)" means the national database used to store EMS data from the U.S. States and Territories and is a national standard for how prehospital and interfacility transport information is collected.

(56) "Ongoing training and evaluation program (OTEP)" means a continuous program of ((prehospital EMS)) education for the recertification of EMS ((personnel after completion of initial training))providers. An OTEP ((is))must be approved by the MPD and the department. ((An OTEP must meet the EMS education requirements and core topic content required for recertification. The OTEP method includes evaluations of the knowledge and skills covered in the topic content following each topic presentation.

(49) "PALS" means a pediatric advanced life support course.

(50)))(57) "Pediatric advanced life support (PALS)" means a training course established with department recognized national standards for clinical interventions used to treat pediatric cardiac arrest and other acute cardiac related problems.

(58) "Paramedic" or "physician's trained emergency medical service paramedic" means a person who has been trained in an approved program to perform all phases of prehospital emergency medical care, including advanced life support, under written or oral authorization of an MPD or approved physician delegate, examined and certified by the secretary under chapter 18.71 RCW.

(((51)))(59) "Pediatric education requirement (PER)" means the pediatric education and training standards required for certain specialty physicians and nurses who care for pediatric patients in designated trauma services as identified in WAC 246-976-886 and 246-976-887.

(((52) "PEPP" means pediatric education for prehospital professionals.

(53) "PHTLS" means a prehospital trauma life support course.

(54)))(60) "Pediatric education for prehospital providers (PEPP)" means a training course for EMS providers established with department recognized national standards for clinical interventions used to treat pediatric emergencies.

(61) "Physician" means an individual licensed under the provisions of chapters 18.71 or 18.57 RCW.

(((55)))(62) "Physician with specific delineation of surgical privileges" means a physician with surgical privileges delineated for emergency/life-saving surgical intervention and stabilization of a trauma patient prior to transfer to a higher level of care. Surgery privileges are awarded by the facility's credentialing process.

(((56)))(63) "Postgraduate year" means the classification system for residents who are undergoing postgraduate training. The number indicates the year the resident is in during ((his/her))the resident's postmedical school residency program.

(((57)))(64) "Practical skills examination" means a test conducted in an initial course, or a test conducted during a recertification period, to determine competence in each of the practical skills or group of skills specified by the department.

(((58)))(65) "Prehospital index (PHI)" means a scoring system used to trigger activation of a hospital trauma resuscitation team.

(((59)))(66) "Prehospital patient care protocols" means the department-approved, written orders adopted by the MPD under RCW 18.73.030(((15)))(16) and 70.168.015(27) which direct the out-of-hospital care of patients. These protocols are related only to delivery and documentation of direct patient treatment. The protocols meet or exceed statewide minimum standards developed by the department in rule as authorized in chapter 70.168 RCW. Protocols must be compatible with and work in coordination with state triage and destination procedures, regional patient care procedures, and county operating procedures.

(((60)))(67) "Prehospital provider" means EMS provider.

(((61)))(68) "Prehospital trauma care service" means an EMS agency that is verified by the secretary to provide prehospital trauma care.

(((62)))(69) "Prehospital trauma life support (PHTLS)" means a training course for EMS providers established with department recognized national standards for clinical interventions used to treat trauma patients.

(70) "Prehospital ((trauma)) triage and destination procedure" means the statewide minimum standard and method used by prehospital providers to evaluate ((injured patients and determine whether to activate the trauma system from the field. It is described in WAC 246-976-930(2).

(63)))patients for time sensitive emergencies, identify the most appropriate destination, and alert the receiving facility of the patient's condition to help inform activation of the trauma, cardiac or stroke system of care from the field.

(71) "Public education" means education of the population at large, targeted groups, or individuals, in preventive measures and efforts to alter specific injury, trauma, and medical-related behaviors.

(((64)))(72) "Quality improvement (QI)" or "quality assurance (QA)" means a process/program to monitor and evaluate care provided in the EMS/TC system.

(((65)))(73) "Recertification" means the process of renewing a current EMS certification.

(74) "Recognition application procedure (RAP)" means the application and procedure that must be completed by a department recognized senior EMS instructor (SEI) to apply for renewal of an SEI recognition.

(75) "Regional council" means the regional EMS/TC council established by RCW 70.168.100.

(((66)))(76) "Regional patient care procedure((s))(PCP)" means department-approved written operating guidelines adopted by the regional emergency medical services and trauma care council, in consultation with the local emergency medical services and trauma care councils, emergency communication centers, and the emergency medical services county medical program directors((, in accordance with statewide minimum standards. The patient care procedures)). PCPs provide an operational framework and broad overarching guidance for the coordination of patient transport and movement within the regional emergency care system. PCPs identify the level of medical care personnel to be dispatched to an emergency scene, procedures for triage of patients, the level of trauma care facility, mental health facility, or chemical dependency program to first receive the patient, and the name and location of other trauma care facilities, mental health facilities, or chemical dependency programs to receive the patient should an interfacility transfer be necessary. Procedures on interfacility transfer of patients are consistent with the transfer procedures in chapter 70.170 RCW. Patient care procedures do not relate to direct patient care and must be compatible with and work in coordination with state triage and destination procedures.

(((67)))(77) "Regional plan" means the plan defined in WAC 246-976-960 (1)(b) that has been approved by the department.

(((68)))(78) "Registered nurse" means an individual licensed under the provisions of chapter 18.79 RCW.

(((69)))(79) "Reinstatement" means the process of reissuing an EMS certification that is revoked or suspended by the department.

(80) "Reissuance" means the process of reissuing a certification that is expired.

(81) "Reversion" means the process of reverting a current EMS certification to a lower level of EMS certification.

(82) "Rural" means an unincorporated or incorporated area with a total population of less than ((ten thousand))10,000 people, or with a population density of less than ((one thousand))1,000 people per square mile.

(((70)))(83) "Secretary" means the secretary of the department of health.

(((71)))(84) "Senior EMS instructor (SEI)" means an individual approved and recognized by the department to ((be responsible for the administration, quality of instruction and the)) conduct ((of)) initial emergency medical responder (EMR) ((and))or emergency medical technician (EMT) training courses.

(((72)))(85) "Special competence" means that an individual has been deemed competent and committed to a medical specialty area with documented training, board certification and((/or)) experience, which has been reviewed and accepted as evidence of a practitioner's expertise:

(a) For physicians, by the facility's medical staff;

(b) For registered nurses, by the facility's department of nursing;

(((73)))(86) "Specialty care transport (SCT)" means the level of care or service needed during an interfacility transport for a patient who is critically injured or ill and whose condition requires care by a physician, registered nurse, or a paramedic who has received special training and approval of the MPD.

(87) "State plan" means the emergency medical services and trauma care system plan described in RCW 70.168.015(7), adopted by the department under RCW 70.168.060(10).

(((74)))(88) "Steering committee" means the EMS/TC steering committee created by RCW 70.168.020.

(((75)))(89) "Substance use disorder professional (SUDP)" means an individual certified in substance use disorder counseling under chapters 18.205 RCW and 246-811 WAC.

(90) "Suburban" means an incorporated or unincorporated area with a population of ((ten thousand to twenty-nine thousand nine hundred ninety-nine))10,000 to 29,999 or any area with a population density of between ((one thousand and two thousand))1,000 and 2,000 people per square mile.

(((76)))(91) "System response time" for trauma means the interval from discovery of an injury until the patient arrives at a designated trauma facility.

(((77)))(92) "Training program" means an organization that is approved by the department to ((be responsible for specified aspects of training EMS personnel))conduct initial and ongoing EMS training as identified in the approved training program application on file with the department.

(((78)))(93) "Training program director" means the individual responsible for oversight of a department-approved EMS training program.

(94) "Trauma registry" means the statewide data registry to collect data on incidence, severity, and causes of trauma described in RCW 70.168.090(1).

(95) "Trauma rehabilitation coordinator" means a person designated to facilitate early rehabilitation interventions and the trauma patient's access to a designated rehabilitation center.

(((79)))(96) "Trauma response area" means a service coverage zone identified in an approved regional plan.

(((80)))(97) "Trauma service" means the clinical service within a hospital or clinic that is designated by the department to provide care to trauma patients.

(((81)))(98) "Urban" means:

(a) An incorporated area over ((thirty thousand))30,000; or

(b) An incorporated or unincorporated area of at least ((ten thousand))10,000 people and a population density over ((two thousand))2,000 people per square mile.

(((82)))(99) "Verification" means ((a prehospital))an EMS agency is capable of providing verified trauma care services and is credentialed under chapters 18.73 and 70.168 RCW.

(((83)))(100) "Washington EMS information system (WEMSIS)" means the statewide electronic EMS data system responsible for collecting EMS data described in RCW 70.168.090(2).

(101) "WEMSIS data administrator" means an EMS agency representative who is assigned by their agency as the primary contact for WEMSIS data submission management as indicated in the department-approved EMS agency licensing application.

(102) "Wilderness" means any rural area not readily accessible by public or private maintained road.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-022EMS training program requirements, approval, reapproval, discipline.

(1) To apply for initial department approval as an EMS training program, applicants ((shall meet the requirements in Table A of this section.

Table A

EMS Training Program Requirements For Approval

REQUIREMENTS
Organization type	Must be one of the following:
	•	A local EMS and trauma care council or a county office responsible for EMS training for the county. This includes county agencies established by ordinance and approved by the MPD to coordinate and conduct EMS programs;
	•	A regional EMS and trauma care council providing EMS training throughout the region;
	•	An accredited institution of higher education; or
	•	A private educational business, licensed as a private vocational school.
Optional organization	•	If the organizations listed above do not exist or are unable to provide an EMS training program, the local EMS and trauma care council may recommend to the department another entity that is able to provide training.
	•	In the absence of a local EMS council, the regional EMS and trauma care council may provide such recommendation.
	•	Initial training courses conducted for licensed EMS agencies under the oversight of a department-approved EMS training program.
Need for new training program	Applicant must demonstrate need for new or additional EMS training programs.
Training program application	Complete a DOH EMS training program application on forms provided by the department indicating the levels of EMS training the program wants to conduct.
Class room and laboratory	Provide a description of classroom and laboratory facilities.
Training equipment and supplies	Provide a list of equipment and supplies on hand (or accessible) for use in the training program.
Course enrollment	For each level of EMS training applying for, provide a description of:
	•	Course entry prerequisites;
	•	Selection criteria; and
	•	The process used to screen applicants.
Student handbook	Provide a student handbook for each level of EMS training applied for that provides:
	•	Training program policies, including minimum standards to enter training consistent with this chapter;
	•	Course requirements and minimum standards required for successful completion of examinations, clinical/field internship rotations, and the EMS course;
	•	Initial certification requirements the student must meet to become certified as identified in WAC 246-976-141; and
	•	A listing of clinical and field internship sites available.

(2) Approved training programs shall meet the requirements in Table B of this section.

Table B

EMS Training Program Requirements

REQUIREMENTS
General	An approved training program must:
	•	Conduct courses following department requirements;
	•	If conducting paramedic training courses, be accredited by a national accrediting organization approved by the department;
	•	In conjunction with the course instructor, ensure course applicants meet the course application requirements in WAC 246-976-041;
	•	Maintain clinical and field internship sites to meet course requirements, including the requirement that internship rotations on EMS vehicles must be performed as a third person, not replacing required staff on the vehicle;
	•	For the purposes of program and course evaluation, provide to the department, county MPD, or MPD delegate access to all course related materials;
	•	Conduct examinations over course lessons and other Washington state required topics; and
	•	Participate in EMS and trauma care council educational planning.
Certification examination	Coordinate activities with the department-approved certification examination provider, including:
	•	Registering the training program;
	•	Assisting students in registering with the examination provider;
	•	Providing verification of cognitive knowledge and psychomotor skills for students successfully completing the EMS course; and
	•	Assisting students in scheduling the examination.
Student records	Maintain student records for a minimum of four years.
Evaluation	Monitor and evaluate the quality of instruction for the purposes of quality improvement, including course examination scores for each level taught.
Reporting	Submit an annual report to the department which includes:
	•	Annual, overall certification examination results;
	•	A summary of complaints against the training program and what was done to resolve the issues;
	•	Quality improvement activities including a summary of issues and actions to improve training results.

(3) To apply for reapproval, an EMS training program must meet the requirements in Table C of this section.

Table C

EMS Training Program Reapproval

REAPPROVAL
Requirements	An EMS training program must be in good standing with the department and:
	•	Have no violations of the statute and rules;
	•	Have no pending disciplinary actions;
	•	Maintain an overall pass rate of seventy-five percent on department-approved state certification examinations;
	•	If conducting paramedic training courses, be accredited by a national accrediting organization approved by the department.
Reapplication	Complete:
	•	The requirements in Tables A and B of this section; and
	•	Submit an updated EMS training program application to the department at least six months prior to the program expiration date.

(4) Training program approval is effective on the date the department issues the certificate. Approval must be renewed every five years. The expiration date is indicated on the approval letter.

(5)))must:

(a) Contact the Washington workforce training and education board to determine if the EMS training program is subject to private vocational school requirements;

(b) Submit a completed application on forms provided by the department and provide supplemental information that:

(i) Demonstrates the need for a new or additional training program; and

(ii) Demonstrates how the training program will maintain the resources needed to sustain a quality education program;

(i) A local EMS and trauma care council or county office responsible for EMS training for the county. This includes organizations established by local ordinance and approved by the county medical program director to coordinate and conduct EMS training programs;

(ii) A regional EMS and trauma care council providing EMS training throughout the EMS and trauma care region that it serves;

(iii) An accredited institution of higher education or a private educational business licensed as a private vocational school; or

(iv) An optional organization. If the organizations listed above do not exist or are unable to provide an EMS training program, the local EMS and trauma care council may recommend to the department another entity that is able to provide training. In the absence of a local EMS council, the regional EMS and trauma care council may provide such recommendation;

(d) Identify the training program director for the training program. The training program director must meet the minimum requirements listed in the EMS Training Program and Instructor Manual (DOH 530-126);

(e) Identify additional training program personnel who meet the minimum requirements and would perform roles listed in the EMS Training Program Instructor Manual (DOH 530-126);

(f) Indicate what levels of initial EMS training courses (EMR, EMT, AEMT, paramedic), endorsements and other courses the training program is seeking approval to conduct;

(g) If the training program is conducting a paramedic program, provide proof of accreditation by a national accrediting organization approved by the department;

(h) Provide a list of clinical and field internship sites available to students. Include information that clearly depicts a formal relationship between the training organization and the clinical site;

(i) Provide an operations manual that includes:

(i) Training program policies and procedures that meet the requirements listed in the EMS Training Program and Instructor Manual (DOH 530-126); and

(ii) The training program handbook that is provided to students. The handbook must meet the requirements listed in the EMS Training Program and Instructor Manual (DOH 530-126);

(j) Provide a list of equipment and supplies on hand or accessible for use in the training program;

(k) Provide an example of a certificate or letter of completion meeting the department requirements listed in the EMS Training Program and Instructor Manual (DOH 530-126);

(l) Obtain the recommendation from the county medical program director in each county where the training program will reside; and

(m) Obtain the recommendation from each local EMS and trauma council in each county where the training program will reside. In the absence of a local EMS and trauma care council, the regional EMS and trauma care council may provide such a recommendation.

(2) Approved training programs shall:

(a) Conduct courses in accordance with department requirements;

(b) Collaborate with the course instructor to ensure course applicants meet the course application requirements in WAC 246-976-041;

(c) Maintain clinical and field internship sites to meet course requirements. Students conducting field internship rotations on EMS vehicles may not replace required staff on the vehicle;

(d) Provide the department, MPD, or MPD delegate access to all course related materials upon request;

(e) Conduct examinations over course lessons and other Washington state required topics;

(f) Participate in educational planning conducted by local and regional EMS and trauma care councils;

(g) Coordinate certification examination activities with the department-approved certification examination provider. This includes:

(i) Registering the training program with the examination provider;

(ii) Assisting students in registering with the examination provider and scheduling the cognitive examination. Students who successfully pass the course must be provided an opportunity to take the certification examination;

(iii) Provide verification to the examination provider of cognitive knowledge and psychomotor skills for students successfully completing the EMS course; and

(iv) For BLS, ILS, and ALS level courses, the training program must conduct psychomotor examinations and competence assessments as required by the department;

(h) Maintain student records for a minimum of seven years in a retrievable electronic or paper format;

(i) Monitor and evaluate the quality of instruction for the purposes of quality improvement, including course examination scores for each level taught;

(j) Provide students access to the Washington state EMS student survey;

(k) Maintain an overall pass rate of 75 percent on department-approved state certification examinations;

(l) Submit a report to the department annually that includes:

(i) Attrition rates;

(ii) Annual certification examination rates;

(iii) Postgraduation survey results; and

(m) Seek reapproval of the training program as follows:

(i) For BLS or ILS level courses training programs must be reapproved every three years.

(ii) For ALS level courses, training programs must be renewed every five years.

(iii) If the training program is approved to conduct multiple levels of training, the program is required to renew in accordance with the higher training level requirement.

(3) Training program approval is effective on the date the department issues the certificate. The expiration date is indicated on the approval letter. To apply for reapproval, an EMS training program must:

(a) Complete the requirements in subsection (1) of this section;

(b) Be in compliance with the requirements in subsection (2) of this section;

(c) Be in good standing with the department, have no violations of the statute and rules, and no pending disciplinary actions; and

(d) Have an overall pass rate of 75 percent on department-approved state certification examinations.

(4) Discipline of EMS training programs.

(a) The secretary may deny, suspend, modify, or revoke the approval of a training program when it finds any of the following:

(i) Violations of chapter 246-976 WAC((;)).

(ii) Pending disciplinary actions((;)).

(iii) Falsification of EMS course documents.

(iv) Failure to maintain EMS course documents((; or))as required.

(iv) Failure to update training program information with the department as changes occur.

(b) The training program may request a hearing to contest the secretary's decisions ((in regard to))regarding denial, suspension, modification, or revocation of training program approval in accordance with the Administrative Procedure Act (APA) (chapter 34.05 RCW) and chapter 246-10 WAC.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-023Initial EMS training course requirements and course approval.

((To be approved to conduct each initial EMS training course, an EMS training program must:

(1) Meet the requirements identified in Table A of this section;

(2) Submit a completed EMS course training application on forms provided by the department, postmarked or received by the department at least three weeks prior to the course start date identified on the application;

(3) Have the approval of the training program's medical director and the recommendation for approval from the county medical program director; and

(4) Have written course approval from the department.

Table A

Initial EMS Training Course Requirements

REQUIREMENTS
The EMS training program must:
•	If conducting paramedic training courses, be accredited by a national accrediting organization approved by the department;
•	With the course SEI or lead instructor, ensure course applicants meet the course application requirements in WAC 246-976-041;
•	Supply each student with a student handbook as specified in WAC 246-976-022;
•	Provide each student, prior to beginning their field internship rotations, current, county specific, county medical program director field protocols and any specific information they will need while completing the internship; and
•	Use field internship preceptors who monitor and evaluate students in a standard and consistent manner.
EMS course SEI or lead instructor:
The EMS course instructors identified in this section, under the general supervision of the county medical program director (MPD) are responsible:
•	For the overall conduct of the course, quality of instruction, and administrative paperwork;
•	For following the course curricula or instructional guidelines for the level of training conducted;
•	For evaluating the students' knowledge and practical skills throughout the course;
•	For providing on-site instruction during each class and to supervise any other course instruction, unless arrangements have been made for another SEI or lead instructor to supervise. When using other instructors, the SEI or lead need not be physically present but must be immediately available for consultation.
Emergency medical responder (EMR) and EMT courses:
The course instructor must be a department-approved SEI. An SEI candidate may instruct under the supervision of the SEI for the purpose of demonstrating instructional proficiency to the SEI.
AEMT courses:
The course instructor for advanced EMT courses must be:
•	An AEMT that is recognized by the department as an SEI; or
•	A paramedic; or
•	Program instructional staff when training is provided by an accredited paramedic training program; and
•	Approved by the county medical program director.
Paramedic/EMT-paramedic courses:
•	The lead instructor for paramedic courses must have proof of clinical experience at the paramedic level or above; and
•	Must have the approval of the training program's medical director and the county medical program director.
EMS Evaluators:
•	Evaluators must be MPD and department-approved EMS evaluators;
•	EMS evaluators for EMR and EMT courses must be certified at the EMT level or higher;
•	EMS evaluators for advanced EMT courses must be certified at the AEMT or paramedic level.
Other instructors that may instruct individual course lessons when knowledgeable and skilled in the topic, approved by the MPD and under supervision of the SEI or lead instructor:
•	Guest instructors;
•	Department-approved EMS evaluators, to assist the SEI or lead instructor in the instruction of the course, who must be certified at or above the level of education provided; and
•	The MPD, MPD delegate or other physicians approved by the MPD.
Course curriculum or instructor guidelines:
The National Emergency Medical Services Training Standards - Instructor Guidelines published January 2009 for the level of instruction; and
•	Instruction in multicultural health appropriate to the level of training; and
•	A department-approved, four hour infectious disease training program that meets the requirements of chapter 70.24 RCW; and
•	Other training consistent with MPD protocols.
EMS course practical skill evaluations:
SEIs or department-approved EMS evaluators conduct psychomotor evaluations during the course and provide corrective instruction for students. For EMR and EMT courses, evaluators must be certified as an EMT or higher level.
End of course practical skill examinations:
Department-approved SEIs or department-approved EMS evaluators must conduct practical skill examinations. For EMR and EMT courses, evaluators must be certified at the EMT level or higher. ))

(1) EMS training course applications are required for the following initial and refresher courses:

(a) EMR, EMT, AEMT, and paramedic training;

(b) EMS endorsements; and

(2) To conduct an EMS training course an applicant must:

(a) Submit a completed application on forms provided by the department, postmarked or received by the department at least 30 days prior to the course start date identified on the application.

(b) Provide the following supplemental information:

(i) Type of course being taught;

(ii) Training program the course will be affiliated with;

(iii) The course delivery method;

(iv) The location where the course will be held;

(v) The location where clinical and field training will be conducted and how it will be conducted;

(vi) The location where the psychomotor practical skills examination and minimum student competency verifications will be conducted and how these assessments will be conducted;

(vii) A list of instructional personnel participating in course delivery;

(viii) An example of a certificate of completion that meets the criteria in EMS Training Program and Instructor Manual (DOH 530-126);

(ix) A course schedule or agenda that meets the criteria in EMS Training Program and Instructor Manual (DOH 530-126); and

(c) A recommendation from the county medical program director(s) in the county(s) where the course will be held. The county medical program director must sign the course application.

(d) Be approved by the department.

(3) To conduct an EMS training course, training program directors and instructors must:

(a) Have written approval from the department to conduct the course prior to the start of the course. The department will send written approval to the training program director;

(b) Meet requirements for training programs identified in WAC 246-976-022;

(d) Verify students meet the requirements identified in WAC 246-976-041;

(e) Conduct or facilitate EMS course practical skill evaluations and psychomotor examinations and reexaminations. Use department-approved EMS evaluators that meet requirements in WAC 246-976-031. Evaluators must be certified to perform the skill being evaluated; and

(f) Submit the EMS Course Completion Verification form (DOH-530-008) within 30 days of the course completion date included on the course approval notification from the department.

(4) Course curriculum must meet all of the following standards:

(a) Current national EMS education standards for the level of training conducted including skills identified in the Washington state approved skills and procedures list (DOH 530-173) required for all Washington state certified EMS providers.

(b) Include education on multicultural health awareness as required in RCW 43.70.615, portable orders for life sustaining treatment (POLST) as provided in RCW 43.70.480, and legal obligations and reporting for vulnerable populations as provided in RCW 74.34.035.

(5) Instructional personnel required for courses is as follows:

(a) If the course being taught is provided by a training program that is recognized by an accreditation organization recognized by the department, then instructional personnel must meet standards of the accrediting organization.

(b) For an emergency medical responder (EMR) course, the course instructor must be a department-approved senior EMS instructor (SEI). An SEI candidate (SEI-C) may instruct under the supervision of a current department-approved SEI for the purposes of demonstrating instructional proficiency to SEI.

(c) For an emergency medical technician (EMT) course, the course instructor must be a department-approved SEI. An SEI candidate (SEI-C) may instruct under the supervision of the SEI for the purposes of demonstrating instructional proficiency to the SEI.

(d) For an advanced emergency medical technician (AEMT) course, the course instructor must be certified at the AEMT or paramedic level and be a department-approved SEI. An SEI candidate (SEI-C) may instruct under the supervision of the SEI for the purposes of demonstrating instructional proficiency to the SEI.

(e) For a paramedic course, the lead instructor must have proof of clinical experience at the paramedic level or above.

(f) For a supraglottic airway (SGA) endorsement course for EMT, the course instructor must have proof of clinical experience and the depth and breadth of knowledge of the subject matter and be approved by the MPD.

(g) For an intravenous (IV) therapy endorsement course for EMT, the course instructor must have proof of clinical experience and the depth and breadth of knowledge of the subject matter and be approved by the MPD.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-024((EMS))MPD specialized training and pilot projects.

(1) MPDs may submit a proposal to conduct a pilot ((training programs))project to determine the need for training, skills, techniques, ((or)) equipment, or medications that ((is))are not included in standard course curricula((/))and instructional guidelines. A pilot ((program))project allows the MPD to conduct field research to determine:

(a) The effectiveness of the training;

(b) EMS provider knowledge and skills competency; and

(2) To request approval of a pilot ((training program))project, the MPD must submit a proposal ((which includes the following information to the department for review:

(a) A needs statement describing what the))on forms provided by the department at least 90 days prior to the start of the pilot project. Proposals must include all the following:

(a) Describe the pilot project and the need that the proposed pilot will address;

(b) ((The level of certified EMS provider who will be participating in the pilot training;

(d) The method by which the pilot project will be evaluated;

(e) Course curriculum/lesson plans;

(f) Type of instructional personnel required to conduct the pilot training;

(g) Course prerequisites;

(h) Criteria for successful course completion, including student evaluations and/or examinations; and

(i) Prehospital patient care protocols for use in the pilot program.))Identify the proposed length of the pilot project. Projects may be approved for up to two years;

(d) Provide research to support that the proposal is an evidence-based practice relevant and appropriate to EMS activities;

(e) Identify the outcome the project is aiming to achieve, level of risk to patients, and the expected clinical outcomes;

(f) Provide information regarding the economic burden of additional hours of training, equipment, and other applicable costs;

(g) Identify the level of certified EMS providers who will be participating in the project and explain how it was determined that the provider level has the breadth and depth of knowledge needed to participate in the project;

(h) Describe how certified EMS providers will be trained and provide the course prerequisites, curriculum/lesson plans, including any student evaluations and examinations;

(i) Identify the instructional personnel required to conduct the pilot training. Instructional personnel must meet the requirements in WAC 246-976-031;

(j) Describe the medical oversight for the project and provide the proposed patient care protocols relevant to the activities being conducted;

(k) Describe the provisions for protecting patient safety;

(l) Describe quality assurance activities to include what data will be collected, the method of data collection, and evaluation; and

(m) Evaluate and determine if a review from an IRB is necessary and supply documentation to support the decision.

(3) The department will:

(a) Review the ((request and training plan))proposal;

(b) Determine what additional consultation with advisory groups is needed;

(c) Consult with the ((prehospital technical advisory committee))EMS and trauma care steering committee and any other applicable advisory groups as determined by the department, to determine the need for, and the expected benefits of the ((requested training throughout the state.

(c) Based on recommendation of the prehospital TAC, approve or deny the request for the pilot program.))proposed activities if implemented statewide; and

(d) Make the final determination to approve or deny the request to conduct the proposed pilot project.

(4) The MPD must report the results of the pilot ((training))project to the department, applicable advisory groups, and the ((prehospital TAC.

(5) The department and the prehospital TAC will review the results of the pilot training project to determine whether or not the new training will be implemented statewide.

(6) If the pilot training is approved for statewide use, the department will adopt it as specialized training and notify all county MPDs to advise if the skill is required or not))EMS and trauma care steering committee.

(5) Upon favorable results of the pilot project and with the recommendation of the EMS and trauma care steering committee, the department will make the final determination to approve or deny the proposed activities to continue in whole or in part and determine if the project will be implemented statewide on a mandatory or optional basis.

NEW SECTION

WAC 246-976-026Ongoing training and education programs (OTEP).

(1) The purpose of this section is to identify requirements to apply for, conduct, and renew an OTEP program. OTEP is a method of recertification defined in WAC 246-976-010.

(2) To apply for approval of an OTEP, an applicant must:

(a) Be a licensed EMS service, ESSO, a local county or regional EMS office, or an EMS county medical program director (MPD);

(b) Submit a completed application on forms provided by the department, postmarked or received by the department at least 90 days prior to the OTEP start date identified on the application;

(c) Obtain the recommendation for approval from the MPD in each county where the OTEP will be conducted. The MPD(s) must sign the application; and

(d) Provide the following supplemental information:

(i) The levels of training included in the OTEP;

(ii) What skills, endorsements, or specialized training are to be included in the OTEP;

(iii) The name of the EMS services that will be participating in the OTEP;

(iv) A description of how the OTEP program meets the education requirements described in WAC 246-976-161 and how the topics will be covered over a three-year period;

(v) Identify the sources of the instructional material that will be used. All training and education content must meet the requirements in WAC 246-976-163;

(vi) Describe how specialized training or other components required by the MPD will be incorporated into the OTEP;

(vii) Describe how and when the OTEP will be reviewed and updated to remain current with state and national standards;

(viii) Identify the course delivery method for didactic components;

(ix) Describe how the effectiveness of the OTEP is evaluated including what testing mechanisms are in place to evaluate participant competency;

(x) Describe how quality improvement activities are incorporated into the OTEP;

(xi) Describe how OTEP records will be managed and tracked, if the record is electronic or paper, the position within the organization responsible for tracking how participants are notified of their progress, completion, and compliance with OTEP, how participants can request and receive copies of their training records during and after affiliation with the EMS service, and how records will be maintained;

(xii) Describe how the EMS service supervisor verifies attendance and completion of OTEP modules and that a participant has met the minimum requirements of the OTEP for recertification; and

(xiii) Provide a description of the remediation plan to include how failed or missed courses can be made up and when a certified EMS provider must recertify using the CME method because they did not meet the minimum standards of the OTEP.

(3) To conduct an OTEP program, the applicant must:

(a) Have approval from the MPD and the department prior to the start of the OTEP. The department will send written approval to the applicant and the MPD;

(b) Develop, implement, and keep updated an OTEP that meets education requirements in WAC 246-976-161;

(d) Provide knowledge and skill evaluations following completion of training to assess the competency of the participant. Practical skill evaluations must be recorded on department-approved practical skill evaluation forms or nationally recognized skill evaluation forms. An MPD may approve an alternative method and documentation standard for skill evaluations;

(e) Provide education at least on a quarterly basis. An EMS service in a rural area who uses volunteers may submit an alternative schedule and request an exception to this requirement from the department;

(f) Maintain training records for a minimum of seven years or in accordance with the records retention requirements of the organization, whichever is greater; and

(g) Provide training records to participants, the department and MPD upon request. This includes skill sheets, rosters, evaluations, quizzes, and training content.

(4) OTEP programs may use a distributed learning model to provide OTEP when the training and content meets requirements in WAC 246-976-161 and each topic includes a cognitive evaluation after the training.

(a) Instruction and demonstration of practical skills may be provided using a distributed learning model.

(b) Evaluation of all practical skills must be provided in person.

(c) To receive credit for the topic, the participant must successfully complete both the didactic and any required skill evaluation for that topic.

(5) OTEP programs must be renewed every five years. To renew an OTEP program:

(a) Submit a completed application on forms provided by the department, postmarked or received by the department at least 90 days prior to the OTEP start date identified on the application; and

(b) Meet all the requirements in this section.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-031((Senior EMS instructor (SEI)))EMS instructors, initial approval, and recognition.

(((1) Responsibilities and requirements.

(a) The SEI is responsible for the overall instructional quality and the administrative paperwork associated with initial EMR or EMT courses, under the general supervision of the MPD.

(b) The SEI must:

(i) Follow department-approved curricula/instructional guidelines identified in WAC 246-976-023;

(ii) Ensure course applicants meet the course application requirements in WAC 246-976-041; and

(2) To become an approved SEI, an EMS provider must meet the requirements identified in Table A of this section.

Table A

Requirements For Initial Senior EMS Instructor Approval

REQUIREMENTS
Prerequisites:
Candidates for initial recognition must submit proof of successful completion of the following prerequisites to the department. Candidates meeting the prerequisites will be issued the Initial Recognition Application Procedures (IRAP) for Senior EMS Instructors, which include the Initial Senior EMS Instructor Application and Agreement, instructor objectives, instructions and forms necessary for initial recognition:
•	Current Washington state certification at the EMT or higher EMS certification level;
•	At least three years prehospital EMS experience at the EMT or higher EMS certification level, with at least one recertification;
•	Approval as an EMS evaluator as identified in WAC 246-976-161;
•	Current recognition as a health care provider level CPR instructor from a nationally recognized training program for CPR, foreign body airway obstruction (FBAO), and defibrillation;
•	Successful completion of an instructor training course by the U.S. Department of Transportation, National Highway Traffic Safety Administration, an instructor training course from an accredited institution of higher education, or equivalent instructor course approved by the department;
•	Pass an examination developed and administered by the department on current EMS training and certification statutes, Washington Administrative Code (WAC), the Uniform Disciplinary Act (UDA) and course administration.
Candidate objectives:
Candidates must successfully complete the IRAP under the supervision of a currently recognized SEI.
As part of an initial EMT course, the candidate must demonstrate to the course lead SEI the knowledge and skills necessary to complete the following instructor objectives:
•	Accurately complete the course application process and meet application timelines;
•	Notify potential EMT course applicants of course entry prerequisites;
•	Assure that applicants selected for admittance to the course meet department training and certification prerequisites;
•	Maintain course records;
•	Track student attendance, scores, quizzes, and performance, and counsel/remediate students as necessary;
•	Assist in the coordination and instruction of one entire EMT course, including practical skills, under the supervision of the course lead SEI using the EMT training course instructor guidelines identified in WAC 246-976-023, and be evaluated on the instruction of each of the following sections/lessons:
	–	Preparatory section, including Infectious Disease Prevention for EMS Providers, Revised 01/2009;
	–	Airway section;
	–	Assessment section;
	–	Pharmacology section;
	–	Medical section, Cardiovascular and Respiratory lessons;
	–	Special Patient Populations section, Obstetrics, Neonatal Care, and Pediatrics lessons;
	–	Trauma section, Head, Facial, Neck and Spine Trauma and Chest Trauma lessons;
	–	EMS Operations section, Vehicle Extrication, Incident Management, and Multiple Casualty Incidents lessons; and
	–	Multicultural Awareness component.
•	Coordinate and conduct an EMT final end of course comprehensive practical skills evaluation.
Candidate evaluation:
Performance evaluations must be conducted by an SEI for each instructor objective performed by the candidate on documents identified in the IRAP. These documents consist of:
•	An evaluation form, to evaluate lesson instruction objectives performed by the candidate;
•	A quality improvement record, to document improvement necessary to successfully complete an instructor objective performed by the candidate; and
•	An objective completion record, to document successful completion of each instructor objective performed by the candidate.
Application:
Submit the following documents to the county MPD to obtain a recommendation:
•	The original initial SEI application/agreement, signed by the candidate; and
•	The original completed IRAP, all objective completion records, and evaluation documents.
The completed application must be submitted to the department including:
•	The original application signed by both the candidate and the MPD;
•	The original completed IRAP, all objective completion records, and evaluation documents.

(3) SEI approval is effective on the date the department issues the certification card. Certifications must be renewed every three years. The expiration date is indicated on the certification card.))(1) EMS instructor types include:

(a) "EMS evaluator (ESE)" means a person approved and recognized by the department that is authorized to conduct continuing medical education and ongoing training and evaluate psychomotor skills during initial, refresher, and continuing medical education and ongoing training. The ESE may provide field training and evaluate newly hired providers who are pending certification and are participating in an EMS service field training program. The ESE may function as a clinical preceptor to mentor and evaluate the clinical performance of students enrolled in initial EMS courses.

(b) "Senior EMS instructor candidate (SEIC)" means an applicant that has met requirements to start the initial recognition process to become a senior EMS instructor (SEI). The applicant is approved and recognized by the department as an SEIC and may conduct EMS training courses under the supervision of a currently approved and recognized SEI and county medical program director. An SEIC may only conduct courses at or below the level for which they hold a current and valid Washington state EMS certification.

(c) "Senior EMS instructor (SEI)" means an applicant that has met the requirements to become approved and recognized by the department as an SEI and may conduct initial EMS training courses and continuing medical education and ongoing training. An SEI may only conduct courses at or below the level for which they hold a current and valid Washington state EMS certification. An SEI is responsible for the overall administration and quality of instruction. The SEI must meet the requirements in this chapter and the department EMS Training Program and Instructor Manual (DOH 530-126) to maintain recognition as an SEI.

(d) "Lead instructor" means a person that has specific knowledge, experience, and skills in the field of prehospital emergency care and is approved by the county medical program director to instruct EMS training courses that do not require an SEI.

(e) "Guest instructor" means a person that has specific knowledge, experience, and skills in the field of prehospital emergency care and is approved by the county medical program director to instruct course lessons for initial and refresher EMS courses and continuing medical education and ongoing training under the supervision of an SEI or lead instructor.

(2) To apply for recognition as an EMS evaluator (ESE), an applicant must:

(a) Hold a current and valid Washington state EMS certification;

(b) Have a minimum of three years' experience at or above the level of certification being evaluated;

(d) Submit an application on forms provided by the department;

(e) Provide proof of successful completion of a department-approved initial EMS evaluator course within the past three years; and

(f) Be recommended by the county medical program director. The county medical program director must sign the application.

(3) To apply for recognition as a senior EMS instructor candidate (SEIC), an applicant must:

(a) Be a current Washington state certified EMS provider at or above the level of certification being instructed;

(b) Have a minimum of three years' experience in direct patient care at or above the level of certification being instructed;

(d) Hold current recognition as a health care provider level CPR instructor from a nationally recognized training program recognized by the department for CPR, foreign body airway obstruction (FBAO), and defibrillation;

(e) Provide proof of successful completion of an instructor training course by the U.S. Department of Transportation, National Highway Traffic Safety Administration, an instructor training course from an accredited institution of higher education, or equivalent instructor course approved by the department;

(f) Provide proof of successful completion of a one-hour Washington state EMS instructor orientation provided by the department;

(g) Pass a written evaluation developed and administered by the department on current EMS training and certification regulations including the Washington Administrative Code (WAC), the Uniform Disciplinary Act (UDA), and EMS course administration;

(h) Be affiliated with a department-approved EMS training program that meets the standards in WAC 246-976-022;

(i) Submit an application on forms provided by the department; and

(j) Be recommended by the county medical program director. The county medical program director must sign the application.

(4) If approved for recognition as a senior EMS instructor candidate (SEIC), the department will issue the applicant an initial recognition application procedure packet (IRAP). The IRAP must be successfully completed in accordance with department standards and policies, under the oversight of a currently recognized SEI. The SEIC must demonstrate the knowledge and skills necessary to administer, coordinate, and conduct initial EMS courses to apply for and be considered for approval and recognition as an SEI.

(5) A SEIC recognition will be issued for three years.

(6) An applicant who is an EMS instructor in another state, country, or U.S. military branch may apply to obtain reciprocal recognition as an SEI candidate (SEIC). To become an SEI candidate (SEIC), the applicant must meet the criteria in this section and provide proof of at least three years of instructional experience as an EMS instructor. If approved for recognition as an SEIC, the department will issue the applicant an abridged initial recognition application procedure packet (IRAP) which must be successfully completed in accordance with department standards and policies, under the oversight of a currently recognized SEI to apply for full SEI recognition.

(7) To apply for recognition as a senior EMS instructor (SEI), an applicant must:

(a) Meet all the criteria in subsection (3) of this section and be currently approved and recognized as a senior EMS instructor candidate (SEIC);

(b) Submit the completed initial recognition application procedure packet (IRAP) that was issued by the department; and

(c) Be recommended by the county medical program director. The county medical program director must sign the application.

(8) If approved, SEI recognition is effective on the date the department issues the recognition card. SEI recognition must be renewed every three years. The expiration date is indicated on the certification card.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-032((Senior)) EMS instructor (((SEI))) reapproval ((of))and recognition.

(((1) To become reapproved, an SEI must meet the requirements identified in Table A of this section.

(2) The renewal application procedures (RAP) will be provided by the department to individuals upon recognition as an SEI. The RAP must be completed by the SEI during the recognition period.

Table A

Requirements For Senior EMS Instructor Reapproval

REQUIREMENTS
Prerequisites:
Document proof of completion of the following prerequisites:
•	Current or previous recognition as a Washington state SEI;
•	Current Washington state certification at the EMT or higher EMS certification level;
•	Current recognition as a health care provider level CPR instructor from a nationally recognized training program for CPR, foreign body airway obstruction (FBAO), and defibrillation;
•	Pass an examination developed and administered by the department on current EMS training and certification statutes, Washington Administrative Code (WAC), the Uniform Disciplinary Act (UDA) and course administration.
Candidate objectives:
Successfully complete the following objectives for each recognition period:
•	Coordinate and perform as the lead SEI for one initial EMR or EMT course including the supervision of all practical skills evaluations;
•	Receive performance evaluations from a currently recognized SEI, on two candidate instructed EMR or EMT course lessons;
•	Perform two performance evaluations on the instruction of EMR or EMT course lessons for SEI initial or renewal recognition candidates; and
•	Attend one department-approved SEI or instructor improvement workshop.
Candidate evaluation:
Evaluations of the performance of instructor objectives will be conducted by an SEI and completed on documents identified in the RAP. These documents consist of;
•	An evaluation form, to evaluate lesson instruction objectives performed by the candidate;
•	A quality improvement record, to document improvement necessary to successfully complete an instructor objective performed by the candidate; and
•	An objective completion record, to document successful completion of each instructor objective performed by the candidate.
Application:
Submit the documented prerequisites and the completed RAP, including the application/agreement and all documents completed during the renewal of recognition process, to the county MPD to obtain a recommendation.
The completed application must be submitted to the department including:
•	Current proof of successful completion of the prerequisites listed in this section;
•	The original SEI renewal application/agreement that has been signed by the candidate and the county MPD; and
•	The original completed RAP document and all forms used for evaluation, quality improvement purposes and verification of successful completion as identified in the RAP.

(3) An EMS instructor approved in another state, country, or U.S. military branch may obtain reciprocal recognition. To become an SEI, the applicant must:

(a) Meet the initial recognition prerequisites as defined in this section;

(b) Provide proof of at least three years of instructional experience as a state approved EMS instructor. If the applicant cannot provide proof of instructional experience, the initial recognition application process must be completed;

(c) Instruct two initial EMT course topics, be evaluated on the instruction by a current Washington SEI, and receive a positive recommendation for approval by the SEI; and

(d) Complete the renewal application and submit it to the department.

(4) An SEI whose recognition has expired for more than twelve months must complete the initial recognition process.

(5) Approval is effective on the date the department issues the certificate. Certifications must be renewed every three years. The expiration date is indicated on the certification card.))(1) To apply for rerecognition as an EMS evaluator (ESE), an applicant must:

(a) Hold a current and valid Washington state EMS certification at or above the level of certification being evaluated;

(b) Submit an application on forms provided by the department;

(d) Provide proof of successful completion of a department-approved EMS evaluator refresher course; and

(e) Be recommended by the county medical program director. The county medical program director must sign the application.

(2) An ESE whose recognition has expired for more than three years must complete the initial recognition process.

(3) To apply for rerecognition as a senior EMS instructor candidate (SEIC), an applicant must:

(a) Meet the requirements in WAC 246-976-031;

(b) Be currently approved and recognized as an SEIC;

(d) Be recommended by the county medical program director. The county medical program director must sign the application.

(4) To apply for rerecognition as a senior EMS instructor (SEI), an applicant must:

(a) Hold a current Washington state certification as an EMS provider at or above the level of certification being instructed;

(b) Be currently approved and recognized as an SEI or have an SEI recognition that is expired less than three years;

(d) Pass a written evaluation developed and administered by the department on current EMS training and certification regulations including Washington Administrative Code (WAC), the Uniform Disciplinary Act (UDA), and EMS course administration;

(e) Successfully complete a one-hour Washington state EMS instructor orientation;

(f) Attend one department-approved SEI or instructor improvement workshop;

(g) Submit an application on forms provided by the department; and

(h) Be recommended by the county medical program director. The county medical program director must sign the application.

(5) An SEI whose recognition has expired for more than three years must complete the recognition process described in WAC 246-976-031 (3)(m).

(6) SEI recognition is effective on the date the department issues the recognition. SEI recognition must be renewed every three years. The expiration is indicated on the certification card.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-033Denial, suspension, modification or revocation of an ESE, SEIC, or SEI recognition.

(1) The secretary may deny, suspend, modify or revoke an ESE, SEIC, or SEI's recognition when it finds the ESE, SEIC, or SEI has:

(a) Violated chapter 18.130 RCW, the Uniform Disciplinary Act;

(b) Failed to:

(i) Maintain EMS certification;

(ii) Update the following personal information with the department as changes occur:

(A) Name;

(B) Address;

(iii) Maintain knowledge of current EMS training and certification statutes, WAC, the UDA, and course administration;

(iv) Comply with requirements in WAC 246-976-031(1);

(v) Participate in the instructor candidate evaluation process in an objective and professional manner without cost to the individual being reviewed or evaluated;

(vi) Complete all forms and maintain records in accordance with this chapter;

(vii) Demonstrate all skills and procedures based on current standards;

(viii) Follow the requirements of the Americans with Disabilities Act; or

(ix) Maintain security on all department-approved examination materials.

(2) The ((candidate))ESE, SEIC, or SEI may request a hearing to contest the secretary's decisions in regard to denial, suspension, modification or revocation of an ESE, SEIC, or SEI recognition in accordance with the Administrative Procedure Act (APA) (chapter 34.05 RCW), the Uniform Disciplinary Act (chapter 18.130 RCW), and chapter 246-10 WAC.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-041To apply for training.

(1) An applicant for EMS training must be at least ((seventeen))17 years old at the beginning of the course. Variances will not be allowed for the age requirement.

(2) An applicant for training at the intermediate (AEMT) level((, must be currently certified as an EMT with at least one year of experience))must meet all entry requirements of the state approved AEMT program.

(3) An applicant for training at the advanced life support (paramedic) level((, must have at least one year of experience as a certified EMT, or equivalent prehospital experience and))must meet all entry requirements of the state approved paramedic training program.

NEW SECTION

WAC 246-976-139Provisional certification.

(1) An individual may apply for a provisional certification to engage in supervised practice as a certified EMS provider for the level they have applied for. Upon completion of any EMS service field training and MPD integration criteria, an applicant may apply for full certification. A provisional certification is valid for up to six months. There is no renewal option for a provisional certification.

(2) To apply for a provisional certification, an applicant must:

(a) Submit a completed application on forms provided by the department;

(b) Be at least 18 years of age and provide their date of birth on the initial certification application. Variances to this age requirement will not be granted;

(c) Successfully complete a background check provided by the department. The background check may include the requirement for fingerprint card and FBI background check. If an applicant has submitted fingerprints and has been informed by the department that their fingerprints were rejected and must be redone, the applicant may request a temporary practice permit in accordance with WAC 246-12-050;

(d) Provide proof of a high school diploma or GED for EMT, AEMT, and paramedic level certifications;

(e) Provide proof of competency and a current and valid certification from another state or national organization recognized by the department;

(f) Provide proof of active membership paid or volunteer with a licensed aid or ambulance service, or an EMS service supervisory organization (ESSO) recognized by the department; and

(g) Be recommended by the county medical program director. The county medical program director must sign the application.

(3) A person holding a provisional certification may apply for full certification upon successful completion of any EMS service field training and MPD integration criteria. To apply for certification, an applicant must:

(a) Submit a completed application on forms provided by the department;

(b) Provide proof of active membership paid or volunteer with a licensed aid or ambulance service, or an EMS service supervisory organization (ESSO) recognized by the department; and

(c) Be recommended by the county medical program director. The county medical program director must sign the application.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-141To obtain initial EMS provider certification following the successful completion of Washington state approved EMS course.

To apply for initial EMS provider certification following the successful completion of a Washington state approved EMS course, an applicant must ((submit to the department)):

(((1) A completed initial certification application on forms provided by the department.

(2) Proof of meeting the requirements identified in Table A of this section.

Table A

Applicants Who Have Completed a Washington State Approved EMS Course

REQUIREMENTS
EMS education:
Candidate must provide proof of successful EMS course completion from a department-approved EMS training program. For paramedic applicants, this proof must be from a training program accredited by a department-approved national accrediting organization.
Certification examination:
Provide proof of a passing score on the department-approved certification examination for the level of certification. Applicants will have three attempts within twelve months of course completion to pass the examination.
After three unsuccessful attempts, the applicant may retake the initial EMS training course, or within twelve months of the third unsuccessful attempt, complete department-approved refresher training covering airway, medical, pediatric, and trauma topics identified below, and pass the department-approved certification examination:
•	EMR Not applicable. Must repeat EMR course.
•	EMT twenty-four hours.
•	AEMT thirty-six hours - Pharmacology review must be included in the refresher training.
•	Paramedic forty-eight hours - Pharmacology review must be included in the refresher training.
Certification application:
High school diploma or GED: Required for EMT, AEMT and paramedic only.
Provide proof of identity - State or federal photo I.D. (military ID, driver's license, passport).
Provide proof of age - At least eighteen years of age. Variances to this age requirement will not be granted.
Provide proof of EMS agency association - Active membership, paid or volunteer with:
•	Licensed aid or ambulance service;
•	Law enforcement agency;
•	Business with organized industrial safety team;
•	Senior EMS instructors or training coordinators, teaching at department-approved EMS training programs, who are unable to be associated with approved agencies above.
Recommendation of county medical program director - Required. MPD must sign application.
Background check - required. May include requirement for fingerprint card and FBI background check.))

(1) Submit a completed application on forms provided by the department;

(2) Be at least 18 years of age and provide their date of birth on the initial certification application. Variances to this age requirement will not be granted;

(3) Successfully complete a background check provided by the department. The background check may include the requirement for fingerprint card and FBI background check. If an applicant has submitted fingerprints and has been informed by the department that their fingerprints were rejected and must be redone, the applicant may request a temporary practice permit in accordance with WAC 246-12-050;

(4) Provide proof of high school diploma or GED for EMT, AEMT, and paramedic level certifications;

(5) Provide proof of competency, a current and valid certification from another state or national organization recognized by the department;

(6) Provide proof of active membership paid or volunteer with a licensed aid or ambulance service, or an EMS service supervisory organization (ESSO) recognized by the department. Senior EMS instructors or training coordinators teaching at department-approved EMS training programs who are unable to be with approved agencies above may affiliate with department-approved training programs with the approval from the county medical program director; and

(7) Be recommended by the county medical program director. The county medical program director must sign the application.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-142To obtain reciprocal (out-of-state) EMS certification, based on a current out-of-state or national EMS certification approved by the department.

To apply for certification, an applicant must ((submit to the department)):

(((1) A completed certification application on forms provided by the department; and

(2) Proof of meeting the requirements identified in Table A of this section.

Table A

Reciprocity—Out-of-State Applicants Seeking EMS Certification

REQUIREMENTS
EMS educational program:
EMS courses conducted according to the U.S. Department of Transportation, national EMS training course standards.
After June 30, 1996, paramedic training program must be accredited by a national accrediting organization approved by the department.
Additional education:
Provide proof of a department-approved four-hour infectious disease course or a seven-hour HIV/AIDS course as required by chapter 70.24 RCW.
Current credential:
Provide proof of valid EMS certification from another state or national certifying agency approved by the department.
Certification examination:
Provide proof of a passing score on a department-approved certification examination for the level of certification. The score is valid for twelve months from the date of the examination. After twelve months, a passing score on a department-approved certification examination is required. Applicants will have three attempts within twelve months from the first examination date to pass the examination.
Certification application:
High school diploma or GED: Required for EMT, AEMT and paramedic only.
Provide proof of identity - State or federal photo I.D. (military ID, driver's license, passport).
Provide proof of age - At least eighteen years of age. Variances to this age requirement will not be granted.
Provide proof of EMS agency association - Active membership, paid or volunteer with:
•	Licensed aid or ambulance service;
•	Law enforcement agency;
•	Business with organized industrial safety team;
•	Senior EMS instructors or training coordinators, teaching at department-approved EMS training programs, who are unable to be associated with approved agencies above.
Recommendation of county medical program director - required. MPD must sign application.
Background check - required. May include requirement for fingerprint card and FBI background check.))

(1) Submit a completed application on forms provided by the department;

(2) Be at least 18 years of age and provide their date of birth on the initial certification application. Variances to this age requirement will not be granted;

(4) Provide proof of a high school diploma or GED for EMT, AEMT, and paramedic level certifications;

(5) Provide proof of competency, a current and valid certification from another state or national organization recognized by the department;

(7) Be recommended by the county medical program director. The county medical program director must sign the application.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-143To obtain EMS certification ((by challenging the educational requirements,)) based on possession of a current health care providers credential.

To apply for certification, an applicant ((must submit to the department))shall:

(((1) A completed certification application on forms provided by the department; and

(2) Proof of meeting the requirements identified in Table A of this section.

Table A

Health Care Providers Seeking to Challenge the Educational Requirements for EMS Certification

REQUIREMENTS
Education:
Course completion documents showing education equivalent to the knowledge and skills at the EMR, EMT or AEMT training level.
Applicants seeking paramedic certification - Successful completion of a paramedic course through a training program accredited by a department-approved national accrediting organization.
Additional education:
Provide proof of a department-approved four-hour infectious disease course or a seven-hour HIV/AIDS course as required by chapter 70.24 RCW.
Current credential:
Provide proof of a valid health care provider credential.
Certification examination:
A passing score on a department-approved certification examination. Applicants will have three attempts within twelve months from the first examination date to pass the examination. After twelve months, the applicant must complete an approved initial EMS course to reapply for certification.
Certification application:
High school diploma or GED: Required for EMT, AEMT and paramedic only.
Provide proof of identity - State or federal photo I.D. (military ID, driver's license, passport).
Provide proof of age - At least eighteen years of age. Variances to this age requirement will not be granted.
Provide proof of EMS agency association - Active membership, paid or volunteer with:
•	Licensed aid or ambulance service;
•	Law enforcement agency;
•	Business with organized industrial safety team.
Recommendation of county medical program director - Required. MPD must sign application.
Background check - required. May include requirement for fingerprint card and FBI background check.))

(1) Hold a Washington state license or certification in another health profession;

(2) Provide proof of an education that is substantially equivalent to EMS education requirements for the level of certification being applied for; and

(3) Meet the requirements and follow the procedures outlined in WAC 246-976-142.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-144EMS certification.

(1) Certification is effective on the date the department issues the certificate. Certifications must be renewed every three years. The expiration date is indicated on the certification card.

(2) The secretary may extend the certification period to accommodate the efficient processing of recertification applications. Requests to extend the certification period must be coordinated through the county medical program director. The expiration date will be indicated on the certification card issued by the department.

(3) An EMS certification ((of AEMTs and paramedics)) is valid only:

(a) In the county or counties where recommended by the MPD and approved by the secretary;

(b) In other counties where ((formal EMS))department-approved medical ((control))program director agreements are in place; ((or))

(c) In other counties when accompanying a patient in transit((.))or when encountering an incident and stopping to render aid when returning to a home county. In these cases, 911 should be contacted to engage the local EMS system; or

(d)(i) While responding to other counties for mutual aid purposes, mass care, or other incidents in an episodic manner. In these situations((,)):

(ii) The EMS provider will provide patient care following the prehospital patient care protocols of their supervising MPD.

(4) A certified AEMT or paramedic may function at a lower certification level in counties other than those described in subsection (3)(a) through (((c)))(d) of this section, with approval of that county's MPD and the department.

(5) EMTs who ((have successfully completed))hold an IV therapy or supraglottic airway training endorsement may use those skills only when following approved county MPD protocols that permit EMTs with such training to perform those skills.

(6) When certified EMS personnel change or add membership with an EMS agency, EMS service supervisory organization (ESSO), or department-approved training program, or their contact information changes, they must notify the department within ((thirty))30 days of the change. Changes submitted must be made on forms provided by the department.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-161General education and skill maintenance requirements for EMS provider recertification.

(1) Education and skill maintenance is required to recertify as an EMS provider. There are two methods by which the EMS provider may meet continuing medical education and ongoing training and skill requirements for recertification at the end of each certification period. The continuing medical education and examination (CME) method described in WAC 246-976-162 or the ongoing training and evaluation program (OTEP) method described in WAC 246-976-163.

(((a) The EMS provider must complete the continuing medical education and examination (CME) method, identified in WAC 246-976-162 or the ongoing training and evaluation program (OTEP) method, identified in WAC 246-976-163 for each certification period.

(b)))(2) The EMS provider shall maintain records of successfully completed educational, practical skill evaluation and skill maintenance requirements((.

(2) Education for recertification must be approved by the MPD. Educational and topic content requirements must include:

(a) Knowledge and skills found in instructor guidelines identified in WAC 246-976-023, appropriate to the level of certification being taught;

(b) Nationally recognized training programs for CPR, foreign body airway obstruction (FBAO), and defibrillation and patient care appropriate to the level of certification. Training must be at the health care provider level and meet Journal of American Medical Association (JAMA) standards; and

(c) Current county medical program director (MPD) protocols, regional patient care procedures, county operating procedures and state triage destination procedures.

(3) Nationally recognized training programs may be incorporated as part of content identified in subsection (2) of this subsection.

(4) Skill maintenance is a required educational component for recertification:

(a) For EMS providers completing the CME method the required skills are defined in WAC 246-976-162.

(b) For EMS providers completing the OTEP method the required skills are defined in WAC 246-976-163. These requirements may be obtained as part of an OTEP.

(5) Upon approval of the MPD, if an EMS provider is unable to complete the required endotracheal intubations as defined in WAC 246-976-162 or 246-976-163 the EMS provider may meet the endotracheal intubation requirements by completing an MPD and department-approved intensive airway management training program, covering all knowledge and skill aspects of emergency airway management.))for a minimum of seven years. The EMS provider shall provide records to their EMS agency, their county medical program director, and the department upon request.

(3) All training and education content must meet current national EMS education standards to include skill evaluations. Department recognized national EMS training courses for topics such as basic and advanced cardiac life support, pediatric advanced life support, advanced medical life support, and prehospital trauma life support may be used. EMS continuing medical education and ongoing training programs approved by national accreditation organizations recognized by the department may also be used. All training and education content must be approved by the MPD.

(4) Education must include information and psychomotor skill maintenance opportunities relevant to the skills and procedures identified on the Washington State Approved Skills and Procedures for Certified EMS Providers list (DOH 530-173), to all age groups and be appropriate to the level of certification. Topics required for both methods of recertification must include all the following:

(a) Age appropriate patient assessment;

(b) Airway management including the use of airway adjuncts appropriate to the level of certification;

(c) Cardiovascular education that includes recognition, assessment of severity, and care of cardiac and stroke patients, CPR for the health care provider, foreign body airway obstruction, and electrical therapy for the level of certification;

(d) Trauma including spinal motion restriction;

(e) Pharmacology including epinephrine, naloxone, and medications approved by the MPD;

(f) Obstetrics, pediatric, geriatric, bariatric, behavioral, mental health, and chemical dependency;

(g) Patient advocacy concepts including multicultural awareness education as required in RCW 43.70.615, health equity education trainings for health care professionals as required in RCW 43.70.613, portable orders for life sustaining treatment (POLST) as provided in RCW 43.70.480, legal obligations and reporting for vulnerable populations as provided in RCW 70.34.035, and training as required in RCW 43.70.490 for people with disabilities or functional needs;

(h) EMS provider advocacy and wellness concepts including suicide awareness, mental health and physical wellbeing, infectious disease training, and workplace safety;

(i) Law and regulations related to the scope of practice of providers in Washington state and regulatory requirements for an EMS provider to maintain certification;

(j) State, regional, and local policies including state triage tools, regional patient care procedures, county operating procedures, and county MPD patient care protocols and policies;

(k) Disaster preparedness concepts such as the use of incident command system (ICS), multiple patient incidents, mass casualty incidents, disaster triage, all hazard incidents, public health emergencies, and active shooter events;

(l) Documentation standards for patient care including reporting to the Washington state EMS electronic data system as provided in RCW 70.168.090, data quality, evidence-based practice and research; and

(m) Ambulance operations including concepts such as driving an emergency vehicle, stretcher handling, crime scene awareness, safety around air ambulances and landing zones.

(5) If a competency-based education delivery method is not used, the required number of hours for education in each certification period for each level of care is as follows:

(a) EMR – 15 hours;

(b) EMT – 30 hours;

(d) Paramedic – 150 hours.

(6) Skill maintenance is a required component for both OTEP and CME methods of recertification under WAC 246-976-162 and 246-976-163. Skill maintenance activities should include skills identified in the department-approved EMS skills and procedures list (DOH 530-173) appropriate to the level of certification. Skill maintenance should include an educational component. The provider must demonstrate the ability to perform a skill properly to the satisfaction of the MPD or approved MPD delegate. Skill proficiency must include opportunities for EMS providers to annually practice and demonstrate proficiency in high risk, low frequency skills, and must include:

(a) Airway, respiration, and ventilation:

(i) For EMR include airway management, airway adjuncts, bag valve mask, and oral suctioning for all age groups.

(ii) For EMT and AEMT include content prescribed for EMR and if supraglottic airway is included in the scope of practice for the level of certification or if the EMS provider holds an endorsement for supraglottic airway. "Supraglottic airway" means airway adjuncts not intended for insertion into the trachea. This includes verification of initial placement and continued placement, in a skill lab setting, through procedures identified in county MPD protocols.

(iii) For paramedic include content prescribed for EMR, EMT, AEMT, and paramedics. Paramedics must successfully complete a department-approved MPD airway management education program throughout each three-year certification period.

(iv) Distributive learning may be used to provide the didactic portion of the airway management education and must include a cognitive assessment for each module.

(v) The airway management program must include a minimum of all the following:

(A) Respiratory system anatomy and physiology;

(B) Basic airway management and airway adjuncts;

(D) Post intubation management including monitoring airway, patient movement considerations, and documentation.

(vi) Paramedics must annually demonstrate psychomotor skills to the satisfaction of the MPD or approved MPD delegate. Psychomotor skills must include:

(A) Appropriate use and placement of oral and nasal airway adjuncts for pediatric and adult patients;

(B) Appropriate use and placement of supraglottic airways for pediatric and adult patients;

(C) Appropriate use and placement of endotracheal tube for pediatric and adult patients. Successful human intubation or successful placement on MPD approved high-fidelity mannequins satisfy the psychomotor requirements with approval from the MPD; and

(D) Appropriate use and placement of surgical airway management techniques for pediatric and adult patients.

(vii) If a paramedic is unable to obtain human intubations or successfully demonstrate competency for advanced airway management and intubation the MPD may conduct a quality improvement review of patient care provided in accordance with department-approved MPD quality improvement plan. The MPD may also require additional education and psychomotor opportunities to demonstrate competency.

(b) Vascular access:

(i) AEMT and EMTs that hold an IV therapy endorsement must:

(A) Demonstrate proficiency of intravenous insertion and infusion on patients to the satisfaction of the MPD or an approved MPD delegate. Skills can be performed while in the course of duty as an EMS provider on sick, injured, or preoperative adult and pediatric patients; and

(B) Demonstrate proficiency of intraosseous insertion and infusion to the satisfaction of the MPD or an approved MPD delegate. Skills can be performed while in the course of duty as an EMS provider on sick, injured, or preoperative adult and pediatric patients.

(ii) Paramedics must:

(A) Complete requirements for AEMT; and

(B) Demonstrate proficiency to the satisfaction of the MPD or approved MPD delegate for advanced level vascular access, infusion, and monitoring of lines such as central venous and external jugular lines and other relevant skills identified in the Washington state approved EMS skills and procedures list (DOH 530-173).

(iii) If an EMS provider is unable to complete any of the skill requirements identified above, upon approval from the MPD, the EMS provider may meet the requirements by performing the skill on artificial training aids.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-162The CME method of recertification.

(1) To complete the CME method of recertification, an EMS provider must((:

(1)))complete and document the requirements((, indicated in Table A of))in WAC 246-976-161 and this section((, appropriate to the level of certification for each certification period.

Table A

Education Requirements for Recertification

	EMR	EMT	AEMT	Paramedic
Annual Requirements
Cardiovascular education and training	X	X	X	X
Spinal immobilization	X	X	X	X
Patient assessment	X	X	X	X
Certification Period Requirements
Infectious disease	X	X	X	X
Trauma	X	X	X	X
Pharmacology		X	X	X
Other pediatric topics	X	X	X	X
Total minimum education hours per certification period:	15 hrs	30 hrs	60 hrs	150 hrs

"X"	Indicates an individual must demonstrate knowledge and competency in the topic or skill.

(2) Complete and document the skills maintenance requirements, indicated in Table B of this section, appropriate to the level of certification.

Table B

Skills Maintenance Requirements for the CME Method

		EMR	EMT	AEMT	Paramedic
First Certification Period or Three Years
□	First Year
	IV starts		EMT w/IV therapy skill	36	36
			36
	Endotracheal intubations (4 must be performed on humans)				12
	Intraosseous infusion placement		EMT w/IV therapy skill	X	X
			X
□	Second and Third Years
	IV starts over the two-year period		EMT w/IV therapy skill	72	72
			72
	Endotracheal intubations over the two-year period (4 per year must be performed on humans)				24
	Intraosseous infusion placement		EMT w/IV therapy skill
			X
During the Certification Period
	Pediatric airway management				X
	Supraglottic airway placement		EMT w/supraglottic airway skill	X	X
			X
	Defibrillation	X	X	X	X
Later Certification Periods
□	Annual Requirements
	IV starts		EMT w/IV therapy skill	X	X
			X
	Endotracheal intubations (2 per year must be performed on humans)				4
	Intraosseous infusion placement		EMT w/IV therapy skill	X	X
			X
□	During the Certification Period
	Pediatric airway management				X
	Supraglottic airway placement		EMT w/supraglottic airway skill	X	X
			X
	Defibrillation	X	X	X	X

"X"	Indicates an individual must demonstrate proficiency of the skill to the satisfaction of the MPD.))

(2) The EMS provider must complete requirements appropriate to the level of certification for each certification period and maintain competency in knowledge and skills. The EMS provider must demonstrate competency in knowledge and the ability to perform a skill properly to the satisfaction of the MPD or approved MPD delegate.

(3) An EMS provider who applies for recertification using the CME method must successfully complete department-approved knowledge and any practical skill examinations as identified in WAC 246-976-171.

(4) An EMS provider ((changing from the CME method to the OTEP method must meet all requirements of the OTEP method.

(5) Definitions of selected terms used in Tables A and B of this section:

(a) Cardiovascular education and training for adults, children, and infants includes:

(i) Nationally recognized training programs for CPR, foreign body airway obstruction (FBAO), and defibrillation and patient care appropriate to the level of certification;

(ii) The use of airway adjuncts appropriate to the level of certification;

(iii) The care of cardiac and stroke patients.

(b) Endotracheal intubation: Proficiency includes the verification of proper tube placement and continued placement of the endotracheal tube in the trachea through procedures identified in county MPD protocols.

(d) Intraosseous infusion: Proficiency in intraosseous line placement.

(e) 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.

(f) Supraglottic airway placement: Proficiency includes the verification of tube placement and continued placement of the supraglottic airway, in a skill lab setting, through procedures identified in county MPD protocols.

(g) Other pediatric topics: This includes anatomy and physiology and medical problems including special needs patients appropriate to the level of certification.

(h) Patient assessment: This includes adult, pediatric and geriatric patients appropriate to the level of certification.

(i) Pharmacology: Pharmacology specific to the medications approved by the MPD (not required for EMRs).

(j) Proficiency: Ability to demonstrate and perform all aspects of a skill properly to the satisfaction of the MPD or delegate.

(k) Spinal immobilization and packaging: This includes adult, pediatric, and geriatric patients appropriate to the level of certification

(l) Trauma: For adult, pediatric, and geriatric patients appropriate to the level of certification.))may transition from the OTEP to the CME method of recertification within their certification period if the provider meets all the following:

(a) Meets all requirements in WAC 246-976-161 by the end of their certification cycle;

(b) Meets all of the requirements in this section by the end of their certification cycle;

(d) Has received an MPD approved education plan to meet any deficiencies; and

(e) Has been approved by the MPD to transition recertification methods.

(5) An EMS provider must transition from OTEP to CME if they are unable to meet the requirements of the OTEP method of recertification.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-163The OTEP method of recertification.

(((1) Ongoing training and evaluation programs (OTEP):

(a) Must provide knowledge and skill evaluations following completion of each topic presentation to determine student competence of topic content.

(i) Must record practical skill evaluations on skill evaluation forms from nationally recognized training programs, or on department-approved practical skill evaluation forms, for the level of certification being taught.

(ii) If an evaluation form is not provided, a skill evaluation form must be developed and approved by the MPD and the department to evaluate the skill;

(b) Must be conducted at least on a quarterly basis;

(c) Must be approved by the MPD and the department. Any additions or major changes to an approved OTEP requires documented approval from the county MPD and the department;

(d) Must be presented and evaluated by course personnel meeting the following qualifications:

(i) Evaluators must:

(A) Be a currently certified Washington EMS provider who has completed at least one certification cycle. Certification must be at or above the level of certification being evaluated;

(B) Complete an MPD approved evaluator's workshop, specific to the level of certification being evaluated, which teaches participants to properly evaluate practical skills using the skill evaluation forms identified in (a) of this subsection. Participants must demonstrate proficiency to successfully complete the workshop;

(I) Be approved by the county MPD and the department; and

(II) Submit the MPD approved EMS evaluator application to the department.

(D) Meet education and participation requirements as identified by the county medical program director;

(E) Be recommended for reapproval by the county medical program director upon EMS credential recertification.

(ii) Instructors must:

(A) Be a currently approved EMS evaluator at or above the level of certification being taught;

(B) Be approved by the county MPD to instruct and evaluate EMS topics;

(iii) Guest lecturers, when used, 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;

(e) May use online training to provide all or a portion of an OTEP when:

(i) Online training provides sufficient topic content to meet all annual and certification period requirements;

(ii) Each didactic training topic requires an online cognitive evaluation after the training. Successful completion of the topic evaluation is required to receive credit for the topic;

(iii) Instruction and demonstration of all practical skills are provided in person by an SEI or qualified EMS evaluator approved by the MPD to instruct the practical skills;

(iv) Each practical evaluation is completed and scored in the presence of a state approved EMS evaluator or SEI. Each evaluation must be successfully completed to receive credit for the practical skill.

(2) To complete the OTEP method of recertification, the EMS provider:

(a) Must complete a county MPD and department-approved OTEP that includes requirements indicated in Table A of this section, for the certification period, appropriate to the level of certification;

Table A

Education Requirements for Recertification

		EMR	EMT	AEMT	Paramedic
Annual Requirements
Cardiovascular education and training		X	X	X	X
Spinal immobilization		X	X	X	X
Patient assessment		X	X	X	X
Certification Period Requirements
Infectious disease		X	X	X	X
Trauma		X	X	X	X
Pharmacology			X	X	X
Other pediatric topics		X	X	X	X
*	Total minimum education hours per certification period:	15 hrs	30 hrs	60 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.

(b) Complete and document the skills maintenance requirements, indicated in Table B of this section, appropriate to the level of certification. Skill maintenance requirements may be obtained as part of the OTEP.

Table B

Skills Maintenance Requirements for the OTEP Method

		EMR	EMT	AEMT	Paramedic
First Certification Period or Three Years
□	First Year
	IV starts		EMT w/IV therapy skill	12	12
			12
	Human endotracheal intubations				4
	Intraosseous infusion placement		EMT w/IV therapy skill	X	X
			X
□	Second and Third Years
	IV starts over the two-year period		EMT w/IV therapy skill	24	24
			12
	Human endotracheal intubations over the two-year period				8
	Intraosseous infusion placement		EMT w/IV therapy skill	X	X
			X
During the Certification Period
	Pediatric airway management		EMR & EMT	X	X
			X
	Supraglottic airway placement		EMT w/supraglottic airway skill	X	X
			X
	Defibrillation	X	X	X	X
Later Certification Periods
□	Annual Requirements
	IV starts		EMT w/IV therapy skill	X	X
			X
	Human endotracheal intubation				2
	Intraosseous infusion placement		EMT w/IV therapy skill	X	X
			X
□	During the Certification Period
	Pediatric airway management		EMR & EMT	X	X
			X
	Supraglottic airway placement		EMT w/supraglottic airway skill	X	X
			X
	Defibrillation	X	X	X	X

"X"	Indicates an individual must demonstrate proficiency of the skill to the satisfaction of the MPD.

(c) EMS providers using the OTEP method meet skill maintenance requirements by demonstrating proficiency in the application of those skills to the county MPD during the OTEP.

(d) Any EMS provider changing from the OTEP method to the CME method must meet all requirements of the CME method.

(3) Skill maintenance requirements for applicants requesting reciprocal certification:

(a) Reciprocity applicants credentialed less than three years must meet Washington state's skill maintenance requirements for the initial certification period identified above.

(b) Reciprocity applicants credentialed three years or more must meet Washington state's skill maintenance requirements for second and subsequent certification periods.

(c) The county MPD may evaluate an EMS provider's skills to determine proficiency in the application of those skills prior to recommending certification. The MPD may recommend that an EMS provider obtain specific training to become proficient in any skills deemed insufficient by the MPD or delegate.

(4) Definitions of selected terms used in Tables A and B of this section:

(a) Cardiovascular education and training for adults, children, and infants includes:

(i) Nationally recognized training programs for CPR, foreign body airway obstruction (FBAO), and defibrillation and patient care appropriate to the level of certification;

(ii) The use of airway adjuncts appropriate to the level of certification; and

(iii) The care of cardiac and stroke patients.

(d) Intraosseous infusion: Proficiency in intraosseous line placement.

(g) Other pediatric topics: This includes anatomy and physiology and medical problems including special needs patients appropriate to the level of certification.

(h) Patient assessment: This includes adult, pediatric, and geriatric patients appropriate to the level of certification.

(i) Pharmacology: Pharmacology specific to the medications approved by the MPD (not required for EMRs).

(j) Proficiency: Ability to demonstrate and perform all aspects of a skill properly to the satisfaction of the MPD or delegate.

(k) Spinal immobilization and packaging: This includes adult, pediatric, and geriatric patients appropriate to the level of certification.

(l) Trauma: For adult, pediatric, and geriatric patients appropriate to the level of certification.))(1) To recertify using the OTEP method, an EMS provider must complete a county MPD and department-approved OTEP that meets requirements in WAC 246-976-026, 246-976-161, and this section. Due to the competency-based nature of OTEP, fewer class hours may be required to complete the requirements than the recommended hours identified in WAC 246-976-161.

(3) An EMS provider may transition from the CME to the OTEP method of recertification within their certification period if the provider meets all the following:

(a) Has at least one year remaining in their certification cycle;

(b) Meets all requirements in WAC 246-976-161 by the end of their certification cycle;

(d) Has completed and submitted the department continuing medical education and ongoing training gap tool to the MPD;

(e) Has received an MPD approved education plan to meet any deficiencies; and

(f) Has been approved by the MPD to transition recertification methods.

(4) An EMS provider must transition from OTEP to CME if they are unable to meet the requirements of the OTEP method of recertification.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-171Recertification, reversion, reissuance, and reinstatement of certification.

(((1) To apply for recertification, an EMS provider must:

(a) Meet the requirements identified in Table A of this section for EMS providers completing the CME method; or

(b) Meet the requirements identified in Table B of this section for EMS providers completing the OTEP method; and

Table A

EMS Providers Participating in the CME Method of Recertification

REQUIREMENTS
EMS Education Requirements:
EMS providers participating in the CME method must provide proof of the following to the MPD or MPD delegate:
•	Successful completion of the educational requirements at the level of certification being sought, as specified in this chapter and identified in WAC 246-976-162, Table A;
•	Successful completion of skills maintenance required for the level of recertification being sought, as specified in this chapter and identified in WAC 246-976-162, Table B;
•	Passing department-approved practical skill certification examination for the level of certification being sought, within twelve months before submitting the application.
Recertification Examination:
Provide proof of a passing score on the department-approved recertification examination for the level of recertification being sought. The EMS provider will have three attempts within twelve months of course completion to pass the examination. If the EMS provider is unsuccessful after three attempts, prior to subsequent attempts, refresher training must be completed as follows:
•	EMR twelve hours.
•	EMT twenty-four hours.
•	AEMT thirty hours - Pharmacology review must be included in the refresher training.
•	Paramedic forty-eight hours - Pharmacology review must be included in the refresher training.
Certification application:
Provide proof of identity - State or federal photo I.D. (military ID, driver's license, passport).
Provide proof of EMS agency association - Active membership, paid or volunteer with:
•	Licensed aid or ambulance service;
•	Law enforcement agency;
•	Business with organized industrial safety team;
•	Senior EMS instructors or training coordinators, teaching at department-approved EMS training programs, who are unable to be associated with approved agencies above.
Recommendation of county medical program director.
•	The county MPD may require additional examinations to determine competency on department-approved MPD protocols prior to recommendation of recertification.
•	Required - MPD must sign application.
Background check - may be required.

Table B

EMS Providers Participating in the OTEP Method of Recertification

REQUIREMENTS
EMS Education Requirements:
EMS providers participating in the CME method must provide proof of the following to the MPD or MPD delegate:
•	Successful completion of the educational requirements at the level of certification being sought, as specified in this chapter and identified in WAC 246-976-163, Table A;
•	Successful completion of skills maintenance required for the level of certification being sought, as specified in this chapter and identified in WAC 246-976-163, Table B;
•	Successful completion of the OTEP knowledge and skill evaluations at the level of recertification being sought.
Recertification Examination:
The evaluations required under this section fulfill the requirement of department-approved knowledge and practical skill recertification examinations.
Certification Application:
Provide proof of identity - State or federal photo I.D. (military ID, driver's license, passport).
Provide proof of EMS agency association - Active membership, paid or volunteer with:
•	Licensed aid or ambulance service;
•	Law enforcement agency;
•	Business with organized industrial safety team;
•	Senior EMS instructors or training coordinators, teaching at department-approved EMS training programs, who are unable to be associated with approved agencies above.
Recommendation of county medical program director.
•	Obtain the county MPD recommendation for recertification and endorsement of EMT specialized training.
•	The county MPD may require additional examinations to determine competency on department-approved MPD protocols prior to recommendation of recertification.
•	Required - MPD must sign application.
Background check - May be required.

(2) To voluntarily revert to a lower level of certification, an EMS provider must:

(a) For the CME method, complete the recertification education requirements identified in WAC 246-976-161 and 246-976-162, Tables A and B for the lower level of certification; or

(b) For the OTEP method, complete the recertification education requirements identified in WAC 246-976-161 and 246-976-163, Tables A and B at the lower level of certification; and

(3) An EMS provider may not provide EMS care with an expired certification.

(4) To apply for reissuance of an expired Washington state EMS certification:

(a) If a certification is expired for one year or less, the EMS provider must provide proof of the following to the county MPD or MPD delegate:

(i) Complete one additional year of annual recertification education requirements; and

(ii) For EMS providers completing the CME method, complete the requirements identified in Table A of this section; or

(iii) For EMS providers completing the OTEP method, complete the requirements identified in Table B of this section.

(b) If a certification is expired more than one year and less than two years, the EMS provider must provide proof of the following to the county MPD or MPD delegate:

(i) One additional year of annual recertification education requirements; and

(ii) Twenty-four hours of educational topics and hours specified by the department and the MPD; and

(iii) For EMS providers completing the CME method, complete the requirements identified in Table A of this section; or

(iv) For EMS providers completing OTEP, complete the requirements identified in Table B of this section.

(c) If a certification is expired for two years or longer, the EMS provider must provide proof of the following to the MPD or delegate:

(i) For nonparamedic EMS personnel:

(A) Complete a department-approved initial training program, and successfully complete department-approved knowledge and practical skill certification examinations;

(B) Complete the initial certification application requirements identified in WAC 246-976-141.

(ii) For paramedics whose certification has been expired between two and six years:

(A) Current status as a provider or instructor in the following: ACLS, PHTLS or BTLS, PALS or PEPPS, or state approved equivalent;

(B) Current status in health care provider level CPR;

(C) Completing a state approved forty-eight hour EMT-paramedic refresher training program or complete forty-eight hours of ALS training that consists of the following core content:

(I) Airway, breathing and cardiology - sixteen hours.

(II) Medical emergencies - eight hours.

(III) Trauma - six hours.

(IV) Obstetrics and pediatrics - sixteen hours.

(V) EMS operations - two hours.

(D) Successful completion of any additional required MPD and department-approved refresher training;

(E) Successful completion of MPD required clinical and field evaluations;

(F) Successful completion of department-approved knowledge and practical skill certification examinations;

(G) Complete the initial certification application requirements identified in WAC 246-976-141.

(d) A request for reissuance of a paramedic certification that has been expired greater than six years will be reviewed by the department to determine the disposition.

(5) Reinstatement of a suspended or revoked Washington state EMS certification.

(a) A person whose EMS certification is suspended or revoked may petition for reinstatement as provided in RCW 18.130.150;

(b) The petitioner must:

(i) Provide proof of completion of all requirements identified by the departmental disciplinary authority; and

(ii) Meet the reissuance requirements in this section.

(6) When EMS personnel change or add membership with an EMS agency, or their contact information changes, they must notify the department within thirty days of the change. Changes will be made on forms provided by the department.))

(1) An EMS provider may not provide care with an expired certification.

(2) To apply for recertification, reversion, reissuance, or reinstatement, an applicant must meet the requirements for the appropriate process described in this section. Applicants must:

(a) Submit a completed application on forms provided by the department;

(b) Successfully complete a background check provided by the department. The background check may include the requirement for fingerprint card and FBI background check. If an applicant has submitted fingerprints and has been informed by the department that their fingerprints were rejected and must be redone, the applicant may request a temporary practice permit in accordance with WAC 246-12-050;

(c) Provide proof of active membership paid or volunteer with a licensed aid or ambulance service, or an EMS service supervisory organization (ESSO) recognized by the department. Senior EMS instructors or training coordinators teaching at department-approved EMS training programs who are unable to be with approved agencies above may affiliate with department-approved training programs with the approval from the county medical program director; and

(d) Be recommended by the county medical program director. The county medical program director must sign the application.

(3)(a) To recertify, applicants must:

(i) Have a current Washington state EMS certification; and

(ii) Successfully complete continuing medical education and ongoing training requirements prescribed in WAC 246-976-161.

(b) For applicants recertifying by the CME method prescribed in WAC 246-976-162:

(i) Provide the county MPD proof of successful completion of education and skill requirements; and

(ii) Provide proof of successful completion of department-approved knowledge examination within the current certification period.

(i) Successfully complete a department and MPD approved OTEP program; and

(ii) Provide the county MPD proof of successful completion of education and skill requirements.

(4) To revert to a lower level of certification, applicants must:

(a) Have a current Washington state EMS certification at a higher level;

(b) Be current in EMS education and skills for the level they are reverting to; and

(5) For the department to reissue an expired certification an applicant, if expired less than two years, must:

(a) Provide the county MPD proof of successful completion of education and skill requirements prescribed in WAC 246-976-161;

(b) Complete any additional MPD required education and skills competency checks;

(i) Provide the county MPD proof of successful completion of education and skill requirements; and

(ii) Provide proof of successful completion of the department-approved knowledge examination within the current certification period;

(d) For applicants seeking reissuance by meeting the OTEP recertification requirements prescribed in WAC 246-976-163:

(i) Successfully complete a department-approved OTEP program; and

(ii) Provide the county MPD proof of successful completion of education and skill requirements.

(6) Regarding a suspended or revoked certification:

(a) A person whose EMS certification is suspended or revoked may petition for reinstatement as provided in RCW 18.130.150.

(b) The petitioner must:

(i) Provide proof of completion of all requirements identified by the departmental disciplinary authority; and

(ii) Meet the appropriate reissuance requirements in this section.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-182Authorized care—Scope of practice.

(1) Certified EMS personnel are only authorized to provide patient care:

(a) When performing:

(i) In a prehospital emergency setting; or

(ii) During interfacility ambulance transport; or

(iii) When participating in a community assistance education and referral (CARES) program authorized under RCW 35.21.930; or

(iv) When providing collaborative medical care in agreement with local, regional, or state public health agencies to control and prevent the spread of communicable diseases; and

(b) When performing for a licensed EMS ((agency))service or an emergency services supervisory organization (ESSO) recognized by the secretary; and

(i)))included in the approved instructional guidelines/curriculum or approved specialized training and is included on the department-approved EMS skills and procedures list (DOH 530-173) for the individual's level of certification((; or

(ii) Included in approved specialized training)); and

(((iii) Included in state))(d) When following department-approved county MPD protocols.

(2) If protocols ((and)), MPD policies, county operating procedures, or regional patient care procedures do not provide off-line direction for the situation, the certified person in charge of the patient must consult with their online medical control as soon as possible. Medical control can only authorize a certified person to perform within their scope of practice.

(3) All prehospital providers must follow state approved triage procedures, county operating procedures, regional patient care procedures ((and)), county MPD policies, and patient care protocols.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-260Licenses required.

(1) The secretary licenses ambulance and aid services and vehicles to provide service that is consistent with the state plan and approved regional plans.

(2) ((To become licensed as an ambulance or aid service, an applicant must submit:

(a) A completed application for licensure on forms provided by the department;

(b) Proof of the following insurance coverage:

(i) Motor vehicle liability coverage required in RCW 46.30.020 (ambulance and aid services only);

(ii) Professional and general liability coverage;

(d) The level of service to be provided: Basic life support (BLS), intermediate life support (ILS), or advanced life support (ALS) (paramedic); and the scheduled hours of operation. Minimum staffing required for each level is as follows:

(i) For aid service response:

(A) A BLS level service will provide care with at least one person qualified in advanced first aid;

(B) An ILS level service will provide care with at least one ILS technician (AEMT);

(ii) For ambulance services:

(A) A BLS level service will provide care and transport with at least one emergency medical technician (EMT) and one person trained in advanced first aid;

(B) An ILS service will provide care and transport with at least one ILS technician and one EMT;

(C) An ALS service will provide care and transport with at least one paramedic and one EMT or higher level of EMS certification;

(D) Licensed services that provide critical care interfacility ambulance transports, must have sufficient medical personnel on each response to provide patient care specific to the transport;

(e) For licensed ambulance services, a written plan to continue patient transport if a vehicle becomes disabled, consistent with regional patient care procedures.

(3) To renew a license, submit application forms to the department at least thirty days before the expiration of the current license.

(4) Licensed ambulance and aid services must comply with department-approved prehospital triage procedures.))The secretary may extend the licensing period to accommodate efficient processing of renewal applications. The expiration date will be indicated on the EMS service license issued by the department.

(3) An aid or ambulance service operating in the state of Washington must:

(a) Be licensed by the department to operate, unless an exception in RCW 18.73.130 applies; and

(b) Comply with all applicable regulations and standards in this chapter.

(4) To apply for an initial aid or ambulance service license, an applicant must:

(a) Submit a completed application on forms provided by the department;

(b) Provide proof of the motor vehicle liability coverage required in RCW 46.30.020 (ambulance and aid services only) and professional and general liability coverage;

(d) Identify the level(s) of service to be provided to include:

(i) Basic life support (BLS);

(ii) Intermediate life support (ILS);

(iii) Advanced life support (ALS) (paramedic); and

(iv) Specialty care transport (SCT). Identify the scope of care and any specialty services (such as neonatal transport) provided;

(e) Identify the scheduled hours of operation for all levels of service provided; and

(f) Meet the minimum staffing requirements for each level of service provided. Staffing requirements are as follows:

(i) For aid services:

(A) An aid service providing BLS level of care must staff an aid vehicle with at least one emergency medical responder (EMR).

(B) An aid service providing ILS level of care must staff an aid vehicle with at least one advanced emergency medical technician (AEMT).

(ii) For ambulance services:

(A) An ambulance service providing BLS level of care must staff an ambulance with a minimum of at least one emergency medical technician (EMT) and one person certified as an emergency medical responder (EMR) or a driver with a certificate of advanced first aid qualification or department-approved equivalent.

(B) An ambulance service providing ILS level of care must staff an ambulance with a minimum of at least one advanced emergency medical technician (AEMT) and one EMT.

(C) An ambulance service providing ALS level of care must staff an ambulance with a minimum of at least one paramedic and one EMT.

(D) A licensed service that provides inter-facility specialty care transport (SCT) must provide a minimum of two certified or licensed health care providers on each transport that have the education, experience, qualifications, and credentials consistent with the patient's needs and scope of care required for the transport and includes:

(I) One paramedic or registered nurse cross trained in prehospital emergency care and certified as an EMT; and

(II) One other person who may be the driver, must be a registered nurse, respiratory therapist, paramedic, advanced EMT, EMT, or other appropriate specialist as appointed by the physician director.

(E) With approval from the department, an ambulance service established by a volunteer or municipal corporation, or association made up of two or more municipalities in a rural area with insufficient personnel may use a driver without any medical or first-aid training as provided in RCW 18.73.150(2).

(g) Provide a current list of certified EMS personnel affiliated with the EMS service;

(h) Provide the number of advanced first-aid trained personnel used in the staffing model by the EMS service;

(i) Provide the number of nonmedically trained drivers used in the staffing model by the EMS service;

(j) Meet the equipment requirements for the level(s) of service provided in WAC 246-976-300;

(k) Provide information about the type of aid or ambulance vehicles that will be used by the service;

(l) Provide supplemental documentation that describes all the following:

(i) The dispatch plan;

(ii) The deployment plan;

(iii) The response plan to include how patient transport will be continued if a vehicle becomes disabled or personnel become unavailable to respond or continue to a call and how patient care will be provided if medical equipment failure occurs; and

(iv) The tiered response and rendezvous plan; and

(m) Be approved by the department.

(5) To renew an aid or ambulance license, applicants must provide a completed application on forms provided by the department at least 30 days before the expiration of the current license and be approved by the department.

(6) Licensed aid and ambulance services must:

(a) Provide initial training and updates to certified EMS personnel on department-approved prehospital triage procedures, regional patient care procedures, county operating procedures, county medical program director policies, and patient care protocols;

(b) In accordance with RCW 43.70.490 provide training to familiarize EMS personnel with techniques, procedures, and protocols for best handling situations in which persons with disabilities are present at the scene of an emergency;

(d) Comply with department-approved prehospital triage procedures, regional patient care procedures, county operating procedures, county medical program director policies, and patient care protocols;

(e) Provide service consistent with the state plan, approved regional plans, and the approved application on file with the department; and

(f) Participate in the Washington state EMS electronic data system in accordance with RCW 70.168.090(2).

(7) The department will:

(a) Develop and administer the application and evaluation process;

(b) Notify the regional EMS and trauma care council and county medical program director when the department receives an application for an aid or ambulance service within their area;

(d) Approve renewal of an aid or ambulance license if the service continues to meet standards; and

(e) Provide written notification to the regional EMS a trauma care council and county medical program director when the license is first issued, when amendments to existing licenses impacting the service provided in the region occur, and when a license has expired.

(8) The department may:

(a) Conduct a site review; and

(b) Grant a provisional license not to exceed 120 days. The secretary may withdraw the provisional license if the service is unable to meet the requirements for licensure within the 120-day period.

NEW SECTION

WAC 246-976-261Emergency services supervisory organizations (ESSO).

(1) An emergency services supervisory organization (ESSO) is defined in RCW 18.73.030 and is an organization recognized by the secretary to use certified EMS providers.

(2) An ESSO must be one of the following organization types:

(a) Federal, state, county, or municipal law enforcement agency;

(b) Disaster management organizations within Washington state that deploy county emergency management teams during disasters. A letter of endorsement from the appropriate department of emergency management having jurisdiction must be provided with the application for recognition as an ESSO;

(i) Ski patrol organizations that provide medical, rescue, and hazard prevention services and medical care to sick and injured people in ski area boundaries or sometimes into backcountry settings and remote environments; or

(ii) SAR organizations functioning under chapter 38.52 RCW. A letter of endorsement from the local chief law enforcement officer (usually the county sheriff) must be provided with the application for recognition as an ESSO for search and rescue operations;

(d) Diversion centers. These are organizations that provide short-term placement and shelter to homeless adults with substance use disorders or behavioral health issues. Diversion centers offer services to divert people away from incarceration and toward treatment; or

(e) Businesses with organized industrial safety teams such as refineries, large manufacturing plants, mining operations, or aerospace manufacturing plants.

(3) To become recognized as an ESSO an applicant must:

(a) Be an organization type identified in subsection (2) of this section;

(b) Provide a completed application on forms provided by the department;

(d) Provide a current list of certified EMS providers;

(e) Request comments and recommendation for recognition as an ESSO from the local EMS and trauma care council and the county medical program director in all counties in which the organization will be conducting activities using certified EMS providers; and

(f) Be approved for recognition by the department.

(4) Recognized ESSOs must:

(a) Ensure that certified emergency medical services providers work under the medical oversight and protocols of a department-approved county medical program director;

(b) Ensure that certified emergency medical services providers work within the scope of practice for their level of certification;

(c) Ensure that certified emergency medical services providers can meet the training requirements to maintain their certification;

(d) Comply with department-approved prehospital triage procedures, regional EMS and trauma care plans, patient care procedures, county operating procedures, MPD policies and patient care protocols; and

(e) Provide the medical equipment listed in WAC 246-976-300 for the level of service the ESSO will provide.

(5) To renew an ESSO recognition, an applicant must:

(a) Be an organization type identified in subsection (2) of this section;

(b) Provide a completed application on forms provided by the department;

(d) Provide a current list of certified EMS personnel; and

(e) Be approved by the department for renewal.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-270Denial, suspension, revocation.

(1) The secretary may suspend, modify, or revoke an agency's license or verification issued under this chapter. The secretary may deny licensure or verification to an applicant when it finds:

(a) Failure to comply with the requirements of chapters 18.71, 18.73, or 70.168 RCW, or other applicable laws or rules, or with this chapter;

(b) Failure to comply or ensure compliance with prehospital patient care protocols or regional patient care procedures;

(d) ((Failure to supply data as required in chapter 70.168 RCW and this chapter; or

(e))) Failure to consistently meet trauma response times identified by the regional plan and approved by the department for trauma verified services.

(2) Modification, suspension, revocation, or denial of licensure or verification will be consistent with the requirements of the Administrative Procedure Act, chapter 34.05 RCW, and chapter 246-10 WAC. The secretary will not take action against a licensed, nonverified service under this section for providing emergency trauma care consistent with regional patient care procedures when the wait for the arrival of a verified service would place the life of the patient in jeopardy or seriously compromise patient outcome.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-290Ground ambulance vehicle standards.

(((1) Essential equipment for patient and provider safety and comfort must be in good working order.

(2) All ambulance vehicles must be clearly identified as an EMS vehicle and display the agency identification by emblems and markings on the front, side, and rear of the vehicle. A current state ambulance credential must be prominently displayed in a clear plastic cover positioned high on the partition behind the driver's seat.

(3) Tires must be in good condition.

(4) The electrical system must meet the following requirements:

(a) Interior lighting in the driver compartment must be designed and located so that no glare is reflected from surrounding areas to the driver's eyes or line of vision from the instrument panel, switch panel, or other areas which may require illumination while the vehicle is in motion; and

(b) Interior lighting in the patient compartment must be provided throughout the compartment, and provide an intensity of twenty foot-candles at the level of the patient; and

(c) Exterior lights must be fully operational, and include body-mounted flood lights over the patient loading doors to provide loading visibility; and

(d) Emergency warning lights must be provided in accordance with RCW 46.37.380, as administered by the state commission on equipment.

(5) Windshield wipers and washers must be dual, electric, multispeed, and functional at all times.

(6) Battery and generator system:

(a) The battery must be capable of sustaining all systems. It must be located in a ventilated area sealed off from the vehicle interior, and completely accessible for checking and removal;

(b) The generating system must be capable of supplying the maximum built-in DC electrical current requirements of the ambulance. If the electrical system uses fuses instead of circuit breakers, extra fuses must be provided.

(7) The ambulance must be equipped with:

(a) Seat belts that comply with Federal Motor Vehicle Safety Standards 207, 208, 209, and 210. Restraints must be provided in all seat positions in the vehicle, including the attendant station; and

(b) Mirrors on the left side and right side of the vehicle. The location of mounting must provide maximum rear vision from the driver's seated position; and

(8) Ambulance body requirements:

(a) The length of the patient compartment must be at least one hundred twelve inches in length, measured from the partition to the inside edge of the rear loading doors; and

(b) The width of the patient compartment, after cabinet and cot installation, must provide at least nine inches of clear walkway between cots or the squad bench; and

(c) The height of the patient compartment must be at least fifty-three inches at the center of the patient area, measured from floor to ceiling, exclusive of cabinets or equipment; and

(d) There must be secondary egress from the vehicle; and

(e) Back doors must open in a manner to increase the width for loading patients without blocking existing working lights of the vehicle; and

(f) The floor at the lowest level permitted by clearances. It must be flat and unencumbered in the access and work area, with no voids or pockets in the floor to side wall areas where water or moisture can become trapped to cause rusting or unsanitary conditions; and

(g) Floor covering applied to the top side of the floor surface. It must withstand washing with soap and water or disinfectant without damage to the surface. All joints in the floor covering must have minimal void between matching edges, cemented with a suitable water-proof and chemical-proof cement to eliminate the possibility of joints loosening or lifting; and

(h) The finish of the entire patient compartment must be impervious to soap and water and disinfectants to permit washing and sanitizing; and

(i) Exterior surfaces must be smooth, with appurtenances kept to a minimum; and

(j) Restraints must be provided for all litters. If the litter is floor supported on its own support wheels, a means must be provided to secure it in position. These restraints must permit quick attachment and detachment for quick transfer of patient.

(9) Vehicle brakes, regular and special electrical equipment, heating and cooling units, safety belts, and window glass, must be functional at all times.))

(1) All ground ambulance vehicles that are used to transport patients must meet the minimum standards in this chapter. Ambulance vehicles that meet a national ground ambulance standard recognized by the department are deemed to have met the minimum standards in this section.

(2) Equipment required for the safety and comfort of all occupants must be in good working order.

(3) The body of ambulance vehicles must meet the following standards:

(a) The length of the patient compartment must be at least 112 inches in length, measured from the partition to the inside edge of the rear loading doors;

(b) The width of the patient compartment after cabinet and gurney installation must provide at least nine inches of clear walkway;

(c) The height of the patient compartment must be at least 53 inches at the center of the patient area, measured from floor to ceiling, exclusive of cabinets or equipment;

(d) There must be secondary egress from the vehicle; and

(e) Back doors must open in a manner to increase the width for loading and unloading patients without blocking existing working lights of the vehicle.

(4) The interior of ambulance vehicles must meet the following standards:

(a) A current state ambulance vehicle credential must be prominently displayed in a clear plastic cover positioned high on the partition behind the driver's seat;

(b) The floor at the lowest level permitted by clearances must provide flat and unencumbered access to the work area, with no voids or pockets in the floor to side wall areas where water or moisture can become trapped to cause rusting or unsanitary conditions;

(c) Floor covering applied to the top side of the floor surface must withstand washing with soap and water or disinfectant without damage to the surface. All joints in the floor covering must have minimal void between matching edges, cemented with a suitable waterproof cement to eliminate the possibility of joints loosening or lifting;

(d) The finish of the entire patient compartment must be impervious to soap and water and disinfectants to permit washing and sanitizing;

(e) Interior lighting in the driver compartment must be designed and located so that no glare is reflected from surrounding areas to the driver's eyes or line of vision from the instrument panel, switch panel, or other areas which may require illumination while the vehicle is in motion;

(f) Interior lighting in the patient compartment must be provided adequately throughout the compartment, and provide an intensity of 215 lumen at the level of the patient;

(g) Ambulance vehicles must have one ABC two and one-half pound fire extinguisher. The extinguisher must be accessible, be in good physical condition, and in compliance with servicing requirements; and

(h) Interior equipment must be kept in a secure manner to provide for the safety of all occupants in the vehicle.

(5) Ambulance vehicles must be equipped with manufacturer recommended restraint systems which include:

(a) Seat belts must comply with Federal Motor Vehicle Safety Standards 207, 208, 209, and 210;

(b) Gurney restraints that comply with manufacturer recommendations must be used on patients during transport;

(c) Ambulance vehicles must have manufacturer recommended hardware installed that is in good working order to secure a gurney in the vehicle for transport;

(d) Restraints must be provided in all seat positions in the vehicle, including attendant stations;

(e) Restraints must be provided for patients when equipment such as a backboard or scoop stretcher is used to move a patient from surface to surface. A means to secure this equipment to the gurney or a bench seat must be provided for transport;

(f) Seat belts and related restraints must permit quick attachment and detachment for quick transfer of a patient; and

(g) Appropriate restraints for pediatric patients must be provided and used in a manner and location consistent with all applicable manufacturer recommendations.

(6) The exterior of ambulance vehicles must meet the following standards:

(a) The ambulance vehicle must be clearly identified as an emergency medical services vehicle;

(b) The ambulance vehicle must display the agency or service identification by reflective emblems and markings on the front, sides, and rear of the vehicle;

(c) The ambulance vehicle must have retro-reflective paint or tape, stripes or markings, or a combination of stripes and markings that are a minimum of six inches in width affixed to the full length of both sides and the rear of the vehicle;

(d) A minimum of 50 percent of the rear of the vehicle surface must be equipped with a retro-reflective pattern on ambulance vehicles built in the year 2020 and thereafter;

(e) Emergency warning lights and audible warning signals must be provided in accordance with national ambulance standards recognized by the department;

(f) Windshield wipers and washers must be dual, multispeed, and functional at all times;

(g) Ambulance vehicles must have exterior mirrors on the left and right side of the vehicle and mounted to provide maximum rear vision from the driver's seated position;

(h) Exterior lights must be fully operational, and include body-mounted floodlights over the patient loading doors to provide loading visibility;

(i) Exterior surfaces must be smooth, with projections kept to a minimum; and

(j) Equipment stored in exterior compartments must be secured in a manner to provide for the safety of all occupants in the vehicle.

(7) Mechanical and electrical components of ambulance vehicles must meet the following standards:

(a) The electrical power generating system must be capable of sustaining all systems and must be appropriately ventilated and sealed according to manufacturer recommendations;

(b) If the electrical system uses fuses instead of circuit breakers, extra fuses must be readily available;

(c) Within the engine compartment of the ambulance vehicle, hoses, belts, and wiring must not have any obvious defects; and

(d) Vehicle brakes, regular and special electrical equipment, heating and cooling units, safety belts, and window glass must be always functional.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-300Ground ambulance and aid service—Equipment.

((Ground ambulance and aid services must provide equipment listed in Table A of this section on each licensed vehicle, when available for service.

Note: "asst" means assortment	ambulance	aid vehicle
table a: equipment
airway management
Airway Adjuncts
Oral airway adult and pediatric	asst	asst
Suction
Portable	1	1
Vehicle mounted and powered, providing: Minimum of 30 L/min. & vacuum ˃ 300 mm Hg	1	0
Tubing, suction	1	1
Bulb syringe, pediatric	1	1
Rigid suction tips	2	1
Catheters as required by local protocol
Water-soluble lubricant	1	1
Oxygen delivery system built in	1	0
3000 L Oxygen supply, with regulator, 500 PSI minimum, or equivalent liquid oxygen system	1	0
300 L Oxygen supply, with regulator, 500 PSI minimum, or equivalent liquid oxygen system	2	1
Cannula, nasal, adult	4	2
O2 mask, nonrebreather, adult	4	2
O2 mask, nonrebreather, pediatric	2	1
BVM, with O2 reservoir
Adult, pediatric, infant	1 ea	1 ea
patient assessment and care
Assessment
Sphygmomanometer
Adult, large	1	1
Adult, regular	1	1
Pediatric	1	1
Stethoscope, adult	1	1
Thermometer, per county protocol	1	0
Flashlight, w/spare or rechargeable batteries & bulb	1	1
Defibrillation capability appropriate to the level of personnel	1	1
Personal infection control and protective equipment as required by the department of labor and industries
Length based tool for estimating pediatric medication and equipment sizes	1	1
trauma emergencies
Triage identification for 12 patients per county protocol	Yes	Yes
Wound care
Dressing, sterile	asst	asst
Dressing, sterile, trauma	2	2
Roller gauze bandage	asst	asst
Medical tape	asst	asst
Self adhesive bandage strips	asst	asst
Cold packs	4	2
Occlusive dressings	2	2
Scissors, bandage	1	1
Irrigation solution	2	1
Splinting
Backboard with straps	2	1
Head immobilization equipment	1	1
Pediatric immobilization device	1	1
Extrication collars, rigid
Adult (small, medium, large)	asst	asst
Pediatric or functionally equivalent sizes	asst	asst
Immobilizer, cervical/thoracic, adult	1	0
Splint, traction, adult w/straps	1	0
Splint, traction, pediatric, w/straps	1	0
Splint, adult (arm and leg)	2 ea	1 ea
Splint, pediatric (arm and leg)	1 ea	1 ea
General
Litter, wheeled, collapsible, with a functional restraint system per the manufacturer	1	0
Pillows, plastic covered or disposable	2	0
Pillow case, cloth or disposable	4	0
Sheets, cloth or disposable	4	2
Blankets	2	2
Towels, cloth or disposable 12" x 23" minimum	4	2
Emesis collection device	1	1
Urinal	1	0
Bed pan	1	0
OB kit	1	1
Epinephrine and supplies appropriate for level of certification per MPD protocols
Adult	1	1
Pediatric	1	1
Storage and handling of pharmaceuticals in ambulances and aid vehicles must be in compliance with the manufacturers' recommendations
Extrication plan: Agency must document how extrication will be provided when needed.))

(1) Licensed and verified ground ambulance, aid services, and emergency services supervisory organizations (ESSO) must provide equipment listed in Table A of this section on each licensed vehicle or to their on-site EMS providers for the service levels they are approved by the department to provide when they are available for service.

Table A: Equipment
*Means the use of this equipment at this level of service is determined by the MPD. Department-approved and MPD specialized training protocols must be in place.
	BLS		ILS		ALS
	Ambulance Vehicle	Aid/ESSO	Ambulance Vehicle	Aid/ESSO	Ambulance Vehicle	Aid/ESSO
Airway Adjuncts
Adjunctive airways, (OPA/NPA) adult and pediatric assorted	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Water-soluble lubricant	1	1	1	1	2	2
Intubation insertion equipment. Enough for all patient sizes with back up equipment including power sources.	N/A	N/A	Assortment	Assortment	Assortment	Assortment
Stylet for endotracheal tubes (adult and pediatric)	N/A	N/A	N/A	N/A	2 each	2 each
Bougie (gum-elastic) for all patient sizes	N/A	N/A	N/A	N/A	1 each	1 each
ET tube holder (adult and pediatric)	N/A	N/A	N/A	N/A	2 each	2 each
End-tidal CO2 detector	*1	*1	1	1	1	1
Supraglottic airways	*Assortment	*Assortment	Assortment	Assortment	Assortment	Assortment
Cricothyrotomy equipment	N/A	N/A	N/A	N/A	1	1
Chest decompression equipment (to include a nonsafety large bore needle, minimum length of 3.25")	N/A	N/A	N/A	N/A	1	1
McGill forceps (adult and pediatric)	N/A	N/A	1 each	1 each	1 each	N/A
Oxygen saturation monitor	*1	*1	1	1	1	1
Suction
Portable	1	1	1	1	1	1
Vehicle mounted and powered, providing: Minimum of 30 L/min. & vacuum ≥ 300 mm Hg	1	0	1	0	1	0
Spare canister	1	0	1	0	1	0
Tubing, suction	1	1	1	1	1	1
Bulb syringe, pediatric	1	1	1	1	1	1
Rigid suction tips	2	1	2	1	2	1
Catheters	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment
Meconium aspirator	N/A	N/A	N/A	N/A	1	1
Oxygen/Delivery Devices
Oxygen delivery system built in or an alternative system approved by the department	1	0	1	0	1	0
3000 L Oxygen supply, with regulator, 500 PSI minimum, or equivalent liquid oxygen system	1	0	1	0	1	0
300 L Oxygen supply, with regulator, 500 PSI minimum, or equivalent liquid oxygen system	2	1	2	1	2	1
Cannula, nasal, adult	4	2	4	2	4	2
O2 mask, nonrebreather, adult	4	2	4	2	4	2
O2 mask, nonrebreather, pediatric	2	1	2	1	2	1
BVM, with O2 reservoir to provide tidal volume appropriate for each (adult, pediatric, infant)	1 each	1 each	1 each	1 each	1 each	1 each
Nebulizer	*2	*2	2	2	2	2
Continuous Positive Airway Pressure (CPAP)	*2	*2	*2	*2	2	2
Patient Assessment and Care
Sphygmomanometer (adult large, regular, and pediatric)	1 each	1 each	1 each	1 each	1 each	1 each
Stethoscope, adult	1	1	1	1	1	1
Thermometer	1	0	1	0	1	0
Flashlight, w/spare or rechargeable batteries & bulb	1	1	1	1	1	1
Automated External Defibrillator (AED)	1	1	1	1	0	0
12 lead ECG monitor with defibrillator	0	0	0	0	1	1
Defibrillator pads - multifunction	2 each	2 each	2 each	2 each	2 each	2 each
Tool for estimating pediatric medication and equipment sizes	1	1	1	1	1	1
Glucometer	1	1	1	1	1	1
Glucose measuring supplies	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Wound Care
Dressing, sterile	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Dressing, sterile, trauma	2	2	2	2	2	2
Roller gauze bandage	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Medical tape	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Self-adhesive bandage strips	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Cold packs	4	2	4	2	4	2
Hot packs	2	2	2	2	2	2
Occlusive dressings	2	2	2	2	2	2
Trauma shears	1	1	1	1	1	1
Irrigation solution	2	1	2	1	2	1
Commercial tourniquet	2	2	2	2	2	2
Extrication and Splinting
Collars, rigid. Adult (small, medium, large) or adjustable	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Collars, rigid. Pediatric or functionally equivalent sizes	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Immobilization device, cervical/thoracic, adult	1	0	1	0	1	0
Immobilization device, cervical/thoracic, pediatric	1	1	1	1	1	1
Backboard with straps	1	1	1	1	1	1
Head immobilization equipment	1	1	1	1	1	1
Splint, traction, adult w/straps	1	0	1	0	1	0
Splint, traction, pediatric, w/straps	1	0	1	0	1	0
Splint, adult (arm and leg)	2 each	1 each	2 each	1 each	2 each	1 each
Splint, pediatric (arm and leg)	1 each	1 each	1 each	1 each	1 each	1 each
IV Access
Intravenous fluid type per protocols	*4	*2	4	2	4	2
Intravenous drip sets per protocols	*4	*2	4	2	4	2
Intravenous start supplies (venous tourniquet, transparent film dressing, antiseptic swab)	*4	*2	4	2	4	2
Catheters, intravenous (14-24 gauge)	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment
Intraosseous (Equipment sufficient to perform IO insertion and infusion adult and pediatric)	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment
Pediatric volume control device	*2	*1	2	1	2	1
Pressure infusion device	*1	0	1	0	1	0
Syringes	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment
Needles
Hypodermic	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment	*Assortment
Medications
Epinephrine for anaphylaxis adult and pediatric dose	1 each	1 each	1 each	1 each	1 each	1 each
Medications consistent with department-approved MPD protocols	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Storage and handling of pharmaceuticals in ambulances and aid vehicles must be in compliance with the manufacturers' recommendations
Personal Protection Equipment
Eye protection	2	2	2	2	2	2
Mask	5	5	5	5	5	5
Exam gloves (assortment of sizes)	Assortment	Assortment	Assortment	Assortment	Assortment	Assortment
Gowns (isolation)	3	3	3	3	3	3
Trauma Emergencies
Triage identification tags	12	12	12	12	12	12
General
Gurney, wheeled, collapsible, with a functional restraint system per the manufacturer	1	0	1	0	1	0
Pillows, plastic covered or disposable	1	0	1	0	1	0
Pillowcase, cloth or disposable	2	0	2	0	2	0
Sheets, cloth or disposable	4	2	4	2	4	2
Blankets	2	2	2	2	2	2
Towels, cloth or disposable 12" x 23" minimum	4	2	4	2	4	2
Emesis collection device	5	1	5	1	5	1
Urinal	1	0	1	0	1	0
Bed pan	1	0	1	0	1	0
OB kit	1	1	1	1	1	1
Patient care restraints (commercial)	2 pair	0	2 pair	0	2 pair	0
Garbage bags	2	2	2	2	2	2
Safety vest or equivalent gear	2	1	2	1	2	1
Sharps container mounted	1 each	0	1 each	0	1 each	0
Sharps container portable	1 each	1 each	1 each	1 each	1 each	1 each

(2) A licensed service that provides interfacility transport of patients needing specialty level care (SCT) must make available equipment and medications consistent with the scope of practice and care required for the transport type. Equipment must include all the following:

(a) ALS equipment required in Table A of this section;

(b) Multimodality ventilators capable of invasive ventilation appropriate to all age groups transported;

(d) Controlled delivery devices for IV infusions;

(e) Medications consistent with scope of practice and care required for the transport type; and

(f) Neonatal and pediatric equipment sufficient for all aspects of prehospital interfacility specialized care if the ambulance service provides transport to this population.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-310Ground ambulance and aid service—Communications equipment.

(1) Licensed ground ambulance and aid services must provide each licensed ambulance and aid vehicle with communication equipment which:

(a) Is consistent with state and regional plans;

(b) Is in good working order;

(d) Allows communication with medical control))with dispatch control point, medical control, and all hospitals in the service area of the vehicle; and

(d) Licensed ground ambulance and aid vehicles capable of transporting patients must also have direct two-way communication from both the driver's and patient's compartment.

(2) If cellular telephones are used, there must also be another method of radio contact with dispatch ((and))control point, medical control, and all hospitals in the service area for use when cellular service is unavailable.

(((3) Licensed ambulance services must provide each licensed ambulance with communication equipment which:

(a) Allows direct two-way communication with medical control and all hospitals in the service area of the vehicle, from both the driver's and patient's compartment; and

(b) Incorporates appropriate encoding and selective signaling devices.))

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-330Ambulance and aid services—Record requirements.

(1) Each ambulance and aid service must ((maintain a record of, and submit to the department, the following information on request:

(a) Current certification levels of all personnel;

(b) Any changes in staff affiliation with the ambulance and aid service to include new employees or employee severance; and

(2) The certified EMS provider in charge of patient care must provide the following information to the receiving facility staff:

(a) At the time of arrival at the receiving facility, a minimum of a brief written or electronic patient report including agency name, EMS personnel, and:

(i) Date and time of the medical emergency;

(ii) Time of onset of symptoms;

(iii) Patient vital signs including serial vital signs where applicable;

(iv) Patient assessment findings;

(v) Procedures and therapies provided by EMS personnel;

(vi) Any changes in patient condition while in the care of the EMS personnel;

(vii) Mechanism of injury or type of illness.

(b) Within twenty-four hours of arrival, a complete written or electronic patient care report that includes at a minimum:

(i) Names and certification levels of all personnel providing patient care;

(ii) Date and time of medical emergency;

(iii) Age of patient;

(iv) Applicable components of system response time;

(v) Patient vital signs, including serial vital signs if applicable;

(vi) Patient assessment findings;

(vii) Procedures performed and therapies provided to the patient; this includes the times each procedure or therapy was provided;

(viii) Patient response to procedures and therapies while in the care of the EMS provider;

(ix) Mechanism of injury or type of illness;

(x) Patient destination.

(c) For trauma patients, all other data points identified in WAC 246-976-430 for inclusion in the trauma registry must be submitted within ten days of transporting the patient to the trauma center.

(3) Licensed services must make all patient care records available for inspection and duplication upon request of the county MPD or the department.)):

(a) Maintain a record of certifications and endorsements of all personnel;

(b) Periodically audit certifications to assure they are current and active;

(c) Maintain a record of nonmedically trained drivers used by the service and relevant records that nonmedically trained drivers meet requirements in RCW 18.73.150;

(d) Report any additions and changes in a certified EMS providers affiliation with the service to include new employees or employee severance within 30 days;

(e) Maintain a record of make, model, and license number of all ambulance and aid vehicles;

(f) Report any additions and changes in ambulance and aid vehicles; and

(g) Maintain and provide a count of ambulance and aid service activations including: Advanced life support service activations, intermediate life support service activations, basic life support service activations, prehospital care, patient transports, interfacility transfers, and canceled activations between January 1st and December 31st of the previous calendar year.

(2) Licensed services must make all patient care records available for inspection and duplication upon request of the county MPD or the department.

AMENDATORY SECTION(Amending WSR 00-08-102, filed 4/5/00, effective 5/6/00)

WAC 246-976-340Ambulance and aid services—Inspections and investigations.

(1) The department may conduct periodic, unannounced inspections of licensed ambulances and aid vehicles and services.

(2) If the service is also verified in accordance with WAC 246-976-390, the department will include a review for compliance with verification standards as part of the inspections described in this section.

(3) At the end of an inspection for the purposes of initial, renewal, or amendment of licensure or verification, the department will:

(a) Present the preliminary findings to the EMS service; and

(b) Send a written report to the EMS service summarizing the department's findings and recommendations. The report shall identify any deficiencies found and the steps to take to address the deficiencies.

(4) Licensed services must provide the department full access to the facility, vehicles, and all records and documents relevant to the inspection or investigation which may include patient care reports, training and certification documentation, policies, procedures, protocols, crew schedules, mutual aid agreements, quality improvement materials or other relevant documents.

(5) Licensed services shall make available to the department and provide copies of any printed or written materials relevant to the inspection, verification review, or investigative process in a timely manner.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-390Standards for trauma ((verification of))verified prehospital EMS services.

(((1) The secretary verifies prehospital EMS services. Verification is a higher form of licensure that requires twenty-four-hour, seven day a week compliance with the standards outlined in chapter 70.168 RCW and this chapter. Verification will expire with the prehospital EMS service's period of licensure.

(2) To qualify for trauma verification, an agency must be a licensed ambulance or aid service as specified in WAC 246-976-260.

(3) The following EMS services may be verified:

(a) Aid service: Basic, intermediate (AEMT), and advanced (paramedic) life support;

(b) Ground ambulance service: Basic, intermediate (AEMT), and advanced (paramedic) life support;

(4) Personnel requirements:

(a) Verified aid services must provide personnel on each trauma response including:

(i) Basic life support: At least one individual who is an EMR or above;

(ii) Intermediate life support: At least one AEMT;

(iii) Advanced life support - Pramedic: At least one paramedic;

(b) Verified ambulance services must provide personnel on each trauma response including:

(i) Basic life support: At least two certified individuals - one EMT plus one EMR;

(ii) Intermediate life support: One AEMT, plus one EMT;

(iii) Advanced life support - Paramedic: At least two certified individuals - One paramedic and one EMT;

(5) Equipment requirements:

(a) Verified BLS vehicles must carry equipment identified in WAC 246-976-300, Table A;

(b) Verified ILS and paramedic vehicles must provide equipment identified in Table A of this section, in addition to meeting the requirements of WAC 246-976-300;

table a: equipment for verified trauma services (note: "asst" means assortments. "x" indicates required.)					ambulance		aid vehicle
					par	ils	par	ils
airway management
	Airway adjuncts
		Adjunctive airways, assorted per protocol			X	X	X	X
		Laryngoscope handle, spare batteries			1	1	1	1
			Adult blades, set		1	1	1	1
			Pediatric blades, straight (0, 1, 2)		1 ea	1 ea	1 ea	1 ea
			Pediatric blades, curved (2)		1 ea	1 ea	1 ea	1 ea
		McGill forceps, adult & pediatric			1	1	1	1
		ET tubes, adult and pediatric			asst	0	asst	0
	Supraglottic airways per MPD protocol				X	X	X	X
	End-tidal CO2 detector				1 ea	1 ea	1 ea	1 ea
	Oxygen saturation monitor				1 ea	1 ea	1 ea	1 ea
trauma emergencies
	IV access
		Administration sets and intravenous fluids per protocol:
			Adult		4	4	2	2
			Pediatric volume control device		2	2	1	1
		Catheters, intravenous (14-24 ga)			asst	asst	asst	asst
			Needles
				Hypodermic	asst	asst	asst	asst
				Intraosseous, per protocol	2	2	1	1
		Sharps container			1	1	1	1
		Syringes			asst	asst	asst	asst
	Glucose measuring supplies				Yes	Yes	Yes	Yes
	Pressure infusion device				1	1
	Length based tool for estimating pediatric medication and equipment sizes				1	1	1	1
	Medications according to local patient care protocols

(6) Aid service response time requirements: Verified aid services must meet the following minimum agency response times as defined by the department and identified in the regional plan:

(a) To urban response areas: Eight minutes or less, eighty percent of the time;

(b) To suburban response areas: Fifteen minutes or less, eighty percent of the time;

(d) To wilderness response areas: As soon as possible.

(7) Ground ambulance service response time requirements: Verified ground ambulance services must meet the following minimum agency response times for all EMS and trauma responses to response areas as defined by the department and identified in the regional plan:

(a) To urban response areas: Ten minutes or less, eighty percent of the time;

(b) To suburban response areas: Twenty minutes or less, eighty percent of the time;

(d) To wilderness response areas: As soon as possible.

(8) Verified air ambulance services must meet minimum agency response times as identified in the state plan.

(9) Verified ambulance and aid services must comply with the approved prehospital trauma triage procedures defined in WAC 246-976-010.

(10) The department will:

(a) Identify minimum and maximum numbers of prehospital services, based on:

(i) The approved regional EMS and trauma plans, including: Distribution and level of service identified for each response area; and

(ii) The Washington state EMS and trauma plan;

(b) With the advice of the steering committee, consider all available data in reviewing response time standards for verified prehospital trauma services at least biennially;

(d) Approve an applicant to provide verified prehospital trauma care, based on satisfactory evaluations as described in this section;

(e) Obtain comments from the regional council as to whether the application(s) appears to be consistent with the approved regional plan;

(f) Provide written notification to the applicant(s) of the final decision in the verification award;

(g) Notify the regional council and the MPD in writing of the name, location, and level of verified services;

(h) Approve renewal of a verified service upon reapplication, if the service continues to meet standards established in this chapter and verification remains consistent with the regional plan.

(11) The department may:

(a) Conduct a preverification site visit; and

(b) Grant a provisional verification not to exceed one hundred twenty days. The secretary may withdraw the provisional verification status if provisions of the service's proposal are not implemented within the one hundred twenty-day period, or as otherwise provided in chapter 70.168 RCW and this chapter.))

Verified EMS services must:

(1) Provide initial training and updates to certified EMS personnel on department-approved prehospital triage procedures, regional patient care procedures, county operating procedures, county medical program director policies and patient care protocols;

(2) Identify how certified EMS providers will receive continuing medical education and ongoing training;

(3) Comply with department-approved prehospital triage procedures, regional patient care procedures, county operating procedures, county medical program director policies and patient care protocols;

(4) Participate in the department-approved regional quality improvement program;

(5) Provide service that is consistent with the department-approved application on file for the EMS service, the state plan and approved regional plan; and

(6) Meet the following minimum agency response times as defined by the department and identified in the regional plan. With the advice of the steering committee, the department will consider all available data in reviewing response time standards for verified prehospital trauma services at least biennially.

(a) Aid service response time requirements: Verified aid services must meet the following minimum agency response times as defined by the department and identified in the regional plan:

(i) To urban response areas: Eight minutes or less, 80 percent of the time.

(ii) To suburban response areas: Fifteen minutes or less, 80 percent of the time.

(iii) To rural response areas: Forty-five minutes or less, 80 percent of the time.

(iv) To wilderness response areas: As soon as possible.

(b) Ground ambulance service response time requirements: Verified ground ambulance services must meet the following minimum agency response times for all EMS and trauma responses to response areas identified in their department-approved application on file, as defined by the department and identified in the regional plan:

(i) To urban response areas: Ten minutes or less, 80 percent of the time.

(ii) To suburban response areas: Twenty minutes or less, 80 percent of the time.

(iii) To rural response areas: Forty-five minutes or less, 80 percent of the time.

(iv) To wilderness response areas: As soon as possible.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-395To apply for initial or renewal of verification or to change verification status as a prehospital EMS service.

(1) ((To select verified prehospital EMS services, the department will:

(a) Provide a description of the documents an applicant must submit to demonstrate that it meets the standards as identified in chapter 70.168 RCW and WAC 246-976-390;

(b) Conduct a preverification on-site review for:

(i) All ALS ambulance service applications;

(ii) All ILS ambulance service applications; and

(iii) All BLS ambulance applications if and when there is any question of duplication of services or lack of coordination of prehospital services within the region;

(c) Request comments from the region in which a verification application is received, to be used in the department's review;

(d) Apply the department's evaluation criteria; and

(e) Apply the department's decision criteria.

(2) To apply for verification you must:

(a) Be a licensed prehospital EMS ambulance or aid service as specified in WAC 246-976-260;

(b) Submit a completed application:

(i) If you are applying for verification in more than one region, you must submit a separate application for each region;

(ii) You must apply for verification when you are:

(A)))The secretary verifies prehospital EMS services to provide service that is consistent with the state plan and approved regional plans. Verification is a higher form of licensure that requires 24-hour, seven day a week compliance with the standards outlined in chapter 70.168 RCW and this chapter. Verification will expire with the prehospital EMS services' periods of licensure.

(2) An aid or ambulance service operating in the state of Washington must apply for verification when you are:

(a) An agency that responds to ((9-1-1))911 emergencies as part of its role in the EMS system;

(((B)))(b) A new business or legal entity that is formed through consolidation of existing services or a newly formed EMS agency;

(((C)))(c) An EMS agency that seeks to provide prehospital emergency response in a ((region in))trauma response area which it previously has not been operating; or

(((D)))(d) A service that is changing((,)) or has changed its type of verification or its verification status.

(3) To apply for initial verification or to change verification status of a verified aid or ambulance service, the applicant must:

(a) Be a licensed aid or ambulance service as specified in WAC 246-976-260 or a licensed air ambulance service as specified in WAC 246-976-320;

(b) Provide a completed application for verification on forms provided by the department;

(i) Basic life support (BLS);

(ii) Intermediate life support (ILS);

(iii) Advanced life support (ALS);

(d) Meet the staffing requirements identified in WAC 246-976-260;

(e) Meet the equipment requirements for the level(s) of service provided in WAC 246-976-300;

(f) Provide information about the type of aid or ambulance vehicles that will be used by the service;

(g) Provide documentation that describes:

(i) The dispatch plan;

(ii) The deployment plan;

(iii) The response plan to include how patient transport will be continued if a vehicle or EMS providers become disabled;

(iv) The tiered response and rendezvous plan;

(v) Interagency relations. Mutual aid agreements, memoranda of understanding, or other official documents describing interagency relations and the presence of collaboration and cooperation for coordinated services shall be made available to the department upon request; and

(h) Provide service that is consistent with the department-approved application on file for the EMS service, the state plan, and approved regional plan.

(4) To renew verification, you must provide a completed application and documentation for renewal on forms provided by the department at least 30 days before the expiration of the current license.

(5) The department will:

(a) Develop and administer the application and evaluation process for all levels of service;

(b) Provide a description of the documents an applicant must submit to demonstrate that the service meets the standards identified in chapter 70.168 RCW;

(c) Identify minimum and maximum numbers of verified prehospital services, including level of service for each trauma response area based on:

(i) The approved regional EMS and trauma plans; and

(ii) The Washington state EMS and trauma plan;

(d) Develop guidance for local and regional EMS councils regarding trauma response areas and conducting needs assessments to support identification of minimum and maximum numbers of prehospital services;

(e) Request comments to be considered in the department's review from:

(i) The regional council in which a verification application is received;

(ii) The county medical program director in the area which a verification application is applying to provide service; and

(iii) Other stakeholders or interested parties;

(f) Apply the department's evaluation and decision criteria;

(g) Select verified prehospital services;

(h) Approve an applicant to provide verified prehospital trauma care, based on satisfactory evaluations as described in this section;

(i) Approve renewal of a verified service upon reapplication, if the service continues to meet standards established in this chapter and provides service consistent with the department-approved application on file for the EMS service, the state plan and approved regional plan;

(j) Provide written notification to the applicants on the final decision regarding the license and verification; and

(k) Provide written notification to the regional council and county medical program director when the license and verification is first issued, when amendments to existing licenses and verification impacting service provided in the region occur, and when a license with verification has expired.

(6) The department may:

(a) Conduct a preverification site visit; and

(b) Grant a provisional verification not to exceed 120 days. The secretary may withdraw the provisional verification status if provisions of the service's proposal are not implemented within the 120-day period, or as otherwise provided in chapter 70.168 RCW and this chapter.

(7) The department will evaluate ((each)) prehospital EMS service applicants for verification on a point system. In the event there are two or more applicants, the secretary will verify the most qualified applicant. The decision to verify will be based on at least the following:

(a) Total evaluation points received on ((all)) completed applications:

(i) Applicants must receive a minimum of ((one hundred fifty))150 points of the total ((two hundred))200 points possible from the overall evaluation scoring tool to qualify for verification((.));

(ii) Applicants must receive a minimum of ((thirty))30 points in the evaluation of its clinical and equipment capabilities section of the evaluation scoring tool to qualify for verification;

(b) Recommendations from the on-site review team, if applicable; and

(((d) Dispatch plan;

(e) Response plan;

(f) Level of service;

(g) Type of transport, if applicable;

(h) Tiered response and rendezvous plan;

(i) Back-up plan to respond;

(j) Interagency relations;

(k) How the applicant's proposal avoids unnecessary duplication of resources or services;

(l) How the applicant's service is consistent with and will meet the specific needs as outlined in their approved regional EMS and trauma plan including the patient care procedures;

(m) Ability to meet vehicle requirements;

(n) Ability to meet staffing requirements;

(o) How certified EMS personnel have been, or will be, trained so they have the necessary understanding of department-approved MPD protocols, and their obligation to comply with the MPD protocols;

(p) Agreement to participate in the department-approved regional quality improvement program.

(4)))(8) Regional EMS and trauma care councils may provide comments to the department regarding the verification application, including written statements on the following if applicable:

(a) Compliance with the department-approved minimum and maximum number of verified trauma services for the level of verification being sought by the applicant;

(b) How the proposed service will impact care in the region to include discussion on:

(i) Clinical care;

(ii) Response time to prehospital incidents;

(iii) Resource availability; ((and))

(iv) Unserved or ((under served))underserved trauma response areas; and

(((c)))(v) How the applicant's proposed service will impact existing verified services in the region((.));

(((5)))(c) Regional EMS/TC councils will solicit and consider input from local EMS/TC councils where local councils exist.

AMENDATORY SECTION(Amending WSR 11-07-078, filed 3/22/11, effective 5/15/11)

WAC 246-976-920Medical program director.

(1) Qualifications - Applicants for certification as a county medical program director (MPD) must:

(a) Hold and maintain a current and valid license to practice medicine and surgery under chapter 18.71 RCW or osteopathic medicine and surgery under chapter 18.57 RCW; and

(b) Be qualified and knowledgeable in the administration and management of emergency medical care and services; and

(c) Complete a medical director training course approved by the department within the first two years of initial certification as an MPD unless an EMS fellowship has already been completed or a board certification in EMS is held; and

(d) Be recommended for certification by the local medical community and local emergency medical services and trauma care council (EMS/TC).

(2) MPD certification process. In certifying the MPD, the department will:

(a) Notify the local EMS/TC of a vacancy for an MPD and work with the local EMS/TC council and medical community to identify physicians interested in serving as the MPD;

(b) Receive a letter of interest and curriculum vitae from ((the)) MPD candidates;

(d) Work with and provide technical assistance to local EMS/TC councils on evaluating MPD candidates;

(e) Obtain letters of recommendation from the local EMS/TC council and local medical community; and

(f) Make final ((appointment of))determination to certify the MPD.

(3) Medical control and direction. The certified MPD must:

(a) Provide medical control and direction of EMS certified personnel in their medical duties. This is done by oral or written communication; and

(b) Develop and adopt written prehospital patient care protocols for specialized training and to direct EMS certified personnel in patient care. ((These))Protocols ((may))must:

(i) Meet the minimum standards of the department;

(ii) Not conflict with county operating procedures or regional patient care procedures((.));

((Protocols may))(iii) Not exceed the authorized care of the certified prehospital personnel as described in WAC 246-976-182;

(((c)))(iv) Be relevant and meet current nationally recognized and state approved EMS practices;

(v) Be approved by the department. The department may consult with MPDs and other technical advisory groups for input prior to approval of protocols;

(vi) Develop and keep updated a mechanism to familiarize and assess competency of EMS providers with the protocols, county operating procedures, and MPD policies; and

(vii) With approval from the department, may enter into medical control agreements with other MPDs to clarify medical oversight for EMS providers to support the continuity of patient care.

(4) MPD policies. The MPD must:

(a) Establish policies as directed by the department to include a policy for storing, dispensing, and administering controlled substances. Policies must be in accordance with state and federal regulations and guidelines;

(((d)))(b) Work within the parameters of department policies, regional EMS and trauma care plans, and patient care procedures;

(i) Regional EMS and trauma care plans;

(ii) Regional patient care procedures;

(((ii)))(iii) County operating procedures when applicable. COPS ((do))must not conflict with regional patient care procedures or other state standards; and

(((iii) Participate with the local and regional EMS/TC councils to develop and revise regional plans;

(e)))(iv) Recommendations for improvements in medical control communications and EMS system coordination; and

(d) MPDs must work within the parameters of the approved regional patient care procedures and the regional plan((;

(f) Supervise training of all EMS certified personnel;

(g) Develop protocols for special training described in WAC 246-976-023(4);

(h) Periodically audit the medical care performance of EMS certified personnel;

(i))).

(5) MPD oversight of training and education. The MPD:

(a) Must provide oversight of instructors and supervise training of all EMS providers. MPDs may conduct these activities remotely;

(b) Must recommend to the department approval of individuals applying for recognition as senior EMS instructors candidates, senior EMS instructors, EMS evaluators, and locally approve all guest instructors for any EMS education and training;

(c) Must recommend to the department approval of training programs, courses, ongoing education and training plans (OTEP), and content for continuing medical education (CME) and ongoing training;

(d) May develop or approve an intensive airway management program and approve providers to take the program if live intubations cannot be obtained;

(e) May approve providers to perform IV and IO starts on artificial training aids; and

(f) May develop an evaluation form for a procedure or skill if one is not provided by the department.

(6) Certification of EMS providers. The MPD:

(a) Must recommend to the secretary certification, recertification, reciprocity, challenge, reinstatement, reissuance of expired certification or denial of certification of EMS personnel and sign applications; and

(((j)))(b) May develop an integration process to evaluate and determine competency of an applicant's knowledge and skills in accordance with department policies. The MPD may:

(i) Use examinations to determine competency on department-approved MPD protocols prior to making a recommendation;

(ii) Use examinations to determine knowledge and abilities for personnel prior to recommending applicants for certification or recertification;

(iii) Prescribe additional required refresher training for expired providers;

(iv) Request, review and evaluate an EMS providers training records, skills, and documentation of prehospital medical care provided by the person, to determine proficiency and competency in the application of prehospital care prior to making a recommendation;

(v) Prescribe and review clinical and field evaluations; and

(vi) An MPD integration process must be approved by the department and may not take more than 90 days to complete unless unusual or extenuating circumstances exist;

(c) An MPD may recommend denial of certification to the secretary for any applicant the MPD can document is unable to function as an EMS provider, regardless of successful completion of training, evaluation, or examinations;

(d) An MPD must recommend certified providers to be approved or denied endorsements for specialized skills; and

(e) An MPD may approve a certified advanced emergency medical technician or a paramedic to function at a lower level of certification.

(7) Quality improvement and assurance activities. The MPD:

(a) Must adopt an MPD quality improvement plan that describes how quality improvement activities are conducted by the MPD. The plan must meet the minimum standards of the department;

(b) May access patient care records and reports in the statewide electronic EMS data system for EMS services under their oversight;

(c) May audit the medical care performance of EMS providers in accordance with the MPD quality improvement plan. The audit may include a review of documentation of patient care, training, and skills maintenance of EMS personnel;

(d) May perform counseling and assign remediation regarding the clinical practice of EMS providers;

(e) May recommend to the secretary disciplinary action to be taken against EMS personnel, which may include modification, suspension, or revocation of certification; and

(((k) Recommend to the department individuals applying for recognition as senior EMS instructors.

(4)))(f) Must participate in regional quality improvement activities.

(8) Oversight of licensed, verified, or recognized EMS services. The MPD:

(a) Must review and make a recommendation to the department for applications for services applying for recognition as an emergency services supervisory organization (ESSO);

(b) Must approve equipment and medications used to provide medical care by EMS personnel; and

(c) May make recommendations for corrections for EMS services that are out of compliance with the regional plan to the department in accordance with WAC 246-976-400.

(9) Delegation of duties. In accordance with department policies and procedures, the MPD may appoint a qualified physician to be an MPD delegate as defined in WAC 246-976-010. The MPD:

(a) May delegate duties to other physicians, except for duties described in subsections (3)(b), (((i), (j), and (k)))(4)(c)(i), (5) (b) and (c), (6)(a), (d), and (e), (7)(e), and (8)(a) of this section. ((The delegation must be in writing;))

(i) The MPD must notify the department in writing of the names and duties of individuals so delegated, within ((fourteen))14 days of appointment; and

(ii) The MPD may ((remove delegated authority at any time, which shall be effective upon written notice to the delegate and the department))recommend to the secretary removal of a delegate's authority.

(b) The MPD may delegate duties relating to training, evaluation, or examination of certified or recognized EMS personnel, to qualified nonphysicians. ((The delegation must be in writing;

(d) Recommend denial of certification to the secretary for any applicant the MPD can document is unable to function as an EMS provider, regardless of successful completion of training, evaluation, or examinations; and

(e) Utilize examinations to determine the knowledge and abilities of certified EMS personnel prior to recommending applicants for certification or recertification.

(5)))(10) The secretary may withdraw the certification of an MPD ((for failure))when it finds that the MPD:

(a) Failed to comply with the Uniform Disciplinary Act (chapter 18.130 RCW) and other applicable statutes and regulations;

(b) Is not performing the duties required in applicable statutes and regulations;

(d) Is no longer authorized to practice within the local medical community.

(11) Modification, suspension, revocation, or denial of certification will be consistent with the requirements of the Administrative Procedure Act (chapter 34.05 RCW), the Uniform Disciplinary Act (chapter 18.130 RCW), and chapter 246-10 WAC.

(12) The department will make the final determination on termination of the MPD.

AMENDATORY SECTION(Amending WSR 02-14-053, filed 6/27/02, effective 7/28/02)

WAC 246-976-960Regional emergency medical services and trauma care councils.

(((1) In addition to meeting the requirements of chapter 70.168 RCW and elsewhere in this chapter, regional EMS/TC councils must:

(a) Identify and analyze system trends to evaluate the EMS/TC system and its component subsystems, using trauma registry data provided by the department;

(b) Develop and submit to the department regional EMS/TC plans to:

(i) Identify the need for and recommend distribution and level of care (basic, intermediate or advanced life support) for verified aid and ambulance services for each response area. The recommendations will be based on criteria established by the department relating to agency response times, geography, topography, and population density;

(ii) Identify EMS/TC services and resources currently available within the region;

(iii) Describe how the roles and responsibilities of the MPD are coordinated with those of the regional EMS/TC council and the regional plan;

(iv) Describe and recommend improvements in medical control communications and EMS/TC dispatch, with at least the elements of the state communication plan described in RCW 70.168.060 (1)(h);

(v) Include a schedule for implementation.

(2) In developing or modifying its plan, the regional council must seek and consider the recommendations of:

(a) Local EMS/TC councils;

(b) EMS/TC systems established by ordinance, resolution, interlocal agreement or contract by counties, cities, or other governmental bodies.

(3) In developing or modifying its plan, the regional council must use regional and state analyses provided by the department based on trauma registry data and other appropriate sources;

(4) Approved regional plans may include standards, including response times for verified services, which exceed the requirements of this chapter.

(5) An EMS/TC provider who disagrees with the regional plan may bring its concerns to the steering committee before the department approves the plan.

(6) The regional council must adopt regional patient care procedures as part of the regional plans. In addition to meeting the requirements of RCW 18.73.030(14) and 70.168.015(23):

(a) For all emergency patients, regional patient care procedures must identify:

(i) Guidelines for rendezvous with agencies offering higher levels of service if appropriate and available, in accordance with the regional plan.

(ii) The type of facility to receive the patient, as described in regional patient destination and disposition guidelines.

(iii) Procedures to handle types and volumes of trauma that may exceed regional capabilities, taking into consideration resources available in other regions and adjacent states.

(b) For major trauma patients, regional patient care procedures must identify procedures to activate the trauma system.

(7) In areas where no local EMS/TC council exists, the regional EMS/TC council shall:

(a) Make recommendations to the department regarding appointing members to the regional EMS/TC council;

(b) Review applications for initial training classes and OTEP programs, and make recommendations to the department.

(8) Matching grants made under the provisions of chapter 70.168 RCW may include funding to:

(a) Develop, implement, and evaluate prevention programs; or

(b) Accomplish other purposes as approved by the department.))(1) Regional council composition and appointments. The department shall establish regional emergency medical services and trauma care councils (EMS/TC) and shall appoint members to be comprised of a balance of hospital and prehospital trauma care and emergency medical service providers, local elected officials, consumers, local law enforcement representatives, and local government agencies involved in the delivery of trauma care and emergency medical services recommended by the local emergency medical services and trauma care councils within the region.

(a) The department will design and manage the appointment process.

(b) In areas where no local EMS/TC council exists, the regional EMS/TC council shall make recommendations to the department regarding appointing members to the regional EMS/TC council.

(2) Funding and grants. The department, with the assistance of the emergency medical services and trauma care steering committee, shall adopt a program for the disbursement of funds for the development, implementation, and enhancement of the emergency medical services and trauma care system. Under the program, the department shall disburse funds to each emergency medical services and trauma care regional council, or their chosen fiscal agent or agents, which shall be city or county governments, stipulating the purpose for which the funds shall be expended.

(a) The councils shall report in the regional budget the individual source, amount, and purpose of all gifts and payments.

(b) Matching grants may be made under the provisions of chapter 70.168 RCW and awarded for the purposes identified in RCW 70.168.130 and to accomplish other purposes as approved by the department.

(3) Regional council responsibilities. In addition to meeting the requirements of chapter 70.168 RCW and elsewhere in this chapter, regional EMS/TC councils must:

(a) Develop and submit to the department regional EMS/TC plans that meet the minimum standards of the department. In developing and modifying the plans EMS/TC regions must:

(i) Use regional and state analyses provided by the department based on the statewide electronic emergency medical services data system, trauma registry data and other appropriate sources provided by the department;

(ii) Identify and analyze system trends to evaluate the EMS/TC system and its component subsystems, using statewide electronic emergency medical services data system, trauma registry data and other appropriate sources provided by the department;

(iii) Identify the need for and recommend distribution and level of care (basic, intermediate, or advanced life support) for verified aid and ambulance services to assure adequate availability and avoid inefficient duplication and lack of coordination of prehospital care services for each response area. The recommendations will be based on criteria established by the department and will include information related to agency response times, geography, topography, and population density;

(iv) Identify the need for and recommend distribution and level of facilities to be designated which are consistent with state standards and based upon availability of resources and distribution of trauma within the region;

(v) Identify prehospital training and education to meet regional and local needs;

(vi) Identify EMS/TC services and resources currently available within the region;

(vii) Summarize improvements and outcomes from the last approved plan;

(viii) See and consider the recommendations of local EMS/TC councils and systems established by ordinance, resolution, interlocal agreement or contract by counties, cities, and other governmental bodies;

(ix) Include in the plan, patient care procedures adopted by the region that meet the requirements of RCW 18.73.030 and 70.168.015 and the minimum standards of the department and must include:

(A) The level of medical care personnel to be dispatched to an emergency scene;

(B) Guidelines for rendezvous with agencies offering higher levels of service;

(D) On scene command;

(E) Procedures for EMS to identify and triage patients experiencing trauma, cardiac, or stroke emergencies. Procedures must include destination determination including the type and level of facility to first receive the patient, and the process EMS must use to alert the receiving facility;

(F) For major trauma patients, regional patient care procedures must identify procedures to alert and activate the trauma system;

(G) Patient care procedures must include interfacility transport procedures including the name and location of other trauma, cardiac, or stroke care facilities to receive the patient should an interfacility transfer be necessary;

(H) Procedures to allow for the appropriate transport of patients to mental health facilities or chemical dependency programs, as informed by the alternative facility guidelines adopted under RCW 71.168.170;

(I) Procedures to handle types and volumes of medical and trauma patients that may exceed regional capabilities, taking into consideration resources available in other regions and adjacent states;

(J) Procedures for how hospital diversion is managed in the region; and

(K) EMS and medical control communications;

(x) Include a schedule for implementation and identify goals, objectives, and strategies;

(xi) Include strategies that may promote improvements in the regional EMS/TC system;

(xii) Describe how the roles and responsibilities of the MPD are coordinated with those of the regional EMS/TC council and regional plan; and

(xiii) Describe and recommend improvements in medical control communications and EMS/TC dispatch, with at least the elements of the state communication plan described in RCW 70.168.060 (1)(h).

(b) Review applications for verification of ambulance and aid services and make recommendations to the department regarding:

(i) Compliance with the department-approved minimum and maximum number of verified trauma services for the level of verification being sought by the applicant;

(ii) How proposed service will impact care in the region in relations to clinical care, response time to prehospital incidents, and resource availability;

(iii) How the proposed service impacts unserved and underserved trauma response areas;

(iv) How the proposed service will impact existing verified services in the region; and

(v) Include any comments from local EMS/TC councils and systems established by ordinance, resolution, interlocal agreement or contract by counties, cities, or other governmental bodies.

AMENDATORY SECTION(Amending WSR 02-14-053, filed 6/27/02, effective 7/28/02)

WAC 246-976-970Local emergency medical services and trauma care councils.

(1) Local council composition. If a county or group of counties creates a local EMS/TC council, it must be composed of a balance of representatives of hospital and ((prehospital trauma care and)) EMS providers, local elected officials, consumers, local law enforcement officials, local government agencies, physicians, and prevention specialists involved in the delivery of EMS/TC.

(2) Local council responsibilities. In addition to meeting the requirements of chapter 70.168 RCW and this chapter, local EMS/TC councils ((must)):

(a) ((Participate with the MPD and emergency communication centers in making recommendations to the regional council about the development of regional patient care procedures; and

(b) Review applications for initial training classes and OTEP programs, and make recommendations to the department.))Must make recommendations to the regional council regarding appointing members representing the local council to the regional EMS/TC council;

(b) Must develop county operating procedures as defined in WAC 246-976-010 in collaboration with the county medical program director;

(d) Must make recommendations to the regional council about the development of regional patient care procedures;

(e) Review applications for EMS training programs and make recommendations to the department;

(f) Conduct activities to assess, support, and improve EMS training programs within the county;

(g) Identify prehospital training and education to meet local needs and make recommendations to the regional council for regional planning;

(h) Review applications for EMS service verification at the request of regional EMS councils. The review must include:

(i) Compliance with the department-approved minimum and maximum number of trauma verified services for the level of verification being sought by the applicant;

(ii) How the proposed service will impact care in the region in relation to clinical care, response time to prehospital incidents, and resource availability;

(iii) How the proposed service impacts unserved or underserved trauma response areas;

(iv) How the proposed service will impact existing verified services in the region; and

(v) Seek and include any comments from local systems established by ordinance, resolution, interlocal agreement or contract by counties, cities, or other governmental bodies;

(i) Provide recommendation to the regional EMS/TC council in accordance with RCW 70.168.080, for remediation activities to support a prehospital provider that is out of compliance with regional plan;

(j) Identify how the roles and responsibilities of the MPD are coordinated with those of the local council.

(3) Local EMS/TC councils may make recommendations to the department regarding certification and termination of MPDs, as provided in RCW 18.71.205(4).