The purpose of these rules is to implement RCW 18.71.200 through 18.71.215, and chapters 18.73 and 70.168 RCW; and those sections of chapter 70.24 RCW relating to EMS personnel and services.

(1) This chapter establishes criteria for:

(a) Training and certification of EMS providers;

(b) Licensure and inspection of ambulance services and aid services;

(c) Verification of prehospital trauma services;

(d) Development and operation of a statewide trauma registry;

(e) The designation process and operating requirements for designated trauma care services;

(f) A statewide emergency medical communication system;

(g) Administration of the statewide EMS/TC system;

(h) Development and operation of a statewide electronic EMS data system.

(2) This chapter does not contain detailed procedures to implement the state EMS/TC system. Requests for procedures, guidelines, or any publications referred to in this chapter must be obtained from the Office of Community Health Systems, Department of Health, Olympia, WA 98504-7853 or on the internet at www.doh.wa.gov.

(1) A trauma care provider shall protect the confidentiality of data in their possession and as it is transferred to the department.

(2) A verified prehospital agency that transports trauma patients must:

(a) Provide an initial report of patient care to the receiving facility at the time the trauma patient is delivered as described in WAC ((246-976-330))246-976-455.

(b) Within ((twenty-four))24 hours after the trauma patient is delivered, send a complete patient care report to the receiving facility to include the data shown in Table A.

Table A:

Prehospital Patient Care Report Elements for the Washington Trauma Registry

(3) A designated trauma service must:

(a) Have a person identified as responsible for trauma registry activities, and who has completed the department trauma registry training course within ((eighteen))18 months of hire. For level I-III trauma services the person identified must also complete the abbreviated injury scale (AIS) course within ((eighteen))18 months of hire;

(b) Report data elements for all patients defined in WAC 246-976-420;

(c) Report patients with a discharge date for each calendar quarter in a department-approved format by the end of the following quarter;

(d) Have procedures in place for internal monitoring of data validity, which may include methods to reabstract data for accuracy; and

(e) Correct and resubmit records that fail the department's validity tests as described in WAC 246-976-420(7) within three months of notification of errors.

(4) A designated trauma rehabilitation service must provide data, as identified in subsection (7) of this section, to the trauma registry in a format determined by the department upon request.

(5) A designated trauma service must submit the following data elements for trauma patients:

(a) Record identification data elements must include:

(i) Identification (ID) of reporting facility;

(ii) Date and time of arrival at reporting facility;

(iii) Unique patient identification number assigned to the patient by the reporting facility.

(b) Patient identification data elements must include:

(i) Name;

(ii) Date of birth;

(iii) Sex;

(iv) Race;

(v) Ethnicity;

(vi) Last four digits of the patient's Social Security number;

(vii) Home zip code.

(c) Prehospital data elements must include:

(i) Date and time of incident;

(ii) Incident zip code;

(iii) Mechanism/type of injury;

(iv) External cause codes;

(v) Injury location codes;

(vi) First EMS agency on-scene identification (ID) number;

(vii) Transporting agency ID and unit number;

(viii) Transporting agency patient care report number;

(ix) Cause of injury;

(x) Incident county code;

(xi) Work related;

(xii) Use of safety equipment;

(xiii) Procedures performed.

(d) Prehospital vital signs data elements (from first EMS agency on scene) must include:

(i) Time;

(ii) First systolic blood pressure;

(iii) First respiratory rate;

(iv) First pulse rate;

(v) First oxygen saturation;

(vi) First GCS with individual component values (eye, verbal, motor, total, and qualifiers);

(vii) Intubated at time of first vital sign assessment;

(viii) Pharmacologically paralyzed at time of first vital sign assessment;

(ix) Extrication.

(e) Transportation data elements must include:

(i) Date and time unit dispatched;

(ii) Time unit arrived at scene;

(iii) Time unit left scene;

(iv) Transportation mode;

(v) Transferred in from another facility;

(vi) Transferring facility ID number.

(f) Emergency department (ED) data elements must include:

(i) Readmission;

(ii) Direct admit;

(iii) Time ED physician was called;

(iv) Time ED physician was available for patient care;

(v) Trauma team activated;

(vi) Level of trauma team activation;

(vii) Time of trauma team activation;

(viii) Time trauma surgeon was called;

(ix) Time trauma surgeon was available for patient care;

(x) Vital signs in ED, which must also include:

(A) First systolic blood pressure;

(B) First temperature;

(C) First pulse rate;

(D) First spontaneous respiration rate;

(E) Controlled rate of respiration;

(F) First oxygen saturation measurement;

(G) Lowest systolic blood pressure (SBP);

(H) GCS score with individual component values (eye, verbal, motor, total, and qualifiers);

(I) Whether intubated at time of ED GCS;

(J) Whether pharmacologically paralyzed at time of ED GCS;

(K) Height;

(L) Weight;

(M) Whether mass casualty incident disaster plan implemented.

(xi) Injury scores must include:

(A) Injury severity score;

(B) Revised trauma score on admission;

(C) Pediatric trauma score on admission;

(D) Trauma and injury severity score.

(xii) ED procedures performed;

(xiii) Blood and blood components administered;

(xiv) Date and time of ED discharge;

(xv) ED discharge disposition, including:

(A) If transferred, ID number of receiving hospital;

(B) Was patient admitted to hospital?

(C) If admitted, the admitting service;

(D) Reason for transfer (sending facility).

(g) Diagnostic and consultative data elements must include:

(i) Whether the patient received aspirin in the four days prior to the injury;

(ii) Whether the patient received any oral antiplatelet medication in the four days prior to the injury, such as clopidogrel (Plavix), or other antiplatelet medication, and, if so, include:

(A) Whether the patient received any oral anticoagulation medication in the four days prior to the injury, such as warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto), or other anticoagulation medication, and, if so, include:

(B) The name of the anticoagulation medication.

(iii) Date and time of head computed tomography scan;

(iv) Date and time of first international normalized ratio (INR) performed at the reporting trauma service;

(v) Results of first INR ((preformed [performed]))performed at the reporting trauma service;

(vi) Date and time of first partial thromboplastin time (PTT) performed at the reporting trauma service;

(vii) Results of first PTT performed at the reporting trauma service;

(viii) Whether any attempt was made to reverse anticoagulation at the reporting trauma service;

(ix) Whether any medication (other than Vitamin K) was first used to reverse anticoagulation at the reporting trauma service;

(x) Date and time of the first dose of anticoagulation reversal medication at the reporting trauma service;

(xi) Elapsed time from ED arrival;

(xii) Date of rehabilitation consult;

(xiii) Blood alcohol content;

(xiv) Toxicology results;

(xv) Whether a brief substance abuse assessment, intervention, and referral for treatment done at the reporting trauma service;

(xvi) Comorbid factors/preexisting conditions;

(xvii) Hospital events.

(h) Procedural data elements:

(i) First operation information must include:

(A) Date and time operation started;

(B) Operating room (OR) procedure codes;

(C) OR disposition.

(ii) For later operations information must include:

(A) Date and time of operation;

(B) OR procedure codes;

(C) OR disposition.

(i) Admission data elements must include:

(i) Date and time of admission order;

(ii) Date and time of admission or readmission;

(iii) Date and time of admission for primary stay in critical care unit;

(iv) Date and time of discharge from primary stay in critical care unit;

(v) Length of readmission stay(s) in critical care unit;

(vi) Other in-house procedures performed (not in OR).

(j) Disposition data elements must include:

(i) Date and time of facility discharge;

(ii) Most recent ICD diagnosis codes/discharge codes, including nontrauma diagnosis codes;

(iii) Disability at discharge (feeding/locomotion/expression);

(iv) Total ventilator days;

(v) Discharge disposition location;

(vi) If transferred out, ID of facility the patient was transferred to;

(vii) If transferred to rehabilitation, facility ID;

(viii) Death in facility.

(A) Date and time of death;

(B) Location of death;

(C) Autopsy performed;

(D) Organ donation requested;

(E) Organs donated.

(ix) End-of-life care and documentation;

(A) Whether the patient had an end-of-life care document before injury;

(B) Whether there was any new end-of-life care decision documented during the inpatient stay at the reporting trauma service;

(C) Whether the patient receive a consult for comfort care, hospice care, or palliative care during the inpatient stay at the reporting trauma service;

(D) Whether the patient received any comfort care, in-house hospice care, or palliative care during the inpatient stay (i.e., was acute care withdrawn) at the reporting trauma service;

(k) Financial information must include:

(i) Total billed charges;

(ii) Payer sources (by category);

(iii) Reimbursement received (by payer category).

(6) Designated trauma rehabilitation services must provide the following data upon request by the department for patients identified in WAC 246-976-420(3).

(a) Data submission elements will be based on the current inpatient rehabilitation facility patient assessment instrument (IRF-PAI). All individual data elements included in the IRF-PAI categories below and defined in the data dictionary must be submitted upon request:

(i) Identification information;

(ii) Payer information;

(iii) Medical information;

(iv) Function modifiers (admission and discharge);

(v) Functional measures (admission and discharge);

(vi) Discharge information;

(vii) Therapy information.

(b) In addition to IRF-PAI data elements each rehabilitation service must submit the following information to the department:

(i) Admit from (facility ID);

(ii) Payer source (primary and secondary);

(iii) Total charges;

(iv) Total remitted reimbursement.

(1) The department will:

(a) Develop guidelines for a regional EMS/TC system quality assurance and improvement program including:

(i) Purpose and principles of the program;

(ii) Establishing and maintaining the program;

(iii) Process;

(iv) Membership of the quality assurance and improvement program committee;

(v) Authority and responsibilities of the quality assurance and improvement program committee;

(b) Review and approve written regional quality assurance and improvement plans;

(c) Provide trauma registry and EMS data to regional quality assurance and improvement programs in the following formats:

(i) Quarterly standard reports;

(ii) Ad hoc reports as requested according to department guidelines.

(2) Levels I, II, and III, and Level I, II and III pediatric trauma care services must:

(a) Establish, coordinate and participate in regional EMS/TC systems quality assurance and improvement programs;

(b) Ensure participation in the regional quality assurance and improvement program of:

(i) Their trauma service director or codirector; and

(ii) The RN who coordinates the trauma service;

(c) Ensure maintenance and continuation of the regional quality assurance and improvement program.

(3) The regional quality assurance and improvement program committee must include:

(a) At least one member of each designated facility's medical staff;

(b) The RN coordinator of each designated trauma service;

(c) An EMS provider.

(4) The regional quality assurance program must invite the MPD and all other health care providers and facilities providing trauma care in the region, to participate in the regional trauma quality assurance program.

(5) The regional quality assurance and improvement program may invite:

(a) One or more regional EMS/TC council members;

(b) A trauma care provider who does not work or reside in the region.

(6) The regional quality assurance and improvement program must include a written plan for implementation including:

(a) Operational policies and procedures that detail committee actions and processes;

(b) Audit filters for adult and pediatric patients;

(c) Monitoring compliance with the requirements of chapter 70.168 RCW and this chapter;

(d) Policies and procedures for notifying the department and the regional EMS/TC council of identified regional or statewide trauma system issues, and any recommendations;

(e) Policies regarding confidentiality of:

(i) Information related to provider's and facility's clinical care, and patient outcomes, in accordance with chapter 70.168 RCW;

(ii) Quality assurance and improvement committee minutes, records, and reports in accordance with RCW 70.168.090(4), including a requirement that each attendee of a regional quality assurance and improvement committee meeting is informed in writing of the confidentiality requirement. Information identifying individual patients may not be publicly disclosed without the patient's consent.

(1) Purpose: The department maintains a statewide electronic emergency medical services data system, as required by RCW 70.168.090. The purpose of this data system is to:

(a) Provide data for EMS activity surveillance, analysis, and quality assurance programs;

(b) Monitor and evaluate the outcome of care provided by EMS services personnel, in support of statewide and regional quality assurance and system evaluation activities;

(c) Assess compliance with state standards for EMS care (chapters 18.71, 18.73, 70.168 RCW and this chapter);

(d) Provide information for resource planning, system design and management; and

(e) Provide a resource for research and education.

(2) Confidentiality: RCW 70.168.090 and chapter 42.56 RCW apply to EMS data, records, and reports developed pursuant to RCW 70.168.090. Data elements related to the identification of individual patient's, provider's, and facility's care outcomes shall be confidential, shall be exempt from chapter 42.56 RCW, and shall not be subject to discovery by subpoena or admissible as evidence. Patient care quality assurance proceedings, records, and reports developed pursuant to RCW 70.168.090 are confidential, exempt from chapter 42.56 RCW, and are not subject to discovery by subpoena or admissible as evidence.

(a) The department may release confidential information from the electronic EMS data system in compliance with applicable laws and regulations. No other person may release confidential information from the data system without express written permission from the department.

(b) The department may approve requests for EMS data system data and reports consistent with applicable statutes and rules.

(c) The department has established criteria defining situations in which EMS data system information is confidential and situations in which data may be shared, in order to protect confidentiality for patients, providers, and facilities.

(d) Subsection (2)(a) through (c) of this section does not limit access to confidential data by approved regional quality assurance and improvement programs and medical program directors established under chapter 70.168 RCW and described in WAC 246-976-910 and 246-976-920.

(3) Data submission: The department establishes and maintains procedures and format for ambulance and aid services to submit data electronically. Reporting mechanisms will meet state requirements for data security, data interoperability, and national reporting standards. These will include a mechanism for the reporting agency to check data for validity and completeness before data is sent to WEMSIS.

(4) Data quality: The department establishes mechanisms to evaluate the quality of EMS data. These mechanisms will include:

(a) Detailed protocols for quality control, consistent with the department's most current data quality guidelines.

(b) Validity studies to assess the timeliness, completeness, and accuracy of case identification and data collection.

(5) Data reports and data sharing: The department may create, release, and provide access to data files and reports in accordance with RCW 70.168.090. The type of information contained in the file, including direct and indirect patient, provider and facility identifiers, determines the permitted release of, or access to, the data file or report.

(a) Annually, the department reports:

(i) Summary statistics and trends for demographic and related EMS care and activity information for the state and for each emergency medical service/trauma care (EMS/TC) region;

(ii) Benchmarking and performance measures, for system-wide evaluation and regional quality improvement programs;

(iii) Trends, patient care outcomes, and other data, for the state and each EMS/TC region, for the purpose of regional evaluation; and

(iv) Aggregate regional data upon request, excluding any confidential or identifying data.

(b) The department will provide reports to EMS services, approved regional quality assurance and improvement programs and medical program directors upon request, according to the confidentiality provisions in subsection (2) of this section and all applicable laws and regulations.

(c) In order to comply with WAC 246-976-920, the department may provide aggregate reports and directly identifiable patient record access to medical program directors for EMS services within their jurisdiction.

(d) In order to comply with RCW 70.168.090, the department will provide reports, patient data and record access related to suspected drug overdoses to government agencies, including local public health agencies, tribal authorities, and other organizations at the discretion of the department, for the purposes of including, but not limited to, identifying individuals to engage substance use disorder peer professionals, patient navigators, outreach workers, and other professionals as appropriate to prevent further overdoses and to induct into treatment and provide other needed supports as may be available. Data for this purpose will be provided upon request and according to the confidentiality provisions in subsection (2) of this section and all applicable laws and regulations.

(e) The department may share confidential data files containing one or more direct patient identifiers with researchers with approval from the Washington state institutional review board (IRB) and a signed confidentiality agreement. The department may also require researchers to enter into a data sharing agreement.

(f) The department may provide a hospital with access to the complete electronic patient care report for activations in which the patient was delivered to their facility.

(g) The department may provide data and reports to other parties not listed in (c) through (f) of this subsection upon request, according to the confidentiality provisions in subsection (2) of this section and all applicable laws and regulations.

(h) When fulfilling a request for data, the department may provide the fewest data elements and patient records necessary for the stated purpose of a requestor's project.

(1) Licensed EMS services and certified EMS providers shall protect the confidentiality of data in their possession and as it is transferred to the receiving facility or the department.

(2) The certified EMS provider in charge of patient care shall 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 24 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 to the receiving facility within 10 days of transporting the patient to the trauma center.

(3) A licensed EMS service must:

(a) Within 48 hours after the initial dispatch, send a complete electronic patient care report to the department for all activations that meet inclusion criteria in subsection (4) of this section.

The electronic patient care reports must:

(i) Be sent in a secure format determined by the department; and

(ii) Include all data elements specified in subsection (5) of this section.

(b) Submit any and all updates or modifications to previously submitted electronic patient care reports to the department within 48 hours of the update.

(c) EMS services who are unable to submit or update electronic patient care reports within 48 hours should notify the department within 30 days from when the delay began. The service must work with the department to submit a modified submission plan in a format determined by the department.

(d) Identify one or more EMS service WEMSIS administrator(s) responsible for EMS data activities. An EMS service WEMSIS administrator must:

(i) Complete the department EMS data system training course within 18 months of being assigned to this role;

(ii) Adhere to WEMSIS data confidentiality restrictions determined by the department; and

(iii) Act as the primary contact for the department regarding WEMSIS related communications including those pertaining to data submission, data validity, data quality, account access, and reporting;

(iv) Adhere to processes and protocols for WEMSIS data use and access as determined by the department.

(e) Notify the department within 30 days of any change or addition of EMS service WEMSIS administrators or a change to an administrator's contact information. Changes submitted must be made on forms provided by the department.

(f) Have procedures in place for internal monitoring of data validity, which may include methods to reabstract data for accuracy.

(g) Correct and resubmit patient care records that fail the department's validity tests as described in WAC 246-976-445 within 30 days of notification of errors.

(h) Make all patient care records available for inspection and review upon request of the county MPD or the department. Records provided shall be in electronic format where capabilities allow and will be provided in the most secure method available.

(i) By January 31st each year, submit or update EMS service demographic information for the previous calendar year in a format determined by the department. Demographic information should include:

(i) EMS dispatch volume;

(ii) EMS patient transport volume;

(iii) EMS patient contact volume;

(iv) EMS interfacility transport volume;

(v) EMS interfacility transport volume by ALS;

(vi) EMS interfacility transport volume by ILS;

(vii) EMS interfacility transport volume by BLS;

(viii) EMS interfacility transport volume by first response;

(ix) EMS interfacility transport volume by second response;

(x) EMS ground transport volume;

(xi) EMS air transport volume;

(xii) EMS critical care transport volume.

(4) Inclusion criteria: Ambulance and aid services must submit electronic patient care reports for all activations to which they are dispatched. Criteria includes 911 and interfacility activations where treatment or transport occurred, patient refusal of treatment or transport, and canceled activations. All activations which cross Washington borders and involve a Washington licensed ambulance or aid service must be included if the service is dispatched to a location in Washington state or if a patient is transported to a facility in Washington state.

(5) A licensed ambulance or aid service must submit data elements in adherence with the National Emergency Medical Services Information System (NEMSIS) national EMS data standards and requirements except where they differ from the reporting requirements specified in subsection (6) of this section.

(6) In addition to adhering to the NEMSIS EMS data standards, all licensed ambulance or aid services must submit the following data elements for all records where applicable:

Patient last name;

Patient first name;

Middle initial or name;

Patient Social Security number;

Gender;

Race;

Age;

Age units;

Patient date of birth;

Patient driver's license;

Patient home address;

Alternate home residence;

Patient phone number;

Recent exposure to infectious disease;

Recent travel;

Recent local travel;

Recent international travel;

Recent state travel;

Recent city travel;

Temperature;

Respiratory effort;

Chest/lungs assessment;

Ending travel date;

Beginning travel date;

Personal protective equipment used;

Airway device placement confirmed method;

Cardiac arrest during EMS event;

Cardiac arrest etiology;

Cardiac arrest, resuscitation attempted by EMS;

Cardiac arrest, witnessed by;

Cardiac arrest, who first initiated CPR;

Patient evaluation/care;

Crew disposition;

Transport disposition;

Reason for refusal/release;

Destination/transferred to, name;

Destination/transferred to, code;

Destination street address;

Destination zip code;

EMS transport method;

Final patient acuity;

Type of destination;

Destination team prearrival activation;

Mental status assessment;

Medication allergies;

Medical/surgical history;

Trauma triage criteria;

Cause of injury code;

Use of safety equipment;

Extrication required;

Hospital disposition;

Procedure performed date/time;

Procedure performed prior to EMS care;

Procedure performed;

Procedure number of attempts;

Procedure successful;

Symptom onset date/time;

Symptom, primary;

Symptoms, other associated;

Provider's primary impression;

Provider's secondary impression;

Last known well date/time;

PSAP call date/time;

Dispatch notified date/time;

Unit arrived on scene date/time;

Unit arrived at patient date/time;

Unit left scene date/time;

Patient arrived at destination date/time;

Destination patient transfer of care date/time.

Date/time of first vital signs taken;

First systolic blood pressure;

First respiratory rate;

First pulse;

First oxygen saturation;

First Glasgow coma score (GCS) with individual component values (eye, verbal, motor, total, and qualifier);

Vital sign, taken date/time;

Vital sign, obtained prior to EMS care;

Vital sign, cardiac rhythm/ECG;

Vital sign, ECG type;

Vital sign, blood glucose level;

Vital sign, stroke scale score;

Vital sign, stroke scale type;

Vital sign, stroke scale value/severity score - LAMS;

Type of scene delay;

First EMS unit on scene;

Incident zip code;

Incident county;

Scene GPS location;

Incident location type;

Facility transported from (code);

Other EMS or public safety agencies at scene;

Type of other service at scene;

Medication administered;

Medication administered route;

Date/time medication administered;

Medication administered prior to this unit's EMS care;

Medication response;

Role/type of person administering medication;

Alcohol/drug use indicators;

Respiratory rate;

Total Glasgow coma score;

Eye assessment;

ACS risk score.

Emergency medical services (EMS) agency number;

Unit enroute date/time;

Patient care report number;

First EMS agency on scene identification number;

Crew member level;

Method of transport;

Incident location type;

Patient information.

Emergency department disposition;

Hospital disposition;

External report ID/number type;

External report ID/number;

Emergency department diagnosis;

Hospital diagnosis.